Advance healthcare directive: Difference between revisions - Wikipedia

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An '''advance healthcare directive''', also known as '''living will''', '''personal directive''', '''advance directive''', '''medical directive''' or '''advance decision''', is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.

A living will is one form of advance directive, leaving instructions for treatment. Another form is a specific type of [[power of attorney]] or [[health care proxy]], in which the person authorizes someone (an agent) to make decisions on their behalf when they are incapacitated. People are often encouraged to complete both documents to provide comprehensive guidance regarding their care, although they may be combined into a single form.<ref>{{cite web|last1=Larson|first1=Aaron|title=How a Power of Attorney Works|url=https://www.expertlaw.com/library/estate_planning/power_of_attorney.html|website=ExpertLaw.com|publisher=ExpertLaw|access-date=4 May 2017}}</ref> An example of combination documents includes the [[Five Wishes]] in the United States. The term ''living will'' is also the commonly recognised vernacular in many countries, especially the U.K.<ref>Docker, C. ''Advance Directives/Living Wills'' in: McLean S.A.M., "Contemporary Issues in Law, Medicine and Ethics," Dartmouth 1996</ref> The legality of [[consent|advance consent]] for advance healthcare directives depends on [[jurisdiction]].<ref name="b306">{{cite journal | last=Oliver | first=Jill | last2=Petropanagos | first2=Angel | last3=Chidwick | first3=Paula | title=Final consent, advance consent and alleviating suffering in frail adults requesting MAiD | journal=Canadian Medical Association Journal | volume=194 | issue=18 | date=9 May 2022 | issn=0820-3946 | pmid=35534025 | pmc=9259404 | doi=10.1503/cmaj.81239 | pages=E652–E652}}</ref>

==Background==

Advance directives were created in response to the increasing sophistication and prevalence of medical technology.<ref>{{cite journal | author = Childress J | year = 1989 | title = Dying Patients. Who's in Control? | journal = Law, Medicine and Health Care| volume = 17 | issue = 3| pages = 227–228 | doi = 10.1111/j.1748-720x.1989.tb01099.x | s2cid = 57182781 }}</ref><ref name="ReferenceA">Choice in Dying (now: Partnership in Caring). ''Choice in Dying: an historical perspective.'' CID 1035-30th Street, N.W. Washington, DC. 2007</ref> Numerous studies have documented critical deficits in the medical care of the dying; it has been found to be unnecessarily prolonged,<ref>Callahan, D. ''Setting Limits'' Simon & Schuster. 1983</ref> painful,<ref>{{cite journal | year = 1995 | title = A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) | journal = Journal of the American Medical Association | volume = 274 | issue = 20| pages = 1591–1598 | doi = 10.1001/jama.1995.03530200027032 }}</ref> expensive,<ref>{{cite journal | author = Lubitz J, Riley GF | year = 1993 | title = Trends in Medicare payments in the last year of life | journal = New England Journal of Medicine | volume = 328 | issue = 15| pages = 1092–1096 | doi = 10.1056/nejm199304153281506 | pmid = 8455667 | doi-access = free }}</ref><ref>{{cite journal | author = Scitovsky A.A. | year = 1994 | title = The High Cost of Dying, Revisited | journal = Milbank Quarterly | volume = 72 | issue = 4| pages = 561–591 | doi = 10.2307/3350356 | jstor = 3350356 | pmid = 7997219 }}</ref> and emotionally burdensome to both patients and their families.<ref>{{cite journal | year = 1991 | title = Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders. Council on Ethical and Judicial Affairs | journal = Journal of the American Medical Association | volume = 265 | issue = 14| pages = 1868–1871 | doi = 10.1001/jama.265.14.1868 }}</ref><ref>{{cite journal | author = McGrath RB | year = 1987 | title = In-house Cardiopulmonary resuscitation -- after a quarter of a century | journal = Annals of Emergency Medicine | volume = 16 | issue = 12| pages = 1365–1368 | doi = 10.1016/s0196-0644(87)80420-1 | pmid = 3318591 }}</ref>

==Living will==

[[Image:Refusal of treatment form.jpg|thumb|left|Refusal of treatment form]]

