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Death and Dying - Advance Directives

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Advance Directives

A court must consider many factors and standards in right-to-die cases. It must determine, for example, whether a patient is competent or incompetent. A competent patient is deemed by the court to be able to give informed consent or refusal relative to the treatment under consideration, whereas an incompetent patient (e.g., a patient in a coma) lacks the decision-making capacity to do so. According to the principle of individual autonomy, the court must honor the informed consent of competent patients regarding their medical care.

For incompetent patients who cannot make informed decisions regarding their care, an advance directive may provide a means of decision making for the termination of life-supporting treatment. An advance directive is a document, prepared in advance of incompetence, which gives patients some control over their HEALTH CARE after they have lost the ability to make decisions owing to a medical condition. It may consist of detailed instructions about medical treatment, as in a LIVING WILL; or the appointment of a proxy, or substitute, who will make the difficult choices regarding medical care with the patient's earlier directions in mind. The appointment of a proxy is sometimes called a proxy directive or durable power of attorney. The patient names a proxy decision maker when he or she is competent. In other cases, the physician may appoint a proxy, or the court may appoint a legal guardian who acts on behalf of an incompetent person. Usually, a relative such as a spouse, adult child, or sibling is chosen as a proxy. If an advance directive provides adequate evidence of a patient's wishes, a decision about the termination of life support can often be made without involving a court of law.

For an incompetent patient whose preferences regarding medical care are known from prior oral statements, the patient's proxy may make a substituted judgment—that is, a judgment consistent with what the patient would have chosen for himself. If no preference regarding medical treatment is known, the standard for the proxy's decision is the "best interests of the patient." According to that standard, the proxy's decision should approximate what most reasonable individuals in the same circumstances as the patient would choose. Individual states have statutes governing the requirements for living wills and advance directives.

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