Code Three

Friday, July 22, 2005

Advance Directives, Part Three: State Laws

This is part three of a three-part series on the legal instrument called an Advance Directive. You may have heard of the Advanced Directive by other names, like "DNR" (Do Not Resuscitate order), or "Living Will", but they're all essentially the same instrument, and that's what we're talking about here. You can find the first part here, and the second part here.

The first post in this series talked about why you should have an Advance Directive, and the second discussed the issues from the EMS provider's perspective. This post links to the latest and greatest law from each state on what goes into an Advance Directive.

One final point: Advance Directive laws vary from state to state. Don't assume that what's valid in California will be valid in New York, and vice versa.

Thanks for reading, and click on your state in the list below to find out what its Advance Directive requirements are.

[ A-L | M-Z ]

Advance Directives, Part Two: The EMS Perspective

This is part two of a three-part series on the legal instrument called an Advance Directive. You may have heard of the Advanced Directive by other names, like "DNR" (Do Not Resuscitate order), or "Living Will", but they're all essentially the same instrument, and that's what we're talking about here. You can find the first part here, and the third part here.

The first post in this series talked about why you should have an Advance Directive. This one talks about the other side of the Advance Directive: the EMTs and paramedics who respond to a 911 call.

Understanding EMS Priorities Versus Your Priorities

In EMS, we have a fairly simple mandate: keep you alive, and get your rear end into a hospital, preferably a big, well-equipped one. Your wishes, in terms of what you might or might not want "done" to you, don't enter into the equation unless those wishes are explicitly enumerated in a (legally binding) Advance Directive. Unless we have something in writing (witnessed and notarized) that tells us otherwise, we assume you want us to move heaven and earth to save you.

The Dark Side Of Saving Your Life

As I was saying, unless you have a properly witnessed and notarized Advance Directive (not a copy) at your bedside or on your person, we're going to do everything we can to save you. More importantly, we are legally bound to do so: that means taking the stereotypical heroic measures. "Heroic measures", in this context, tends to mean:

CPR, which, when done correctly, often breaks ribs and sometimes the sternum.
Aggressive cardiac interventions, including defibrillation, cardiac monitoring, and lots of powerful drugs.
Aggressive intravenous measures, up to and including central lines.
Other invasive treatments, potentially including chest tubes and endotracheal intubation.

Why? Because we're legally bound to do so. Under the law, we must take all actions available to us unless a legally binding Advance Directive specifies otherwise. If we don't do everything within our powers, we can (and will) be brought up on charges, including abandonment and professional negligence.

Why Can't My Family Tell You Not To Do These Things?

Well, your family can tell us not to do these things. They can also tell us that you don't wish them to be done. They can tell us just about anything.

Unfortunately, we're not going to listen to your family: we can't. Without proof of your wishes, in the form of an Advance Directive, we're legally bound to act as if you wanted all lifesaving measures to be taken. That's the law, and it's notoriously inflexible on this particular point.

Also, that inflexibility makes a lot of sense. Would you want us taking someone's word for it? Especially if it was in that person's financial interest for you to die? It's not unheard of for people with a fiduciary interest in someone's death to, shall we say, elide the truth. And, no matter how much you trust the people around you, with something of this magnitude there's no downside to drawing up a legal document. Everyone wins: you get insurance that your wishes are followed, and they don't have to make potentially catastrophic decisions.

Fundamentally, if you're incapacitated, your Advance Directive is the only legally guaranteed and viable method you have of "speaking for yourself". It, and not your family, is the only legally accepted final arbiter of the measures EMS personnel will or won't take to preserve your life.

Where To Keep It

If you're going to do one Advance Directive, you should do two. And if you're going to do two, hell, make three. Seriously. There's a simple reason for this: you want the Advance Directive physically present with you.

I recommend getting valid Advance Directives made up in a wallet size and carrying one with you at all times, as well as having a valid Advance Directive both in a safe place (like, for instance, at your attorney's office) and in an easily located place next to your bed, very clearly marked.

The reason for all this precaution? An Advance Directive doesn't do you any good if it can't be found. It doesn't matter if you've got one under the bed, and it just can't be found at the moment. Our work is time-critical, and unless you're waving a legal Advance Directive in our faces, we're going to be going all-out to salvage as much of the Golden Hour as we can.

Next: State By State

In the final installment of this series, you'll find links to each state's Advance Directive laws.