The living will is the oldest form of advance directive. It was first proposed by an [[Illinois]] attorney, [[Luis Kutner]], in a speech to the Euthanasia Society of America in 1967<ref>Benzenhöfer, U, Hack-Molitor, G (2009). Luis Kutner and the development of the advance directive (living will). Frankfurt (Main). [http://publikationen.ub.uni-frankfurt.de/frontdoor/index/index/docId/34515].</ref> and published in a law journal in 1969.<ref>{{cite journal|last1=Kutner|first1=Luis|title=Due Process of Euthanasia: The Living Will, a Proposal|journal=Indiana Law Journal|date=1969|volume=44|issue=4|pages=534–554|url=https://www.repository.law.indiana.edu/ilj/vol44/iss4/2/|access-date=22 March 2018}}</ref> Kutner drew from existing estate law, by which an individual can control property affairs after death (i.e., when no longer available to speak for himself or herself) and devised a way for an individual to express their health care desires when no longer able to express current healthcare wishes. Because this form of "will" was to be used while an individual was still alive (but no longer able to make decisions), it was dubbed the "living will".<ref>{{cite journal | author = Alexander G.J. | year = 1991 | title = Time for a new law on health care advance directives | journal = Hastings Center Law Journal | volume = 42 | issue = 3| pages = 755–778 }}</ref> ~~In the~~The U.S.~~, The~~ [[Patient Self-Determination Act]] (PSDA)<ref>Patient Self-Determination Act U.S.C.A. 1395cc & 1396a, 4206-4207, 4751, Omnibus Budget Reconciliation Act of 1990, P.L:.b 101-508 (101ST Cong. 2nd Sess. Nov. 5, 1990) (West Supp., 1991).</ref> went into effect in December 1991, and required healthcare providers (primarily hospitals, nursing homes, and home health agencies) to give patients information about their rights to make advance directives under state law.<ref>Docker, C. Advance Directives/Living Wills in: McLean S.A.M., Contemporary Issues in Law, Medicine and Ethics," Dartmouth 1996:182.</ref>

A living will usually provides specific directives about the course of treatment healthcare providers and caregivers are to follow. In some cases a living will may forbid the use of various kinds of burdensome medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. The living will is used only if the individual has become unable to give informed consent or refusal due to incapacity. A living will can be very specific or very general. An example of a statement sometimes found in a living will is: "If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued."

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Living wills proved to be very popular, and by 2007, 41% of Americans had completed a living will.<ref>Charmaine Jones, With living wills gaining in popularity, push grows for more extensive directive, ''Crain's Cleveland Business,'' August 20, 2007.</ref> In response to public needs, state legislatures soon passed laws in support of living wills in virtually every state in the union.<ref name="American Bar Association 1991">American Bar Association. ''Patient Self-Determination Act: State Law Guide.'' American Bar Association Commission on Legal Problems of The Elder. August 1991.</ref>

However, as living wills began to be better recognized, key deficits were soon discovered. Most living wills tended to be limited in scope<ref name="Annas, GJ 1210">{{cite journal | author = Annas GJ | year = 1991 | title = The Health Care Proxy and the Living Will | journal = New England Journal of Medicine | volume = 324 | issue = 17| pages = 1210–1213 | doi=10.1056/nejm199104253241711| pmid = 2011167 | url = https://scholarship.law.bu.edu/faculty_scholarship/1297 }}</ref> and often failed to fully address presenting problems and needs.<ref>{{cite journal | author = Hashimoto DM | year = 1983 | title = A structural analysis of the physician-patient relationship in no-code decision-making | url =https://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=6845&context=ylj | journal = Yale Law Journal | volume = 93 | issue = 2| pages = 362–383 | doi=10.2307/796311| jstor = 796311 | pmid = 11658880 }}</ref><ref>Hastings Center. ''Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: a report by the Hastings Center.'' [[Briarcliff Manor, NY]]: Indiana University Press. 1987.</ref> Further, many individuals wrote out their wishes in ways that might conflict with quality medical practice.<ref>{{cite journal | author = Campbell ML | year = 1995 | title = Interpretation of an ambiguous advance directive | journal = Dimensions of Critical Care Nursing | volume = 14 | issue = 5| pages = 226–235 | doi=10.1097/00003465-199509000-00001| pmid = 7656765 }}</ref> Ultimately, it was determined that a living will alone might be insufficient to address many important health care decisions. This led to the development of what some have called "second generation" advance directives<ref name="Annas, GJ 1210"/> – the "health care proxy appointment" or "medical power of attorney."

