Should You Have a Living Will?

There's a fantastic post at GeriPal about the efficacy of the Living Will and Advance Directive documents that many end of life rights advocates -- including myself -- have promoted. What the articles does well is look at a number of current studies and articles and address points made by prominent activists. It asks us what the best way is for a patient to protect their rights at the end of life. Sadly, there is no foolproof way to ensure that the medical decisions made for you will be consistent with what you want. I recommend you read the entire post, but here's a clip:

“Enough. The living will has failed, and it is time to say so.” So said Angela Fagerlin and Carl Schneider in 2004. “Living wills are still widely and confidently urged on patients, and they retain the allegiance of many. For these loyal advocates, we offer systematic proof that such persistence in error is but the triumph of dogma over inquiry and hope over experience.” Joann Lynn wrote an essay titled Why I Don’t Have a Living Will, saying, “I do not have a living will because I fear that the effects of having one would be worse, in my situation, than not having one. How could this be? A living will of the standard format attends to priorities that are not my own, addresses procedures rather than outcomes, and requires substantial interpretation without guaranteeing a reliable interpreter.” Thomas Pendergast said, “[Since the passage of the Patient Self Determination Act in 1990] advance directives are recorded by medical personnel more often but are not completed by patients more frequently. The process of recording them does not enhance patient-physician communication. When available, advance directives do not change care or reduce hospital resources. The most ambitious study of advance care planning, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT], failed to show any change in outcomes after an extensive intervention.” Prominent figures in palliative care decried persistent research and health policy efforts to promote living wills, saying, “when have living wills ever been shown to do anything???!!!”

And yet, after being thrashed to within an inch of death, two recent studies breathed life into advance directives. Before getting into the particulars of these studies, it’s important to understand how and why we came to have advance directives in the first place.

How We Define Death And The Future of Hospice.

Larry Beresford challenges the latest meme that hospice patients have declined in number recently. He notes that, among others, Tim Cousounis at Palliative Care Success and the Urban Institute's Howard Gleckman, who wrote a recent article for Kaiser Health News, have examined hospice enrollment and concluded the same thing. It is in decline.

The reasons they cite are varied but predictable: a bad economy makes doctors hesitant to refer profit-generating patients to hospice where the income derived from costly curative treatments naturally declines; Medicare rules require that a patient have less than 6 months to live before going into hospice and sometimes patients, particularly chronically ill ones, live beyond that time frame, a situation Medicare would like to avoid; and of course, the constant challenge of image that hospice faces as a place where one goes when they have "given up" continues to prevent ever-growing enrollment.

From Beresford's latest blog post:

I contacted a couple of leading hospice executives to ask them if the declining enrollments trend is true. One said that hospice patient census fluctuates up and down for all sorts of reasons, but that his agency's is up, after a sharp drop in 2008. But Samira Beckwith, CEO of the highly successful Hope Hospice and Palliative Care in Fort Myers, Florida, responds, "I think that everything [Gleckman] says in his article is true." One of the problems, she says, is that America's hospices still have not successfully communicated the idea that hospice care means "living" as fully and as well as possible until death comes. Instead, Americans have learned a little bit about hospice and believe it means "they have to die really soon if they say yes."

The problems of misunderstanding, misconceptions and mistrust of hospice care by people confronting hard choices at the end of life have been around throughout the history of hospice in America, even as the number of people receiving hospice care has steadily grown, up to 1.45 million in 2008. Physicians' reluctance to bring up the "H" word with their terminally ill patients has been well-documented. The second-guessing of hospices' enrollment decisions by Medicare has also intensified recently, but is not a new phenomenon. A similar round of government scrutiny occurred in the mid-1990s. And still the trends of the number of hospices, number of patients served and total Medicare outlays have pointed steadily upward since the first U.S. hospice opened in 1974 and since Medicare began paying for hospice care in 1984.

Beresford's conclusion is that perhaps this ebb in enrollment is really a reflection of market capacity:

The MBAs who run fast food or pharmacy chains are taught that when your company or your industry stops growing, it is already dying. But is that the right model for a service designed to promote compassionate, individualized, quality of life-promoting care for dying patients and their families? Shouldn't hospice's goal be to offer a meaningful option to all those who might need it and want it, and who might qualify, according to the rules of those who would pay for it, as being terminally ill -- rather than just continuing to grow? And if there is a current decline in referrals, given the recent proliferation and rampant competition of mom-and-pop hospice providers, particularly in certain metro areas and in the states of Alabama, Mississippi and Oklahoma, perhaps what's happening now is what the economists might call a necessary market correction.

