# Living will



## Itchy54 (Feb 12, 2012)

My father suffered a stroke last week. I am his POA, enduring, and I very mistakenly thought this included decisions regarding health issues. I am mad that I didn't look into this more and a little embarrassed. I found out that my dad does not have a living will and so I post this question, who gets to make medical decisions if there is no living will in place?

I will get information next week when I go back to see him in the hospital but am interested if someone has gone through this and can give some advice.

Dad is slowly getting some speech back and we hope he can walk again.....time will tell.


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## rikk (May 28, 2012)

Fwiw ... years ago when my mom took a fall, I was called in as next of kin to approve/sign for surgery.


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## carverman (Nov 8, 2010)

You being his son, or another family member will have to make those decisions for him. 
Read section 3: POWER OF ATTORNEY FOR PERSONAL CARE


Here is the full information document on Living wills and POA for Ontario. 
http://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/livingwillqa.pdf

Depending where your father lives, other provinces should probably be similar in what needs to be done.

*If I don’t make a Power of Attorney or a “living will”, will the government 
automatically step in if I can’t manage my own affairs?*



> No. In these circumstances a family member has the right to make your health
> care decisions or apply to become your “guardian” of property.
> Alternatively, someone else – such as a close friend - could apply to act for you in these
> matters.
> ...


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## hystat (Jun 18, 2010)

when my parents reached the end, no one asked to see our paperwork. I suspect if my siblings and I had been contradicting each other, they would have asked to see the documents.


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## heyjude (May 16, 2009)

Sorry to hear about your Dad. I hope he recovers to enjoy some more time. 

A key question is whether your father is receiving any form of artificial life support, such as mechanical ventilation. Your OP suggests that he is not. If his care consists of nursing support and medical interventions, things will evolve as they evolve. If he is in the ICU with an endotracheal tube attached to a ventilator and unstable blood pressure, that is more complicated. Decisions may have to be made to continue this invasive treatment or not. 

As a physician, I can tell you that we really appreciate it when competent adults have written living wills, assuming they are clear. The majority of people do not have them. So when a patient is rendered unable to express his or her desires, we have to rely on family members' interpretations of what he or she would want. The next of kin takes priority. However, things become very difficult when family members disagree. On occasion, a "daughter from California" flies in and demands that "everything" be done, even if the spouse and other siblings all agree that Mom or Dad would want comfort care. This is a nightmare scenario where everyone loses and the conflict can destroy a family. 

Good communication between all parties is essential. If your father is able to express himself, his wishes should be honoured. Medical staff and family need to meet as a team, often several times, and sometimes religious advisers can contribute. I have found that this is a process, not a single conversation. It often takes time for the patient's prognosis to become clear and for everyone involved to reach a consensus.


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## Itchy54 (Feb 12, 2012)

Thank you all so much for your replies.
heyjude, you hit the nail on the head regarding family. My four brothers have been nothing short of ugly. I think we may have finally all calmed down. I hope to discuss this issue with my father when I visit again next week. our family is all across Canada and that makes things difficult, I am the closest and it's a four hour drive over the mountain passes of beautiful bc....I will certainly make sure things are in place before we leave in December.

thanks again


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## heyjude (May 16, 2009)

You're welcome, itchy. 

About living wills (aka advance directives): make sure that what you write is easy to interpret. If you don't want to be ventilated, say so. If you don't want dialysis, say so. If you want everything the ICU can offer, write that you want full intensive care. If you have an opinion about tube feeding, write it down. But please don't write "do everything reasonable". Your idea of reasonableness may be completely different from mine. That kind of vagueness makes an advance directive worse than useless IMHO.


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## OhGreatGuru (May 24, 2009)

If there are five siblings who can't agree now, that makes things very difficult for both the medical system and the legal system. And it will get worse if one sibling makes a critical decision that other(s) disagree with without proper authority. This could be a family feud in the making. If your father is well enough to express his wishes, and understand what he is signing, get a Power of Attorney for Personal Care ASAP.