Living wills also reflect a moment in time, and may therefore need regular updating to ensure that the correct course of action can be chosen.

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Power of attorney statutes have existed in the United States since the days of "[[common law]]" (i.e., laws brought from England to the United States during the colonial period). These early powers of attorney allowed an individual to name someone to act in their stead. Drawing upon these laws, "durable powers of attorney for health care" and "healthcare proxy appointment" documents were created and codified in law, allowing an individual to appoint someone to make healthcare decisions in their behalf if they should ever be rendered incapable of making their wishes known.<ref name="AmericanBarAsso.1991">American Bar Association. ''Patient Self-Determination Act: State Law Guide.'' American Bar Association Commission on Legal Problems of the Elderly. August 1991.</ref> People will normally benefit from having both a durable power of attorney and a healthcare proxy.<ref name="ReferenceC">{{cite journal |last1=Brett |first1=AS |title=Limitations of listing specific medical interventions in advance directives. |journal=JAMA |date=14 August 1991 |volume=266 |issue=6 |pages=~~825-8~~825–8 |doi=10.1001/jama.1991.03470060087032 |pmid=1865521}}</ref><ref name="Silverman, H 1031">{{cite journal |last1=Silverman |first1=HJ |last2=Vinicky |first2=JK |last3=Gasner |first3=MR |title=Advance directives: implications for critical care. |journal=Critical ~~care~~Care ~~medicine~~Medicine |date=July 1992 |volume=20 |issue=7 |pages=~~1027~~1027–31 |doi=10.1097/00003246-31199207000-00021 |pmid=1617972|s2cid=7025389 }}</ref>

A healthcare proxy document appoints a person, the proxy, who can make decisions on behalf of the granting individual in the event of incapacity. The appointed healthcare proxy has, in essence, the same rights to request or refuse treatment that the individual would have if still capable of making and communicating health care decisions.<ref name="AmericanBarAsso.1991"/>

The appointed representative is authorized to make real-time decisions in actual circumstances, as opposed to advance decisions framed in hypothetical situations, as might be recorded in a living will. The healthcare proxy was rapidly accepted within the U.S. and authorizing legislation was soon enacted in most states.<ref name="AmericanBarAsso.1991"/>

One problem with a conventional healthcare proxy is that it may not be possible for the appointed proxy to determine what care choices the individual would have made if still capable, as healthcare proxies may be too vague for meaningful interpretation.<ref>{{cite journal |last1=High |first1=Dallas M. |title=All in the Family: Extended Autonomy and Expectations in Surrogate Health Care Decision-Making1 |journal=The Gerontologist |date=1 June 1988 |volume=28 |issue=Suppl |pages=46–51 |doi=10.1093/geront/28.Suppl.46|pmid=3139501 }}</ref><ref>{{cite journal |last1=Cohen-Mansfield |first1=J |last2=Rabinovich |first2=BA |last3=Lipson |first3=S |last4=Fein |first4=A |last5=Gerber |first5=B |last6=Weisman |first6=S |last7=Pawlson |first7=LG |title=The decision to execute a durable power of attorney for health care and preferences regarding the utilization of life-sustaining treatments in nursing home residents. |journal=Archives of ~~internal~~Internal ~~medicine~~Medicine |date=February 1991 |volume=151 |issue=2 |pages=~~289-94~~289–94 |doi=10.1001/archinte.1991.00400020053012 |pmid=1992956}}</ref> While a study comparing next-of-kin decisions on behalf of an incapacitated person, (who later recovered) found that these surrogates chose correctly 68% of the time overall.<ref name=ArchInternMed.2006>{{cite journal|title=The Accuracy of Surrogate Decision Makers: A Systematic Review|journal=Archives of Internal Medicine|quote=Conclusions Patient-designated and next-of-kin surrogates incorrectly predict patients' end-of-life treatment preferences in one third of cases.|doi=10.1001/archinte.166.5.493|pmid=16534034|volume=166|issue=5|pages=493–7|year=2006|last1=Shalowitz|first1=David I.|last2=Garrett-Mayer|first2=Elizabeth|last3=Wendler|first3=David|doi-access=~~free~~}}</ref>