I tend to disagree with Beresford and here's why: hospice is really the only option for patients who wish to die at home and so, as long as statistics continue to show that a majority of Americans wish to die at home (80%) and that most continue to die in facilities (75%) there's room for hospice to grow.

Whatever strides the hospice community has made in the past three decades or so of convincing society that the patient can decide where they die (and increasingly, when), the prevailing institutions in our culture - the church, the medical industry, and the state - haven't done much to change the tone of discussion about death. Only in Oregon, where the state population has had a long and in-depth conversation about end of life care (primarily because of the successful initiative to legalize assisted suicide) is there a more sophisticated understanding of end of life care options. I suspect that, as statistics in 2007 showed, that Oregon continues to lead the country in hospice enrollment. A couple of other factors that are working against hospice enrollment:

1. The rise of "pro-life" opposition to end of life choice (as conveyed through fear of "socialized" medicine, removal of artificial nutrition and hydration, end of life care planning (DNR, living wills, medical proxy designation), and aid in dying) and simple statistics that show the devoutly religious are more inclined to seek aggressive, futile care at the end of life are only one front that prevents society from viewing hospice as a healthy, life-affirming choice.

2. The medical industry has absolutely no incentive to direct terminal patients to hospice. Doctors are entrenched in a culture that, as Joanne Lynn says, puts patients on a "glide path" that involves aggressive treatment until death, as though death is a "failure" of medicine that can be cured. Doctors have only begun to be trained in medical schools for end of life care discussions (and continue to not be reimbursed for the necessarily lengthy discussions); palliative care is growing but still in its infancy; doctors tend to grossly over-estimate the time a patient has before death (hence delayed and briefer hospice enrollment); aggressive care is revenue for medical institutions and doctors; the conservative AMA and other medical associations (with the exception of many nursing organizations) have resisted society's call for greater improvements to end of life care. As well, advancements like 911, CPR, and the ability to lengthen a patient's life have prevented serious discussion about "quality of life." "Doing everything we can" to save a patient is the default, whether it lengthens the patient's life or keeps them comfortable - or not.

3. As we've seen during the year-long health care debate, the state has done little - either at the state or federal levels - to promote or legislate sound end of life care laws. I can think of only a handful of state laws that promote end of life planning. Veteran's Affairs, the largest health care provider in the US, has made commendable, great strides in meeting patient's needs and wishes in the last months of life but at the end of last year we saw them come under attack for distributing a planning guide, then termed the "death book." This noise, however illegitimate, makes institutions, health care providers, and doctors hesitant to discuss these issues.

In essence, the media and society have allowed fear-mongering and inaccurate accusations to shut down the end of life discussion.

The entire non-sensical circus that stemmed from the health care debate - death panels, the state's gonna euthanize you, etc. - has had an effect. The environment we're in at the moment (a political battle that has less to do with patient care than politics) has had a dampening effect on legislative efforts to enforce good end of life care planning.

The powerful Catholic church, a strong opponent of removal from ANH and of assisted suicide, is in a position where they must articulate nuanced and complicated arguments for hospice (an organization founded by the Catholic Cicely Saunders and long affiliated with the Catholic church) if they want to support hospice at all. For their political purposes, it is much better to push "all life is sacred" than "you're bound for a better place," both rhetorical constructs that sound true enough but work to As well, the church is firmly under the influence of a staunchly conservative leadership right now. And, as the second largest operator of hospitals in the US, they too have an interest in keeping patients in hospitals, receiving aggressive care. Their force and influence was proven during the health care debate.

And lastly, death just isn't what it used to be. Death used to mean the almost simultaneous end of a heart beat, breathing and brain function. In the past 30 or so years medicine has figured out how to maintain the first two indefinitely. And brain function, as we've seen with the cases of three young women - Karen Ann Quinlan (1985), Nancy Cruzan (1990), and Terri Schiavo (2005) - is increasingly considered not a suitable qualification for death.

But there is hope for hospice. Baby boomers are increasingly greying and, as they have changed every other institution their generation has moved through, end of life care is bound to be altered by their increasing need of it. As well, our health care system is not equipped for such a large influx of elder patients. The threat of economic destruction should be enough to push US society and government to reconsider how we care for those who are dying. Hospice will play a vital role in that reconsideration.

