Who will make sure that others will honor your Last Wishes

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Who will make sure that others will honor your Last Wishes if they are to refuse food and fluid?

If you use a Living Will, we recommend that your Physician sign a "Physician's Order for Life-Sustaining Treatment (POLST)," and attach Document A to that signed POLST.
If you live in a community where your Emergency Medical Services responders will not recognize your physician's signed POLST, appoint someone to be your Living Will Advocate and arm them with Document B.

Document A

If your physician signs a POLST:

Authorization for the Physician who signs my POLST to also Withhold Food & Fluid:

I. General Considerations:

I may reach a point in the progression of a serious illness when I will no longer want nutrition and hydration by any route—whether its administration is considered "medical" or "artificial" because it enters my circulatory system or gastrointestinal system via tubes; or considered "non-medical" and "natural" because the route is oral; that is, I still can swallow what another person puts into my mouth.

I have discussed my values and preferences with my physicians and I have informed them about MY criteria for when I want Food & Fluid withheld on my behalf if I reach the state when I no longer possess decision-making capacity. MY criteria are NOT diagnosis-dependent, although I clearly would NOT want to continue Food & Fluid in either the Minimally Conscious State or the Permanent Vegetative State.

I expect my future treating physicians to honor this written request, but if for any reason my then-treating physician does not honor my written requests then I want my Living Will Advocate (if I have appointed one), to request a second opinion from another physician, a consultation from an ethics committee, or a judicial review.

II. Empowering Statements for My Physician to Withhold Food & Fluid

I expect my last physician to Withhold Food & Fluid and to provide me with adequate Comfort Care, including treatment for thirst, pain, agitation, and anxiety and other suffering, for the following reasons:

With adequate Comfort Care, Withholding Food & Fluid would provide a compassionate, humane method for me to avoid prolonged physical, spiritual, and existential suffering;

Withholding Food & Fluid would reduce the time of emotional suffering by my family members and close friends as they wait for me to pass on from a disease from which I have no, or a very unlikely chance of recovering;

Withholding Food & Fluid would limit the bad memories my family members (especially younger ones) might have of me in a state of indignity, when most of my energy was devoted to medical care, or when I was totally dependent on others for basic care, or when I lacked control over my body functions, or when I could no longer interact with other human beings in a positive and meaningful way;

Withholding Food & Fluid would reduce the consumption of financial resources of my personal estate and/or of society so that these resources can be put to better use than to merely prolong my biologic existence;

Refusal of Food & Fluid is NOT a "cruel sentence to die by starvation and dehydration," but rather MY preferred way to Permit Natural Dying.

My mental state as I write this statement:

I understand the choice to forgo nutrition and hydration compared to its alternatives. I appreciate the consequences of this choice for myself and others. I have used reasoning to authorize my Living Will Advocate to let my future physician know that I want him or her to Withhold Food & Fluid on my behalf. I considered this decision long enough to express consistently my preference for this way to hasten the process of my dying. This choice, which I fully discussed with my physician, is consistent with my life-long values, made voluntarily without undue influence, or my feeling I am a burden on others, or the result of an acute depression. [My current physician may wish to offer her opinion in her own words in my medical chart.]

To those who visit me while Food & Fluid are being Withheld, please realize the following, and if necessary, consult with my physician to appreciate the following:

Human behavior in severely brain damaged people can be confusing for those not trained in Neurology. Primitive reflexes from the still functioning lower brain may appear similar to the purposeful movements from higher brain functions that are meant to communicate intent. To help reduce confusion, I provide some examples below but the actual circumstance may be different so let me be clear: I trust my physician to decide whether or not I have reached the point when I would want to Withhold Food & Fluid.

A. Even if I moan and "an interested party" argues that I appear to be suffering, my physician should decide whether I should receive only Comfort Care (including medications for thirst, pain, insomnia and agitation) instead of resuming administration of Food & Fluid.

B. If I seem to enjoy ice chips or if I move my head toward a spray of water, and "an interested party" argues that I appear to be thirsty, I trust my physician to decide whether I should receive only Comfort Care (especially to the mouth care) rather than administration of fluid.

The words I am writing now express my durable wishes as I currently possess the mental capacity to make medical decisions. If in the future, I no longer can communicate a choice, I do not want an "interested party" to argue that my reflexive behavior indicates that I have changed my mind. Instead, I trust my physician to decide. I also do not want an "interested party" to argue that my wishes would change based on a subsequent edict by a political or religious leader. Instead, I trust my physician to decide. If I have made a mistake in granting this authority to my physician, I will accept the consequences. I prefer this alternative to granting other individuals the opportunity to challenge my physician's authority since, when it comes to making end-of-life decisions, To Delay is To Deny.

