OREGON DIRECTIVE TO PHYSICIANS
Directive made this
make known my desi
below and do
procedui
final
from such
3. lu
make this direc
mind, wilfully and voluntarily
under the circumstances set forth
Iness certified to be a terminal
where the application of life
of my death and where my
procedures are utilized. I
to die naturally.
such life-sustaining
and phystcianis) as the
' the consequences
tally competent to
I hereby witness this direc
(1)1 personally
To the best of m
(a) Am not re
(b) Do not havi
(c) Am not cntitl
operation of
(d) Am not a physi
attending the
Declarant is a
I understand that if I have
responsible for any
Courtesy ot Oregon Health Decisions
LivingWiils
By Wendy Fisher
Of lb* hmerald
Eighty-two percent of adults in Oregon have heard of
living wills; 16 percent actually have them.
The few who have living wills believe that to prolong
their life artificially, to depend on family and machines to
maintain their life, is to throw away any dignity they have
left.
A living will is a written document stating that a pa
tient maintained by “extraordinary" means such as life
sustaining systems, antibiotics or surgery used only to pro
long their life may refuse treatment.
Fear of death or fear of possible pain from removal of
life-sustaining systems lead others to waive the pursuit of a
living will Others believe they may recover from a coma
and having a living will may endanger that chance.
"There are many stories of comatose patients coming
out of a coma despite their doctor’s opinion." according to
Robert Wheeler, a Eugene attorney who specializes in living
wills. Some believe a possible cure may be found while they
linger in a coma, he said.
There are three main types of living wills, each offering
a variety of options. One is specifically for terminal pa
tients. while others may be used by patients even if death is
not imminent. In all cases, the patient must have "extraor
dinary" measures before the living will can lie enacted.
What exactly constitutes "extraordinary" measures is
where the controversy surrounding the issue arises.
Of the three main types of living wills only one, the
Directive to Physicians, has passed through Oregon state
legislative channels. The directive states that if you are cer
tified "terminally ill" by two physicians, you may refuse
antibiotics, surgery or life-sustaining systems used only to
prolong life.
The directive must be signed by two competent adults
not related to or having any claim to the patient’s estate.
The second type of living will is not legally recognized
by the Oregon legislature, but it is upheld as legal by
Oregon courts. The Living Will is not considered as "strict"
or "limiting” as the directive and hence is much more
controversial.
Depending on which version of the Living Will a per
son selects, there is usually a choice of four or more options.
In the face of impending death, a patient may refuse elec
trical and mechanical resuscitation or nasogastric (through
the nose) feeding tubes and mechanical respiration. A pa
tient also can choose where to live during the last days of a
his or her illness and whether to donate organs
The patient who signs a Living Will also may choose to
sign a Durable Power of Attorney; a person is thereby ap
pointed by the patient to make treatment decisions for them
should they become incapable of communicating.
lastly, a fill-in-the blank option allows the patient to
select specific provisions he or she wants. One example
might be deciding whether to be transported to a hospital if
a patient's condition worsens causing an emergency, or to
refuse life-saving surgery. The Living Will then should be
signed and dated by two witnesses over age 18.
The last type of living will is tho Power of Attorney for
Health Care. As with the Living Will's power of attorney,
this document allows a patient to appoint a person to make
treatment decisions based on advisory discussions with
medical professionals, lawyers or a previously appointed
person. Unlike the Living Will, this does not require the
authorization of the patient's signature by a notary public.
The Power of Attorney for Health Care, however, must
be signed by two qualified witnesses.
The power of attorney document states that if you are
terminally ill or in a persistent vegetative state and are com
atose or unable to make decisions, the person designated by
the [lower of attorney will make all treatment decisions.
The document also offers options to choose from such
as whether to withdraw electrical and mechanical resuscita
tion. mechanical respirator, nasogastric, gastrostromy
(through stomach wall) or intravenous feeding and an
tibiotics to treat life-threatening infections.
The directive is the least controversial and simplest of
the three types of wills.
One apparent benefit of the directive is that it does not
prolong life with a respirator. If pneumonia or other il
lnesses develop, there is the choice of whether to treat with
antibiotics or surgery.
Dr. Gary Glasser, a specialist in diseases of the elderly,
and Wheeler both believe the directive is helpful. “It is
useful in terms of setting up guidelines.” Glasser said.
The directive also stimulates communication within
the family, according to Wheeler. “It helps to get people
talking about it, especially with the right people, such as
doctors and family.“ he said.
It is the only legally binding document. Wheeler said.
Because of this, the physician is required to do as the pa
tient wishes or transfer him to a doctor or hospital that will.
Physicians also are protected by law from having any
criminal or civil actions filed against them.
But Wheeler said the directive is too limited. “It only
covers the very end of life, whereas the Living Will and
Power of Attorney turn help earlier," he said.