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## Eder (Feb 16, 2011)

Thanks for the info heyjude! I'm going to have a heart to heart with my wife & kids about my wishes.


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## Karen (Jul 24, 2010)

Heyjude, can you please answer a question for me. I'm a resident of BC, and I have signed a Representation Agreement prepared by my lawyer. I know it gives my two daughters the right to make health decisions for me if I become incapable of making them for myself. My daughters and I have discussed my wishes thoroughly, and I have no doubt that they will honour my wishes. But what I don't know is if the rights given by this document include things that would end my life, such as unplugging life- support equipment. If not, is it possible to do that in BC?

It's my understanding (but I may be wrong about this) that in BC the term "living will" is a layman's term expressing one's wishes, but that, if there are disagreements between the children involved, it has no legal status, and a Representation Agreement would take precedence - is that correct?

Thanks for any help you can give me.


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## cheech10 (Dec 31, 2010)

Here's the Ontario take (where I practice):

- power of attorney for personal care is the situation you are describing, where your daughters have been delegated to make decisions on your behalf if you are incapacitated
- if no power of attorney exists, there is a hierarchy of substitute decision makers that will be asked to make decisions, usually the order is POA, then spouse, then children, then other relatives
- the POA can make decisions that would result in end of life, like withdrawal of life support
- a living will or advance directive provides instruction to the healthcare providers and SDM/POA, but the SDM/POA usually has the final word. Often advance directives are written in general terms and there is some leeway in interpretation.
- if the SDM/POA acts discordantly with the advance directive, in Ontario at least there is a mechanism for the healthcare providers to appeal these decisions to the Consent and Capacity Board for adjudication. Some controversies with the CCB recently, but for now this is the mechanism we have.

Clearly things may be different in BC, so this is not generally applicable, but maybe it helps a bit.


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## Nemo2 (Mar 1, 2012)

heyjude said:


> So when a patient is rendered unable to express his or her desires, we have to rely on family members' interpretations of what he or she would want. The next of kin takes priority. However, things become very difficult when family members disagree. On occasion, a "daughter from California" flies in and demands that "everything" be done, even if the spouse and other siblings all agree that Mom or Dad would want comfort care. This is a nightmare scenario where everyone loses and the conflict can destroy a family.


Shortly before my late wife died, her doctor, (out of obligation, I presume), asked if I wanted her put on a ventilator.....I replied that, if it would save her life/cure her I'd do anything......if it was simply an artificial temporary prolongation of the inevitable......then nothing. (He appeared relieved.)

Luckily her mother & family concurred...(although it was my decision, (knowing it would also be hers), and I wouldn't have been swayed by counter arguments from them anyway.)

Shortly thereafter, a friend of her mother's was in a similar situation with her dying husband......she wanted to let him go, but her 40ish children felt that it was "Killing Dad" and were quite upset.......'luckily' he died before a serious family rift could develop.

From my personal perspective it's essential that one informs those who may be required to make decisions one one's behalf regarding what is wanted and what isn't wanted, (perhaps with emphasis on the latter............a neighbor on Salt Spring Island, after her husband died, had 'Do Not Resuscitate' in capital letters magnetized to her fridge door).


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## carverman (Nov 8, 2010)

Nemo2 said:


> From my personal perspective it's essential that one informs those who may be required to make decisions one one's behalf regarding what is wanted and what isn't wanted, (perhaps with emphasis on the latter............a neighbor on Salt Spring Island, after her husband died,* had 'Do Not Resuscitate' in capital letters magnetized to her fridge door*).


That isn't going to do her much good if she is in a hospital on a resuscitator.

Doctors need a LEGAL form signed by her (POWER OF ATTORNEY FOR PERSONAL CARE) and witnessed by two witnesses, of the person signing at the time of signing, and it has to be part of the living will along with the other P of A.

On the one I have; (drawn up and witnessed by my lawyer) states this:
(excluding the personal information)...