What Then Is A Natural Death?

Alex Schadenberg warns those vulnerable and child-like seniors, incapable of making their own health care decisions, to stay far, far away from those evil living will forms because their lawyers, their family, and doctors are trying to kill them!

Can you think of a greater disservice anyone with the public's ear could do for seniors? Convince them that living wills are deadly? When we living in an age where every citizen should write up a living will as soon as they reach voting age?! And update it annually.

It is just this sort of irresponsible fear-mongering and redefining of natural death, or rather illogical defining of "the culture of death," that alarms me about those who ascribe to a "pro-life" perspective on end of life care. Shaming or scaring seniors into making the decisions you feel they should is coercion, plain and simple. And perpetuates the fear of death and dying that our society battles.

From his site, Euthanasia Prevention Coalition:

Living Will - Killing Will

During the last few days I have received three Power of Attorney/ Living Will legal documents that in fact are designed as Killing Will documents.

A Power of Attorney for Personal Care is a legal document that assigns a person to make medical and care decisions on your behalf when you are unable to do so for yourself. These are important documents because the wording of the document will either protect your life and or may give medical professionals the right to abandon you or even dehydrate you to death.

My concern is that many people will visit their lawyer and have a Will and Power of Attorney documents drawn up for them without understanding that the language in the Power of Attorney document may be neutral, may protect their life, or may actually hasten their death.

Last week a supporter contacted me after reading his Power of Attorney for Personal Care document. He was shocked that he had signed a document that instructed the physician to dehydrate him to death if he were terminally ill or living with a chronic condition.

The Euthanasia Prevention Coalition distributes the Life-Protecting Power of Attorney for Personal Care to protect you from being killed. We charge $25 for this document. The information for ordering the document is at:http://www.euthanasiaprevention.on.ca/lifeprotectingpowerattorney/LifeProtectingPowerAttorney.pdf

Today, I received a Power of Attorney document from a supporter that was by far the worst one I have seen in a while. It stated:

If and when it becomes clear beyond any reasonable doubt that I am afflicted with or suffering from an irreversible injury, disease, illness or condition that is terminal, then:
(a) I direct that I be allowed to die, and that I not be kept alive by artificial means or invasive measures of any kind. Measures of prolonging life that are to be avoided, withheld, withdrawn or discontinued include:
(i) electrical or mechanical resuscitation of my heart;
(ii) nasogastric tube feedings, gastric tube feedings or parentral nutrition;
(iii) artificial mechanical respiration when my brain can no longer sustain my own breathing;
(iv) radiation treatment and chemotherapy, unless used strictly as palliative measures;
(v) any treatment for any other illness or disease (such as pneumonia) which I contract when already afflicted with a terminal disease, illness or condition (such as Alzheimer's Dementia); and
(vi) dialysis when my kidneys fail.
(b) I request that a "Do Not Resuscitate" ("DNR") notification be kept with me at all times - whether I am at home, living with family or friends, or in a hospital or other health care facility.
(c) I desire that medication be mercifully administered to alleviate pain and suffering, even though the result may be to hasten the moment of my death.
(d) If I am under the care of a physician whose moral, religious or personal professional beliefs are not in sympathy with the directives set out herein, I direct my attorney for personal care to ask that physician to withdraw from my care and to arrange for me to be cared for by another physician whose beliefs and views accord more closely with my directives, and, if necessary, to transfer me to a different hospital or health care facility to better ensure that my wishes as expressed herein are respected.

The problem I have with this document is that it not only orders the physician to not provide any medical treatment, other than palliative care, but it also orders the physician to dehydrate the person to death, even if they are not in the dying phase. Read section (a), subsection (ii).

Further to that, the person who sent me this document was a suppoorter of our work and this was the document that his lawyer was suggesting that everyone obtain.

The fact is that many unsuspecting people have obtained, legally signed, and put-in-place, similar power of attorney for personal care documents without knowing how the document will be interpreted.

Further to that: Power of Attorney for Personal Care documents are only legally binding when the person is incapable of making legal decisions. At that point the document can't be amended.

Lifenews Discredits Palliative Care.

Lifenews published an irresponsible and misleading article yesterday by writer Mary Ann Kreitzer that uses friend-of-a-friend conjecture and emotion to discredit palliative care. Like Bill Frist diagnosed Terri Schiavo by video, Kreitzer uses a telephone conversation to determine that her friend's father was "killed" by palliative care.