===Values-based directives===

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===Psychiatric advance directives===

A '''psychiatric advance directive''' (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to ~~be suffering from~~have a [[mental disorder]] in such a way that they are deemed unable to decide for themselves or to communicate effectively.<ref>{{cite web |title=About PADs |url=https://nrc-pad.org/ |website=NRC•PAD |publisher=National Resource Center on Psychiatric Advance Directives |access-date=22 November 2021}}</ref>

A PAD can inform others about what treatment they want or ~~don't~~do not want from [[psychiatrists]] or other [[mental health professionals]], and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of [[advance health care directive]].

====Legal foundations====

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National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD.<ref>"Psychiatric Advance Directives Among Public Mental Health Consumers in Five U.S. Cities: Prevalence, Demand, and Correlates" Jeffrey W. Swanson, Marvin S. Swartz, Joelle Feron, Eric B. Elbogen, and Richard Van Dorn. The Journal of the American Academy of Psychiatry and the Law, Volume 34, Number 1, 2006</ref>

In a survey conducted of 600 [[psychiatrists]], [[psychologists]], and [[social workers]] showed that the vast majority thought advance care planning for crises would help improve ~~patients’~~patients' overall mental health care.<ref>"Clinical Decision Making and Views About Psychiatric Advance Directives" Eric B. Elbogen, Marvin S. Swartz, Richard Van Dorn, Jeffrey W. Swanson, Mimi Kim, and Anna Scheyett Psychiatric Services, Volume 57, Number 3: 350-355, March 2006</ref> Further, the more clinicians knew about PAD laws, the more favorable were their attitudes toward these practices. For instance, while most [[psychiatrists]], [[social workers]], and [[psychologists]] surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labeled with severe [[mental illnesses]], clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of ~~patients’~~patients' treatment planning.

Many clinicians reported not knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs or to help their clients develop crisis plans.

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===Australia===

The laws regarding advance directives, powers of attorney, and enduring guardianships vary from state to state. In Queensland, for example, the concept of an advance health directive is defined in the ''[[Power of attorney|Powers of attorney]] act of 1998'' and ''Guardianship and Administration act of 2000''.<ref>{{cite book |last1= Rothschild |first1= Alan |editor1-first= Dieter |editor1-last= Birnbacher |editor2-first= Edgar |editor2-last= Dahl |title= Giving Death a Helping Hand: Physician-Assisted Suicide and Public Policy. An International Perspective |series= International Library of Ethics, Law, and the New Medicine |volume= 38 |date= 5 Feb 2008 |publisher= Springer |isbn= 9781402064951 |page= 104 |chapter= Physician-Assisted Death. An Australian Perspective}}</ref> Tasmania has no specific legislation concerning advance healthcare directives.<ref>{{Cite web |url=http://advancecareplanning.org.au/advance-care-planning/for-professionals/the-law-of-advance-care-planning |title=~~Archived~~The ~~copy~~law of Advance Care Planning | Advance Care Planning |access-date=2017-02-04 |archive-url=https://web.archive.org/web/20170204171033/http://advancecareplanning.org.au/advance-care-planning/for-professionals/the-law-of-advance-care-planning |archive-date=2017-02-04 |url-status=dead }}</ref> Advance Care Planning (ACP) has been gaining prominence in Australia for its role in enhancing a patient's autonomy and as an important component of good end-of-life care.<ref>{{Cite journal|last1=Rhee|first1=Joel J.|last2=Zwar|first2=Nicholas A.|last3=Kemp|first3=Lynn A.|date=2012-02-24|title=Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews|url=https://www.publish.csiro.au/ah/AH11019|journal=Australian Health Review|language=en|volume=36|issue=1|pages=98–104|doi=10.1071/AH11019|pmid=22513028|issn=1449-8944|hdl=1959.4/unsworks_13380|hdl-access=free}}</ref>

