… two methods, working together
Dr Quill’s book on voluntarily stopping eating and drinking frequently refers to values. But knowing someone “cares passionately about death with dignity” will not always help the health care team, or the proxy, decide on the particular course or degree of palliative care from a panoply of end-of- life options. If the directives are not specific enough they may legally invalid. As a brief reminder, here is the letter from the editor of our print magazine which was published in the British Medical Journal. (1)
Values histories are more useful than advance directives
Winter and Cohen recognise one of the problems with advance directives when they correctly state: “The advance refusal of treatment is legally binding provided certain conditions are met …. A problem still exists unless they are precisely worded.” (2)
Traditional advance directives are sometimes becoming less useful, partly as a result of lack of data on when treatment becomes futile in different clinical scenarios. When advance directives were first introduced, the application of standard “heroic measures,” often without reasonable expectation of result was far more common than it is today. In that situation, a general advance directive about refusing, say, cardio- pulmonary resuscitation, was an appropriate statement of common sense. The situations facing modern intensive care units are far more complex. The tendency towards precise wording in advance directives to make them legally binding has made it diflicult for them to keep up with the pace of medical technology.(3)
An alternative approach that is finding increasing favour, either as an adjunct to the advance directive or as a stand alone instrument, is the “values history” Values histories relate to the declarant’s values rather than instructions. Patients’ values are recorded as a basis for decisions on medical treatment (rather than including explicit instructions on specific treatments).
They identify core values and beliefs in the context of terminal care that are important to the patient.”(4,5)
Values histories take a goal based rather than prescriptive approach, giving guidance on a policy to be implemented rather than the medical means to the end. The legal persuasiveness of them is less strong, but they may be useful adjuncts when a person is seeking to have an advance refusal respected or they may provide valuable guidance in their own right.(6) In general, the trend towards greater use of values in advance statements is more useful to patients and intensive care doctors than is the trend towards increasingly specific wording of treatments to be refused. Use of values histories should therefore be encouraged.
(Dr Quill’s book, Voluntarily Stopping Eating and Drinking, A Compassionate, Widely Available Option for Hastening Death, edited by Timothy E. Quill, Paul T. Menzel, Thaddeus M. Pope, and Judith K. Schwarz, is available from Oxford University Press and Amazon)
(1) BMJ 1999;319:306-8.
(2) Winter R, Cohen S, ABC of intensive care: withdrawal of treatment.
(3) Docker C, Living wills/advance directives. In: McLean S, ed. Contemporary issues in law, medicine and ethics. Aldershot: Dartmouth, 1996:179-214.
[full chapter now made free online for our readers]
(4) Gibson J, Values history focuses on life and death decisions. Med Ethics 1990;5:1-2, 17.
(6) Docker C, Living wills. In: Finance and law for the elderly client. London: Butterworths-Tolley.
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