Understand Advance Directives, Living Wills, & Letter of Wishes for Medical Care
Advance Directive is the term used in British Columbia for a legally binding document that your healthcare teams and substitute decision makers must follow when you are not able or are incapable of speaking for yourself.
Living Wills are non-legally binding documents that states your preferences for healthcare and treatment. It often does not go into depth about your values and beliefs.
Letter of Wishes for Medical Care is sometimes called a “Basic Advance Care Plan”. It is also non-legally binding and does state your values and beliefs.
This article is an outline between the pros and cons of these documents.
Advance Directive
This is the term used in British Columbia for a legally binding document that your healthcare teams and substitute decision makers must follow when you are not able or are incapable of speaking for yourself. It must apply directly to your health care. It is only in place while you are still alive.
Consider this document when you have preferences for care that are not open to discussion, and you will not change your mind about, such as:
Not to have CPR or under what circumstances. This is outlined in detail in the education article, Understanding Resuscitation and Understand the Terms Used in Resuscitation & End of Life.
Refusal of blood products.
Refusal of spoon feeding or tube feeding and under what circumstances.
When a legally-binding Advance Directive might be important:
You are alone and have no one to speak for you.
You feel you can’t have conversations with those you love, especially those who will be making decisions for you when you can’t speak for yourself.
The people who know what you want not might be available in a time of crisis. Emergency health-care treatments might proceed until they can be contacted.
Or they might panic and will ask for health-care treatments (such as resuscitation), even though that is something you have decided you don’t want.
“If you have both a representation agreement and an advance directive and want your advance directive to be followed by your health care provider without your representative being asked for a decision, then you must state this in your representation agreement.”
~ BC Ministry of Health, My Voice, Advance Care Planning, February 2020
An Advance Directive can carry consequences you had not considered. Be very cautious of backing your healthcare team and substitute decision makers into corners and, wherever possible, give them latitude in decision making in the heat of a crisis.
Manny was a healthy 84-year-old having day surgery for a simple abdominal hernia repair. Upon admission he presented his Advance Directive and on it he had stated, “No form of resuscitation under any circumstances.” He reinforced this verbally with his nurse and his surgeon. His surgery went well, and he was ready to go home. His nurse gave him a cheese sandwich and he choked on it. His nurse was not able to give him the Heimlich Manoeuvre because it is a form of resuscitation. He died completely unnecessarily. It caused great distress to his nurses and doctors and, especially, for his family.
If Marvin had simply stated, “No CPR,” it would not have precluded other forms of resuscitation.
Be cautious with statements that can back your loved-one into corners. For example, “Never put me in a nursing home.” Your loved-ones might not have a choice due to your safety and financial considerations of private home care. Be careful with statements like, “Never spoon feed me or give me a tube feed,” as there might be circumstances in which short-term feeding may allow you to recover. Instead, consider writing a statement about when you would want these treatments discontinued.
Living Wills
This is a non-legally binding document that states your preferences for healthcare and treatment. It often does not go into depth about your values and beliefs. Living Wills have fallen out of favour in the legal community because they are not ‘legal’ under the Health Care Consent Act. If you have a Living Will your healthcare teams will take under advisement, but they are not bound by. It is not a term we will be using here.
Letter of Wishes for Medical Care
This is sometimes called a “Basic Advance Care Plan”. It is also non-legally binding and does state your values and beliefs.
There are important reasons to have a non-legally binding document as it allows your healthcare team and decision makers to make decisions in real time with vital information in front of them, while keeping your preferences, values and beliefs in mind. Letter of Wishes for Medical Care is the term that we will use here.
Letters of Wishes can be as simple or detailed as you want to make them. They can be re-written frequently as your health declines and your preferences for treatment change. It does not need to be witnessed – merely signed and dated. Like a Living Will, it will be taken under advisement by your substitute decision maker and healthcare teams.
Joshua was 87 years-old and was about to undergo a complex surgery. While there was a good chance he would make a full recovery and lead a normal life, there was also a significant chance that he would have a stroke during surgery or the doctors would not be able to get him off the ventilator afterward. Despite the potentially life-threatening consequences, he chose to go ahead with the surgery because, as it was, he had no quality of life.
Prior to surgery, he wrote a very simple Letter of Wishes, stating: “If I can’t hold my grandchildren, if I can’t go out in my garden, and if I can’t walk out of this hospital on my own power, I don’t want to live.”
This directive didn’t restrict his healthcare team in any way about the treatment and care to provide him and it was also very clear about what he did and did not want his life to look like.
Things did not go well during the surgery and his team were not able to wean him from the ventilator. His brain and other organs began to fail. Ongoing consultations went on with his family and when it was clear that he would never be able to leave the hospital and they chose to discontinue life support. They felt no guilt or complex grief. His simple sentences were a tremendous gift.