===Canada===

[[Health Canada]] – [[Canada]]'s federal health agency – has acknowledged the need for a greater investment in [[Palliative care|palliative]] and [[hospice]] care as the country faces a rapidly growing population of elderly and terminally ill citizens.<ref>{{cite web|url=http://www.hc-sc.gc.ca/ahc-asc/minist/speeches-discours/_2014/2014_03_06-eng.php |title=Health Canada- Minister's speeches |publisher=Health Canada.ca |date=2014-02-06 |access-date=2014-11-18 |url-status=dead |archive-url=https://web.archive.org/web/20141129081757/http://www.hc-sc.gc.ca/ahc-asc/minist/speeches-discours/_2014/2014_03_06-eng.php |archive-date=2014-11-29 }}</ref>

Much of the current focus in Canada is on [[advance care planning]] which involves encouraging individuals to reflect on and express their wishes for future care, including end-of-life care, before they become terminally ill or incapable of making decisions for themselves. A number of publicly funded initiatives exist to promote advance care planning and to encourage people to appoint "[[Surrogate decision-maker|substitute decision makers]]" who make medical decisions and can give or withhold consent for medical procedures according to the patient's pre-expressed wishes when the patient becomes incapable of doing so themselves<ref>{{cite web|url=http://www.chpca.net/about-us.aspx |title=Canadian Hospice Palliative Care Association |publisher= CHPCA.net |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web|url=http://www.hpcintegration.ca/about-us.aspx |title=The Way Forward |publisher= HPC integration.ca |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web|url=http://thecarenet.ca/about-us |title=The Carenet |publisher= The Carenet.ca |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web |url=http://pallium.ca/about-us/ |title=Pallium Canada |publisher=Pallium.ca |date=2014 |access-date=2014-11-18 |archive-url=https://web.archive.org/web/20141219081109/http://pallium.ca/about-us/ |archive-date=2014-12-19 |url-status=dead }}</ref>

number of publicly funded initiatives exist to promote advance care planning and to encourage people to appoint "[[Surrogate decision-maker|substitute decision makers]]" who make medical decisions and can give or withhold consent for medical procedures according to the patient's

pre-expressed wishes when the patient becomes incapable of doing so themselves<ref>{{cite web|url=http://www.chpca.net/about-us.aspx |title=Canadian Hospice Palliative Care Association |publisher= CHPCA.net |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web|url=http://www.hpcintegration.ca/about-us.aspx |title=The Way Forward |publisher= HPC integration.ca |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web|url=http://thecarenet.ca/about-us |title=The CARENET |publisher= The CARENET.ca |date=2014 |access-date=2014-11-18}}</ref><ref>{{cite web |url=http://pallium.ca/about-us/ |title=Pallium Canada |publisher=Pallium.ca |date=2014 |access-date=2014-11-18 |archive-url=https://web.archive.org/web/20141219081109/http://pallium.ca/about-us/ |archive-date=2014-12-19 |url-status=dead }}</ref>

In 2008, The Advance Care Planning in Canada: A National Framework and Implementation Project was founded.<ref>{{cite web|url=http://www.advancecareplanning.ca/about-advance-care-planning/national-framework-for-acp.aspx |title=National Framework for advance care planning |publisher=SpeakUp |date=2014 |access-date=2014-11-18 |url-status=dead |archive-url=https://web.archive.org/web/20141128195532/http://www.advancecareplanning.ca/about-advance-care-planning/national-framework-for-acp.aspx |archive-date=2014-11-28 }}</ref> The goal was to engage healthcare professionals and educate patients