"This power of attorney is subject to following conditions and restrictions:
(a) If at any time should my treating physician indicate that I suffer from a medical condition that is classified as TERMINALLY ILL and the condition CANNOT BE REVERSED by treatment with any expectation that I could reasonably enjoy a normal life, physically and mentally.

I DIRECT that no effort be made to prolong my life aggressively, including the use of drugs, antibiotics or any other means..OR attempt to resuscitate me if my heart or lungs fail.

I further direct that in such an event, any doctors or medical personnel who are treating me or any medical facility or hospital or nursing home in which I am being treated shall confine their treatment to alleviating pain or suffering I may have at the time.


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## heyjude (May 16, 2009)

Karen said:


> Heyjude, can you please answer a question for me. I'm a resident of BC, and I have signed a Representation Agreement prepared by my lawyer. I know it gives my two daughters the right to make health decisions for me if I become incapable of making them for myself. My daughters and I have discussed my wishes thoroughly, and I have no doubt that they will honour my wishes. But what I don't know is if the rights given by this document include things that would end my life, such as unplugging life- support equipment. If not, is it possible to do that in BC?
> 
> It's my understanding (but I may be wrong about this) that in BC the term "living will" is a layman's term expressing one's wishes, but that, if there are disagreements between the children involved, it has no legal status, and a Representation Agreement would take precedence - is that correct?
> 
> Thanks for any help you can give me.


Karen, I am not a lawyer, just a physician, so please take anything I say with that in mind. I was unfamiliar with the term "representation agreement" and I looked it up here:

http://www.nidus.ca/?page_id=46

As you indicated, that gives your representative legal status in making health care decisions for you should the need arise. I also found information about living wills. Apparently that term has no legal standing in BC; if someone were to write a shopping list of what they do or do not want (often called a living will) and gave it to their legal representative, that would be helpful to the representative in implementing their wishes. The Advance Directive is the legal term for the document that expresses your wishes about health care in BC. So there are two documents that a BC resident should have: a Representation Agreement and an Advance Directive.

OK, back to your question about life ending treatments. The first thing to remember is that physician assisted suicide is illegal in Canada at this time. The law would supersede any Representation Agreement or Advance Directive. For example, if your representative told the physician to give you an overdose of pentobarbital to end your life, even if you had mentioned this in your Advance Directive, the physician would not be able to follow those instructions without risking criminal charges. 

The second thing to know is that withdrawal of ventilation is not considered assisted suicide. It is simply a change in treatment. As I used to explain to families in the ICU, the options include continuing with ventilation, etc, etc, which has (in my example) no hope of bringing your loved one back to a state of awareness, or compassionate care, which means supportive nursing and medical care that does not include invasive treatments, and quality time with family. Full intensive care was appropriate earlier, but compassionate care is indicated now and that is what the team recommends. Families make these decisions every day across Canada and physicians and ICU staff carry them out. A Representation Agreement, combined with a clear understanding and acceptance of your wishes, would, in my opinion, give your daughters the legal right to make this decision, and probably would make it easier for them to do so. 

I hope this is helpful.


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## humble_pie (Jun 7, 2009)

heyjude said:


> ... I hope this is helpful.



your posts are incredibly helpful, thank you for taking the time & trouble to post these messages. I hope many are reading them. It's exactly as if you were speaking to an audience of several hundred people in a hospital auditorium, at a conference for lay persons on contemporary approaches to end-of-life.

it's wonderful to see specific, detailed information coming from an obviously wise & compassionate treatment physician. Mille mercis encore une fois.


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## Karen (Jul 24, 2010)

Thank you, heyjude - I found your explanation very helpful. As I said, I have a Representation Agreement, but I will see my lawyer about preparing an Advance Directive.

I was very conscious when I directed my question to you that you are a doctor in BC and could only answer from that point of view, but that was exactly what I needed, and I appreciate your advice very much.


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## heyjude (May 16, 2009)

Thank you so much Humblepie and Karen for saying nice things. I'm blushing!

Now off to rewrite my own documents. Since I recently moved to BC my documents from another province will need updating.


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