Common Yet Vague Living Will Language

There was a short piece in this week's Canadian Medical Association Journal praising a particular patient's living will which stated in part:

If the situation should arise in which there is no reasonable expectation of my recovery from physical or mental disability, I request that I be allowed to die and not be kept alive by artificial means or "heroic measures." I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain. I, therefore, ask that medication be mercifully administered to me to alleviate suffering even though this may hasten the moment of death.

I posted this response on the CMAJ site:

In the March 11, 2008 CMAJ issue, Belletrutti and DeKock reprint and highly commend a living will from "Edward," one of their patients. They write that "unlike many of today’s legally prepared documents, Edward’s document" gave real "insight into Edward’s views on life, death, infirmity and the burden of illness on family." It "portrayed his deep personal conviction on end-of-life issues."

In fact, Edward's living will had been professionally prepared. It was first published by distinguished bioethicists in JAMA nearly twenty- five years ago. Since then, it has been very widely reprinted as a "form" living will in both elder planning and other books and treatises.

Granted, just because Edward used a "form" living will does not mean that its language did not reflect his end-of-life treatment preferences. But this living will language does not clearly indicate what Edward’s or any patient’s preferences actually are. What physical disabilities trigger the refusal of treatment? What measures are "heroic"? It is unreasonable to expect Edward to have thought through all the possibilities much less lucidly articulate scenario-by-scenario preferences. Consequently, perhaps it is time to abandon the living will and focus instead on the appointment of substitute decision makers.