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====England and Wales====

In [[England and Wales]], people may make an advance directive or appoint a [[healthcare proxy#UK legal situation|proxy]] under the [[Mental Capacity Act 2005]]. This is only for an advance refusal of treatment for when the person lacks mental capacity; to be legally binding, the advance decision must be specific about the treatment that is being refused and the circumstances in which the refusal will apply. To be valid, the person must have been competent and must have understood the decision when they signed the directive. Where the patient's advance decision relates to a refusal of life-prolonging treatment this must be recorded in writing and witnessed. Any advance refusal is legally binding providing that the patient is an adult, the patient was competent and properly informed when reaching the decision, it is clearly applicable to the present circumstances and there is no reason to believe that the patient has changed their mind. If an advance decision does not meet these criteria but appears to set out a clear indication of the patient's wishes, it will not be legally binding but should be taken into consideration in determining the patient's best interests.<ref>{{cite web|url=http://bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/ethics/consenttoolkit_card9.pdf |title= BMA guidance|website=bma.org.uk}}</ref><ref>{{cite journal |last=Johnston |first=Carolyn |author2=Liddle, Jane|year=2007|title=The Mental Capacity Act 2005: a new framework for healthcare decision making|journal=Journal of Medical Ethics |volume=33|issue= 2|pages=94–97|url= |doi=10.1136/jme.2006.016972| pmid = 17264196 |pmc=2598235 }}</ref> In June 2010, the Wealth Management Solicitors, Moore Blatch, announced that research showed demand for Living Wills had trebled in the two years previous, indicating the rising level of people concerned about the way in which their terminal illness will be managed.<ref>{{cite web |author=LONDON (June 10, 2010) |url=http://www.jlns.com/legal-wire/2010/06/10/demand-living-wills-trebles-last-two-years |title=Demand for Living Wills trebles in the last two years |publisher=JLNS |date=2010-06-10 |access-date=2010-06-23 |archive-url=https://web.archive.org/web/20100717033050/http://www.jlns.com/legal-wire/2010/06/10/demand-living-wills-trebles-last-two-years |archive-date=17 July 2010 |url-status=dead |df=dmy-all }}</ref> According to the British Government, every adult with mental capacity has the right to agree to or refuse medical treatment.<ref>For the official guidance to doctors, see: [https://web.archive.org/web/20110809173247/http://www.gmc-uk.org/static/documents/content/End_of_life.pdf "Treatment and care towards the end of life: good practice in decision making"]. [[General Medical Council]], 2010. Although addressed to doctors, the guidance may also provide helpful information to patients and the public; see, [http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_about_this_guidance.asp]. Retrieved 2011-01-05.</ref> ~~In order to~~To make their advance wishes clear, people can use a living will, which can include general statements about wishes, which are not legally binding, and specific refusals of treatment called "advance decisions" or "advance directives".<ref>{{cite web|url=http://www.direct.gov.uk/en/governmentcitizensandrights/death/preparation/dg_10029429 |title=How to make a living will : Directgov - Government, citizens and rights |publisher=Direct.gov.uk |access-date=2010-06-23 |url-status=dead |archive-url=https://web.archive.org/web/20090718011240/http://www.direct.gov.uk/en/Governmentcitizensandrights/Death/Preparation/DG_10029429 |archive-date=2009-07-18 }}</ref>