[I may add specific examples from my personal experience, or from reactions to movies, books, plays, or newspaper or magazine articles, to support my wish that my physician Withhold Refuse Food & Fluid, including knowing someone who remained unconscious for a very long time before they died, or my definite feelings about the highly publicized cases of Terri Schiavo, Karen Ann Quinlan, Nancy Beth Cruzan, or Robert Wendland.]

Document B: If you live in a community where your Emergency Medical Services responders will not recognize your physician's signed POLST, and you appoint another person to be your Living Will Advocate:

To Authorize My Living Will Advocate to Ask My Physician to Withhold Food & Fluid (BASIC FORM-LWA):

Authorization for My Living Will Advocate to Request My Physician to Withhold Food & Fluid

I. General Considerations:

I have discussed my values and preferences with my designated Living Will Advocates and I have informed them about MY criteria for when I want them to ask my physician to withhold nutrition and hydration on my behalf since then, I will no longer possess decision-making capacity. MY criteria are NOT diagnosis-dependent, although I clearly would NOT want to continue Food & Fluid in either the Minimally Conscious State or the Permanent Vegetative State.

I expect my Living Will Advocate (and alternates) to request that my future treating physicians respond to my written requests in my Living Will, and if for any reason my then-treating physician does not honor my written requests (in my Living Will Advocate's opinion), my Living Will Advocate may request a second opinion from another physician, a consultation from an ethics committee, or a judicial review.

II. Empowering Statements for My Living Will Advocate to Ask My Physician to Withhold Food & Fluid on My Behalf

I expect My Living Will Advocate Proxy to ask my last physician to Withhold Food & Fluid and to provide me with adequate Comfort Care, including treatment for thirst, pain, agitation, and anxiety and other suffering, for the following reasons:

With adequate Comfort Care, Withholding Food & Fluid would provide a compassionate, humane method for me to avoid prolonged physical, spiritual, and existential suffering;

Refusal of Food & Fluid is NOT a "cruel sentence to die by starvation and dehydration," but rather MY preferred way to Permit Natural Dying.

My mental state as I write this statement:

I understand the choice to forgo nutrition and hydration compared to its alternatives. I appreciate the consequences of this choice for myself and others. I have used reasoning to authorize my Living Will Advocate to let my future physician know that I want him or her to Withhold Food & Fluid on my behalf. I considered this decision long enough to express consistently my preference for this way to hasten the process of my dying. This choice, which I fully discussed with my Living Will Advocates, is consistent with my life-long values, made voluntarily without undue influence, or my feeling I am a burden on others, or the result of an acute depression.

To those who visit me in the future, please realize, and consult with my Living Will Advocate to appreciate the following:

Human behavior in severely brain damaged people can be confusing for those not trained in Neurology. Primitive reflexes from the still functioning lower brain may appear similar to the purposeful movements from higher brain functions that are meant to communicate intent. To help reduce confusion, I provide some examples below but the actual circumstance may be different so let me be clear: I trust my Living Will Advocate to consult with my physician who will decide whether I have reached the point when I would want to Withhold Food & Fluid.

The words I am writing now express my durable wishes as I currently possess the mental capacity to make medical decisions. If in the future, I no longer can communicate a choice, I do not want an "interested party" to argue that my reflexive behavior indicates that I have changed my mind. Instead, I trust my Living Will Advocate to consult with my physician who will decide. I also do not want an "interested party" to argue that my wishes would change based on a subsequent edict by a political or religious leader. Instead, I trust my Living Will Advocate to consult with my physician who will decide. If I have made a mistake in granting this durable authority to my Proxy, I will accept the consequences. I prefer this alternative to granting other individuals the opportunity to challenge my physician's authority since To Delay is To Deny.

Recommended: Add specific examples from your personal experience, or from your reactions to movies, books, plays, or newspaper or magazine articles, to support your wish that your physician decide to Withhold Food & Fluid. Perhaps you knew someone who remained unconscious for a very long time before they died, or you had definite feelings about the highly publicized cases of Terri Schiavo, Karen Ann Quinlan, Nancy Beth Cruzan, or Robert Wendland. You may also have had feelings about a movie where an end-of-life choice was an important theme.

Caring Advocates: to plan and honor end-of-life decisions

Who will make sure that others will honor your Last Wishes if they are to refuse food and fluid?