Since the directive allows only the removal of the
respirator, patients who continue to breath on their own
after removal of the respirator may linger on the edge of
death until they die of natural causes, he said
The Oregon legislature is currently considering five
proposed laws to change the directive. One proposal would
allow the removal of a feeding tube, giving patients who
linger a choice to die sooner.
Some say the Living Will itself cannot be consciously
separated into good and bad points because it benefits those
in a vegetative state. The Living Will does not require the
holder to lx* terminally ill and allows removal of the
nasogastric feeding tube.
In the United States alone, 10.000 patients are con
sidered to be in persistent vegetative states A vegetative
state implies conditions ranging from slightly brain damag
ed to very brain damaged In all cases, the patient is
unresponsive to stimuli.
“Most people think, of vegetative state as permanent.”
said Brian Churchill, a registered nurse and organ donor
coordinator at Sacred Heart (General Hospital. "This is not
necessarily true."
In fact, some vegetative states are eventually reversible;
still, many continue to linger in zombie-like states. The
directive is no help to them because they are not considered
terminal.
Many are cases such as Karen Ann Quinlan, a young
woman who lingered for 10 years in a persistent vegetative
state after removal of a respirator failed to end her life The
Living Will and Power of Attorney may help patients like
Quinlan die sooner by allowing removal of feeding tubes
The issue is controversial. Starvation is a slow and
agonizing process, and it is not known whether comatose or
vegetative patients have a sense of pain.
In many cases involving terminally ill patients, the
removal of feeding tubes may actually aid in comfort.
Glasser said.
Right to Life, which is concerned with the “sanctity of
human life." is :)avidly against the Living Will, especially
removal of feeding tulies Members of this group believe it
may lie opening doors to suicide and mercy killing.
"We are headed toward the handicapped having their
food and water withheld," said Cayle Atteberry, the chair
woman for Eugene Springfield Right to Life.
The Living Will also could lie abused by dialysis pa
tients and others with active minds who must depend on
machines to keep them alive, Atteberry said If allowed to
sign the Living Will and the physician complies, the patient
may "commit suicide” by having feeding tulies or other
life-sustaining systems removed, she said
"We have gotten ourselves into this with our advanced
technology." Attelierry said. "We're opening a huge door
We've got to stop, got to draw the line."
An act of compassion may lead to mercy killing to slop
the agony a patient goes through as they starve to death after
removal of feeding tubes, she added,
Attelierry used abortion to illustrate her point. "People
felt sorry for rape and incest cases, which am less than 1
percent (of abortion cases), and now we have I ri million
babies killed. 99 percent simply because of inconvenience
— we opened the door,” she said.
The Power of Attorney has generally the same points as
the Living Will because it allows removal of feeding tubes
from non-terminal patients.
Wheeler sees the Power of Attorney as one of the most
useful documents because treatment already lias been
discussed and options marked on the form. Wheeler
believes this allows less chance fur misinterpretation
In addition, a Power of Attorney can Ire used to take ac
tion against a negligent person if the patient's illness was
caused by an accident or carelessness.
()f the five proposed changes to the directive the
Oregon Legislature will decide on. Atteberry (relieves not
all will pass because of outspoken controversies
(’hanging the minimum age of signing a directive from
tH to 15 meets arguments not only from Right to Life, but
from others w'ho believe t5-yeur-olds are not mature enough
to make such large decisions. Another proposed law is to
give oral and non-verbal directives the same legal impact as
a written directive.
Controversies confronting this are Ihe possibility of
misinterpretation, especially non-verbal. Classer believes it
may have an advantage because written words don’t
change, hut patients’ thoughts change as they experience
life on machines.
Requirements of witnesses signing directives may be
relaxed Currently, a witness must not !*• related to the pa
tient by blood, have any claim on the holder’s estate or be
providing health care to the patient These limitations
would be eliminated. If the proposal passes, it could in
crease the likelihood of forgery not only for deviant pur
poses but for emotional and compassionate purposes.
However, "when doctors an* making decisions they always
consider a hidden motive a relative may have,” Classer
said.
Obtaining a living will can still tie done easily, accor
ding to Wheeler, ami a lawyer is not necessarily needed if
the Living Will is reati carefully and signers consult with
their family.
"Any stationery store carrying legal documents carries
a directive for about 25 cents." he said. The forms must he
filled out corrocty, though, or the directive may la* void, he
warned.
A Power of Attorney and directive along with a latoklel
explaining living wills can bn found at the Western Oregon
Health Policy Institute of Kugeoe. OH W. 10th Ave . Room
337. Wheeler said.
The Living Will itself can la* received from Concern for
Dying. 250 W 57th St.. Room 831. New York. N.Y., 10107.
“If (a patient) hasn't made their desires known, there is
no sense of what is right." Classer said. "People come
down to operating on their own sense of values."
Classer said lie hus seen families suffer the trauma of
decisiun. "There is guilt if they do and guilt if they don’t.”
ho said.
A directive helps guide such decisions. "None of these
documents hy themselves or in combination is as important
as good solid discussion with a spouse, family and doctors
about what somebody wants,” Wheeler said
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