Irresponsible: because millions of elders are now facing end of life care and planning and require fact-based, scientific, medically sound advice on what their options are for their dying and death. This article plays on fear of death, the taboo of discussing end of life choices, and religious convictions to damage patients' understanding. It is a horrible disservice to seniors.

Misleading: In short she gets all the facts wrong simply because she is not medically trained, is not intimate with the medical facts of the man's death, does not understand that dementia and alzheimers not only damage the mind but the body, has little knowledge of what palliative sedation is, and in short, contributes to fears that elders already have about end of life issues.

I wish we could say that this type of egregious misinformation and fear-mongering was rare, but unfortunately it's not. While 75% of elders say they would like to die at home, 80% die in health facilities, often without any control over their end of life decisions, financial arrangements, or knowledge of patients' rights. Over the past thirty years, the sort of work that Kreitzer is doing with this post has reduced elders to victims, not in control of their end of life decisions or care. Kreitzer demeans the autonomy of elders by reducing their agency in their own health care decisions.

But there's something else at work in this piece: grief is a complicated and nuanced emotional process that, when stymied by blame and anger, however unjust, can damage the grieving of those who have lost a loved one. Kreitzer's damage is not only to those seniors who must face the dying process without guidance and accurate information but to the loved ones who in the wake of death are faced with the work of their own grief.

By using only the barest outline of a man's death, Kreitzer makes the case that the nebulous "culture of death" is out to kill our vulnerable seniors. Nothing could be farther from the truth. Only accurate information, medically sound decisions, advanced planning, and acceptance of impending death will empower our seniors to die the way they want to. Kreitzer deserves grave criticism for working to distort our human right to a good death.

From Lifenews:

I spoke to a friend this morning whose father was murdered by terminal sedation (aka "palliative" care). Her father suffered from Alzheimer's and his mind was pretty well gone, but physically he was in great shape.

He and his wife lived with one of my friend's children who took him for a long walk every day and knew how to manage all his grandfather's moods. They were good buddies. My friend lived nearby and spent as much time as possible visiting her parents and enjoying her father's company.

But the rest of the family (including my friend's mother who had power of attorney) decided to put him in a nursing home where he was difficult to control because he wanted to be released. My friend told me that every time she went to visit him he was trying to escape -- pulling at every door and even the bookcases looking for a way out. Three nursing homes and several months later he pretty much gave up.

When she went to see him he would be sitting in a wheelchair slumped over and drooling. He got an infection and ended up in a hospital "palliative" ward where he was denied food, water, and antibiotics. Within several months, he went from an elderly man who was walking two miles a day with his grandson, to dead from dehydration and terminal sedation. It was Terri Schiavo and Hugh Finn without the publicity.

My friend considered trying to get guardianship at one point, but she was familiar with the earlier cases and knew it would be a lengthy legal battle and the result would be the same. He had also deteriorated so much she didn't think he could recover. With a number of young children still at home, she didn't think she could deal with the fight. So here was a faithful daughter (and her husband) willing to care for both her parents until they died, who had to watch while her faithless siblings and her mom murdered her father.

Welcome to the realities of the culture of death.

Terminal sedation is abortion for the elderly. You have dementia and get pneumonia? Like Rahm Emmanuel says, Never let a crisis go to waste. See it as an opportunity for a quick exit. No antibiotics and terminal sedation. Abortion completed. Your loved one is healthy but brain damaged like Terri Schiavo and Hugh Finn? No problem. Starvation, dehydration, and terminal sedation. Call it late-term abortion.

You think I'm exaggerating? The New York Times ran an article on December 27, 2009 on the practice. It is common in hospice programs. Hurry the patients along for the peace of the family and to empty the bed. Saves everyone anxiety, money, and hassle. Except, perhaps, the patient. But he is drugged so whatever objections he may have had, you'll never have to hear them.

Sometimes, as in my friend's case, though, things aren't that smooth. Far from bringing peace to families it brings terminal strife and family breakdown. And in the case of my friend's mom, will children who killed their father, hesitate at doing the same thing to the their complicit mother? After all, she had no objections to killing dad; so how can she object to her own quick exit? It's for the children (and their inheritance?).