====Germany====

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Controversy over end-of-life care emerged in Italy in 2006, when a terminally ill patient suffering from muscular dystrophy, Piergiorgio Welby, petitioned the courts for removal of his respirator. Debated in Parliament, no decision was reached. A doctor eventually honored Welby's wishes by removing the respirator under sedation.<ref>{{cite news|last1=Fisher|first1=Ian|title=Euthanasia Advocate in Italy Dies|url=https://www.nytimes.com/2006/12/21/world/europe/22italycnd.html|access-date=23 November 2017|newspaper=New York Times|date=21 December 2006}}</ref> The physician was initially charged for violating Italy's laws against euthanasia, but was later cleared. Further debate ensued after the father of a 38-year-old woman, Eluana Englaro, petitioned the courts for permission to withdraw feeding tubes to allow her to die. Englaro had been in a coma for 17 years, following a car accident. After petitioning the courts for 10 years, authorization was granted and Englaro died in February 2009.<ref>{{cite news|last1=Owen|first1=Richard|title='Right to die' coma woman Eluana Englaro dies|url=https://www.thetimes.co.uk/article/right-to-die-coma-woman-eluana-englaro-dies-mlm26hzjgq5|access-date=23 November 2017|newspaper=The Times|date=10 February 2009}}</ref> In May 2008, apparently as a result of the recent Court of Cassation's holding in the case of Englaro, a guardianship judge in Modena, Italy used relatively new legislation<ref>Law No. 6 of January 9, 2004</ref> to work around the lack of the advance directive legislation. The new law permitted a judicially appointed guardian ("amministratore di sostegno") to make decisions for an individual. Faced with a 70-year-old woman with end-stage Lou Gehrig's Disease who was petitioning the court (with the support of her family) to prevent any later use of a respirator, the judge appointed her husband as guardian with the specific duty to refuse any tracheotomy and/or respirator use if/when the patient became unable to refuse such treatment herself.<ref>Decree of Dr. Guido Stanziani, Guardianship Judge of the Tribunal of Modena, 13 May 2008.</ref>

~~====The Netherlands====~~

In the [[Netherlands]], patients and potential patients can specify the circumstances under which they would want [[euthanasia]] for themselves. They do this by providing a written [[euthanasia directive]]. This helps establish the previously expressed wish of the patient even if the patient is no longer able to communicate. However, it is only one of the factors that is taken into account. Apart from the will in writing of the patients, at least two physicians, the second being totally unrelated to the first physician in a professional matter (e.g. working in another hospital, no prior knowledge of the medical case at hand), have to agree that the patient is terminally ill and that no hope for recovery exists. {{Citation needed|date=June 2008}}

===Japan===

Advance healthcare directives are not legally recognized in Japan. According to a 2017 survey by the Ministry of Health, Labor and Welfare (MHLW), 66% of surveyed individuals supported the idea of such directives, but only 8.1% had prepared their own. The private organization Nihon Songenshi Kyōkai (Japan Society for Dying with Dignity) offers members a semi-standardized "living will" (ribingu uiru) form that is registered with the organization, though it holds no legal weight.<ref>{{cite journal|title=Deciding one's own death in advance: Biopower, living wills, and resistance to a legislation of death with dignity in Japan|journal=Contemporary Japan |date=2020 |volume=32 |issue=1|pages = 63–82|doi = 10.1080/18692729.2020.1714279|last1 = Spoden|first1 = Celia|s2cid=212897004 }}</ref>

===Korea===

Advance healthcare directives are legally recognized in Korea since 2016, when the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care was implemented in Korea, providing a broad framework for end-of-life decision-making. <ref>{{cite journal |title=Nurse roles in the advance directive system in Korea |journal=International Nursing Review|date= 2022|volume=69 | issue=2| pages = 159–166 |doi = 10.1111/inr.12683 |last1=Hwang |first1=Hyeyoung |last2=Kim |first2=Claire Junga |pmid=34115378 |s2cid=235404005 }}</ref>

===Nigeria===

Advance healthcare directives is yet to be legalised in Nigeria, and patient’s “written directives” for determining their preferences, tradition still dominates in Nigeria and the most african country. <ref>{{cite journal|author=Ojedoyin, O. E. |author2=Jegede, A. S. | title=A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan|journal=BMC Medical Ethics|date= 2022|volume=23 | issue=1| pages = 87 |doi = 10.1186/s12910-022-00825-5 |doi-access=free |pmid=36008832 |pmc=9404628 }}</ref>

===Israel===

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In [[Switzerland]], there are several organizations which take care of registering [[patient decree]]s, forms which are signed by the patients declaring that in case of permanent loss of judgement (e.g., inability to communicate or severe brain damage) all means of prolonging life shall be stopped. Family members and these organizations also keep proxies which entitle their holder to enforce such patient decrees. Establishing such decrees is relatively uncomplicated.