Thursday, July 21, 2005

Advance Directives, Part One: Why Have One?

This is part one of a three-part series on the legal instrument called an Advance Directive. You may have heard of the Advanced Directive by other names, like "DNR" (Do Not Resuscitate order), or "Living Will", but they're all essentially the same instrument, and that's what we're talking about here. You can find the first part right by continuing to read, the second part here, and the third part here.

My Position

Let's get this right out front: as far as I'm concerned, if you're currently breathing, you need an advance directive. That's my story, and I'm sticking to it.

If you're like me, the last thing you want is to wind up becoming the next Terri Schiavo. No matter what side of the issue you were on, that entire situation redefined "debacle", from soup to nuts.

The good news is that the Schiavo nightmare is an avoidable problem: with a little bit of footwork and a good lawyer, you can make sure it doesn't happen to you.

What Is An Advance Directive?

Cribbing shamelessly from the excellent overview at familydoctor.org:

"An advance directive tells your doctor what kind of care you would like to have if you become unable to make medical decisions (if you are in a coma, for example). If you are admitted to the hospital, the hospital staff will probably talk to you about advance directives.

A good advance directive describes the kind of treatment you would want depending on how sick you are. For example, the directives would describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are permanently unconscious. Advance directives usually tell your doctor that you don't want certain kinds of treatment. However, they can also say that you want a certain treatment no matter how ill you are.

Advance directives can take many forms. Laws about advance directives are different in each state. You should be aware of the laws in your state."

Isn't That A "Living Will"?

Well, sort of. A Living Will is a flavor of Advance Directive, usually more limited in its application to situations where you're terminally ill. Crucially, in most cases, a Living Will doesn't allow you to select an agent who can act on your behalf. At first blush, this doesn't seem all that large an issue: after all, the Living Will specifies your wishes, so why would you need someone to act on your behalf?

Well, here's why: Living Wills are a black-and-white solution to a big, big gray area. The thing about emergency medical care (and even end-of-life care) is that there are an awful lot of possible options for almost every situation. In theory, you could enumerate every one of them in your Living Will, if you wanted it to have a Table of Contents, Index, and Cliffs Notes. But, in practice, you really want your Advanced Directive to be both clear and flexible: you want absolute clarity on who can make the decisions, but you want to give that person as much leeway as possible to act on your behalf when something unanticipated occurs.

One big caveat: I'm making the line between Living Wills and other Advance Directives seem much clearer than it is: in a lot of states, there's little or no semantic distinction between the two, which is why you need a good lawyer for these things.

Why Should I Have An Advanced Directive?

Disclaimer: I am not a lawyer. I don't even play one on television. Nothing I write here should be construed as any kind of advice: you'd do better asking your beagle.

Anyway. As I said at the top of this post, I don't think anyone wants to have the kind of thing that happened to Terri Schiavo happen to them: a sustained legal wrangle between family members while they lie in a coma. While I think most of us would like to believe that kind of mudslinging grudge match would never happen in our family, my practical experience with families in the immediate aftermath of a drawn-out death tells me otherwise. People behave oddly when they're grieving, and even the most closely-knit family can fracture when there's enough emotional stress involved. And especially when there's money involved: simple venality and major emotional stress make a pretty volatile cocktail.

That's the first part. The second part (and for some of you the more important part) is that a well-crafted Advance Directive allows you, instead of the local protocols, to determine what measures will be taken to "keep you alive". I put "keep you alive" in quotation marks because when it comes right down to it, the EMS-in-the-field definition of "alive" is almost certainly much, much looser than yours.

In EMS, "alive" generally means the following two conditions:

Ventilation through an open airway, with or without artificial assistance.
Perfusion (the maintenance of a blood supply to a given tissue), with or without artificial assistance.

While we strive for a far better outcome (we want you talking to us and intact in your wits), those two criteria are the minimum standard for us to get you in the ambulance and on the way to the trauma center.

You'll notice that I didn't discuss mental status anywhere in that definition. And that's where we start to see the echoes of Florida. Having you cognitively intact is a major goal in EMS, but it's not one of our critical criteria. Put another way, if you're not breathing and perfusing, it won't matter a tinker's damn what we do for you: you're going to be dead soon. So the preservation of breathing and circulation are our first priorities.

Next: The EMS Perspective

In the second part of this series, I'll talk about the legal obligations of the EMS system, and why we do what we do.