I wish I could say this is the only case I know of the deliberate murder of elderly parents, but it isn't. It's common practice in some hospices with or without the complicity of the families. Situations like my friend's are also becoming more and more common as the baby boomers, who often gave their children nothing in the way of faith, face the results of their hedonistic lives. "Hey, Mom put me in day care for most of my childhood and aborted my siblings; I'll put her in a nursing home and pull the plug as soon as possible." So much easier for everyone.

The worst part, however, is that while the body is being killed, the souls of the killers are dying as well. How does God who said, "Honor your father and your mother," look at the deliberate murder of parents? It is mortally sinful! And that's the greatest suffering for my friend. She would like to see her family in heaven, but fears that this life on earth may be the only common ground they ever share.

Please pray for all those in danger of death today from terminal sedation and for those who will carry it out and enable it. It's a soul-killer for sure! You can call it quick and painless, but in the end the palliative care ward, like the abortion mill, is literally hell on earth.

Legal Questions Answered For End of Life Care.

The American Bar Association, in coordination with the National Hospice and Palliative Care Organization, has issued a new document that is meant to aid patients and their care-takers when facing legal issues in preparation for end of life.

The document can be found here and highlights such difficult issues as how to pay for the health care you need, what are a patient's rights, and planning how to manage your money and property.

I hope the Guide for the Seriously Ill gets some good distribution. One of the more challenging aspects of facing terminal illness is not just knowing how to tackle legal challenges but knowing exactly what those legal challenges are. Here's an excerpt from an article at Senior Spectrum:

Knowing what vital steps to take to get your financial and legal affairs in order when confronted by serious illness just became easier thanks to a new guide released by the American Bar Association (ABA).

Seniors and family members facing the onset of a life threatening illness or injury are often unaware of how to get their affairs in order to protect themselves and their families.

“The Legal Guide for the Seriously Ill” — a project by the ABA Commission on Law and Aging commissioned by the National Hospice and Palliative Care Organization (NHPCO) — was designed for both the seriously ill individual and those caring for someone who is seriously ill.

The guide explains “Seven Key Steps” in a brief, clear way while offering additional tips and resources for readers looking for more detailed information and guidance.

“‘The Legal Guide for the Seriously Ill’ is a great resource for anyone facing a serious illness,” noted ABA president Carolyn B. Lamm. “The book provides critical tools that help readers understand their options, make informed decisions and minimize some of the anxiety they may be feeling about their financial and legal affairs at this stage of life.”

Development of the new guide was prompted by current societal issues and concerns facing many Americans, such as paying for health care, managing health and personal decisions, and patient rights.

“The Legal Guide for the Seriously Ill” also explores recent legislative and regulatory changes to give users a thorough understanding of where they stand when making important decisions.

The guide is expected to fill an important gap in resources for many Americans.

Lawyers and the Living Will.

Dr. Muriel Gillick has a must-read article up at her site, Perspectives on Aging, about the problems with living wills (advance directives).

She writes that lawyers have taken up the slack in helping elders fill out living wills and the absence of medical input is creating ineffective and vague forms that give elders a false sense of security over control of their end of life decisions:

The living will my parents were given is a classic example of pseudo-precision: “If a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications or artificial means or procedures which serve only to prolong the process of my dying,” it begins. What is a “reasonable expectation of recovery?” A fifty-fifty chance? Is a 30% chance good enough? 10%? What does “recovery” mean anyway? Going home and living independently? Living in a nursing home and needing help with bathing and dressing? Going from unconsciousness and total paralysis to wakefulness and the ability to move one finger?

But there is more—the document seems, at first glance, to spell out the answers to these questions. It says “without limitation, I intend these instructions to apply if I am (i) terminally ill, (ii) permanently unconscious, or (iii) conscious, but have irreversible brain damage and there is no reasonable expectation that I will regain the ability to make decisions and express my wishes.” What is meant by “terminally ill?” Does it mean conforming to the Medicare hospice definition of having a life-expectancy of 6 months or less, if the disease follows its usual course? Does it mean death is imminent—in the next few hours or days? Or does it mean having a disease that is uniformly fatal, such as Alzheimer’s disease, which lasts 3-5 years, sometimes longer, from diagnosis until death? What is “extreme physical or mental disability?” Does this mean the most advanced stage of Alzheimer’s, or does moderately severe dementia—in which the individual can walk and talk, but has completely lost his short term memory and needs help with bathing, toileting, and personal care—qualify?