In 2013 a law concerning advanced healthcare directives has been voted. Every adult with testamentary capacity can redact a legal binding document declaring ~~his~~a will in the event of loss of judgement. ~~He or she~~They may also designate a natural person ~~who in the event that he or she is no longer capable of judgement should~~to discuss ~~the~~ medical procedures with the attending doctor and ~~decide~~make decisions on ~~his~~their orbehalf ~~her~~if ~~behalf~~they are longer capable of judgment.<ref>{{Cite web|url=https://www.admin.ch/opc/en/classified-compilation/19070042/index.html|title = Fedlex}}</ref>

===United States===

Aggressive medical intervention leaves nearly two million Americans confined to nursing homes,<ref>Wilkkes, JL. Nursing Home Nightmares. ''USAToday.'' August 20, 1996. 11A.</ref> and over 1.4 million Americans remain so [[medically frail]] as to survive only through the use of feeding tubes.<ref name="US Congress 1987">US Congress, Office of Technology Assessment. ''Life-Sustaining Technologies and the Elderly.'' OTA-BA-306. Washington, DC: US Gov't Printing Office. July, 1987.</ref> Of U.S. deaths, about a third occur in health care facilities.<ref>{{cite news |author= |title=A third of Americans die in hospitals, study finds |url=https://www.reuters.com/article/us-death-usa/a-third-of-americans-die-in-hospitals-study-finds-idUSTRE5A34N220091104 |work=Reuters |date=4 November 2009 |access-date=10 March 2021}}</ref> As many as 30,000 persons are kept alive in comatose and permanently vegetative states.<ref name="US Congress 1987"/><ref>{{cite journal | author = American | year = 1995 | title = Practice Parameters: Assessment and Management of Patients in the Persistent Vegetative State: Summary Statement | journal = Neurology | volume = 45 | issue = 5| pages = 1015–1018 | doi = 10.1212/wnl.45.5.1015 | pmid = 7746375 | doi-access = free }}</ref>

Cost burdens to individuals and families are considerable. A national study found that: ~~“In~~"In 20% of cases, a family member had to quit work;”", 31% lost ~~“all~~"all or most ~~savings”~~savings" (even though 96% had insurance);, and ~~“20~~"20% reported loss of [their] major source of income".”<ref>Covinsky, KE; Goldman, L; Cook, EF; etal. The impact of serious illness on patient's families. ''Journal of the American Medical Association.'' 1994;272(23):1839-1844.</ref> Yet, studies indicate that 70-95% of people would rather refuse aggressive medical treatment than have their lives medically prolonged in incompetent or other poor prognosis states.<ref>Heap, MJ; etal. Elderly patients' preferences concerning life support treatment. ''Anaesthesia.'' 1993;48:1027-1033.</ref><ref>Patrick, DL; etal. Measuring preferences for health states worse than death. ''Medical Decision-Making.'' 1994;14:9-19.</ref>

As more and more Americans experienced the burdens and diminishing benefits of invasive and aggressive medical treatment in poor prognosis states – either directly (themselves) or through a loved one – pressure began to mount to devise ways to avoid the suffering and costs associated with treatments one did not want in personally untenable situations.<ref name="ReferenceA"/> The first formal response was the living will.

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===India===

[[Supreme Court of India]] on March 9, 2018, permitted living wills and ~~passive~~withholding ~~euthanasia~~and withdrawing life sustaining treatments. The country's apex court held that the right to a dignified life extends up to the point of having a dignified death.<ref>{{cite news|url=http://www.thehindu.com/opinion/editorial/death-with-dignity/article23009854.ece|title=Death with dignity: on SC's verdict on euthanasia and living wills|date=10 March 2018|via=www.thehindu.com|newspaper=The Hindu}}</ref>

==See also==

*[[Engage with Grace]]

*[[My body, my choice]]

*[[Ordinary and extraordinary care]]

*[[Do not resuscitate]]

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* [http://www.nrc-pad.org National Resource Center on Psychiatric Advance Directives (U.S.)]

* [https://www.bma.org.uk/media/1850/bma-best-interests-toolkit-2019.pdf Best interests decision-making for adults who lack capacity], toolkit for medical professionals from the British Medical Association.

* [https://www.nhs.uk/conditions/end-of-life-care/advance-statement/ ~~patient~~Patient guidance on advance directives (U.K.)]