End of Life, The Novel.

Doctor and pastor Jeff Gordon has written a novel that addresses end of life choices called A Death Prolonged. At his website, eoleducation.org, Gordon writes:

The Human Cost: Death Prolonged

Most elderly people suffer needlessly at the end of their lives because education about end-of-life care is sorely lacking. Today’s high-tech medical care can sustain life, but fails to restore quality of life for many. The result: death prolonged.

The Social Cost: Futile care funded, preventive care neglected

The other critical issue is the astronomical cost of end-of-life care. We spend about thirty percent of Medicare resources on the last year of life and about fifty percent of that in the last two months. In 2008 that was $68 billion spent on the last two months of life. Tragically, in most cases, that expense is worse than waste. That type of care prolongs suffering and provides little hope for quality life.

On the other hand, people delay or decline basic health care because they have inadequate financial means and many preventable conditions go unchecked.

His hope is to educate readers about the dangers of resuscitation and not planning for end of life care and to encourage them to write living wills and durable powers of attorney.

Read more about the book and the author at ColumbusDispatch.

Kerrie Wooltorton's Living Will.

Before she ingested poisons or called an ambulance, Kerri Wooltorton, a depressed, 26 year old, pinned the following living will to her shirt. She wanted to die. She had tried to kill herself 9 times before. On the heels of a revision of the laws governing assisted suicide, British doctors at the hospital where Wooltorton was taken did not treat her. Her death is now causing a stir in Britain; Health Secretary Andy Burnham said the case made him uncomfortable. The laws on living wills may now be reviewed.

14/09/2007 To whom this may concern

If I come into hospital regarding an overdose or any attempt of my life, I would like for NO life saving treatment to be given. I would appreciate it if you could continue to give medicines to help relieve my discomfort, painkillers, oxygen etc. I would hope these wishes would be carried out without loads of questioning.

Please be assured that I am 100% aware of the consequences of this and the probable outcome of drinking antifreeze, eg death in 95-99% of cases and if I survive then kidney failure, I understand and accept them and will take 100% responsibility for this decision.

I am aware that you may think that because I called the ambulance I therefore want treatment, THIS IS NOT THE CASE! I do however want to be comfortable as nobody wants to die alone and scared and without going into details there are loads of reasons I do not want to die at home which I realise you will not understand and I apologise for this.

Please understand that I definitely don’t want any form of ventilation, resuscitation or dialysis. These are my wishes please respect and carry them out.

Yours sincerely

Kerrie Wooltorton

Talking About Death: Where Are the Grown-Ups?

Barbara at Compassion & Choices blog admonishes us to just grow up:

I have written that some national leaders apparently prefer to confine us in perpetual childhood, so we need never acknowledge, grieve over or plan for our own deaths or the deaths of those we love. A peculiarly childish approach to end-of-life issues permeated the August recess, complete with terrifying fabrications and fear-based tantrums. In their coverage of town hall discussions media outlets reinforced a perception that we are children, more interested in playground bullies and shouting matches than in substantial discussion of the issues and the facts. The Washington Post ombudsman writes that its readers think their recent coverage has focused too much on the combat and too little on what’s actually being proposed.

*

What does being treated as an adult look like? One sign is the medical system gives you full and frank information, compassionately supports you through painful emotions and trusts you to make decisions for yourself, based on the facts. H. Gilbert Welch, head of a research team at Dartmouth University wrote last week in the Los Angeles Times, “American men have been engaged in prostate cancer screening for almost two decades with relatively little effort given to communicating the trade-off between the benefit and the potential harm of unnecessary treatment. The time has come to make that trade-off clear.” So far no one has accused Dr. Welch of establishing death panels, but if he keeps advocating for enhanced communication and patient choice, he may have reason to worry.

Powerful forces resist bestowing authority on individuals to choose appropriate medical care for themselves. Behind the hyperbole about “death panels” lies a more nuanced attack on advanced directives themselves. The language is more subtle but its intent is unmistakably patronizing. These advocates would “protect senior citizens,” from their own stated wishes, claiming seniors are “vulnerable people,” “easily susceptible to pressure,” and not capable of making important decisions. This line of thinking asserts advance directives should be “only one factor a doctor takes into consideration” because the patient who wrote it “didn’t know at the time what it would be like.” Some even assert your living will should be ignored completely because others know what’s best for you. Father knows best.