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Five Wishes
is a popular alternative to the
traditional approach of advance directives
By Paul
Malley, President of Aging with Dignity
A recent edition
of the Annals of Internal Medicine (July 3, 2007) includes a
commentary by Henry S. Perkins, M.D. regarding advance directives.
Titled “Controlling Death: The False Promise of Advance Directives,”
it highlights some of the major shortcomings and flaws in
traditional advance directives.
Several people
have asked me recently if Five Wishes meets the seven
standards set forth by Dr. Perkins for an effective advance
directive. I am pleased to say that Five Wishes does in fact
satisfy the recommendations in this article, and that Five Wishes
is a valuable alternative to the traditional advance directives that
Dr. Perkins identifies as flawed.
Dr. Perkins
advocates “using a sample advance directive to help guide the
advance care planning process.” According to Dr. Perkins, “the
ideal sample is easily accessible, concise, accurate, conversational
in style, and available in languages that are commonly spoken by the
physician’s patients.”
Ø
One of the most common
things people cite as the reason for using Five Wishes –
either personally or with their patients – is that Five Wishes
is easy to use and understand. It is written in regular language,
as opposed to medical or legal jargon. It frames the advance care
planning conversation in terms that are meaningful and
understandable for the average person. Health care providers
consistently comment that they spend less time explaining the
details of Five Wishes (and the overall concept of advance
care planning) to patients and families because the document is
understandable as written. The conversational tone of the document
also makes it easier to have important conversations between
patients, families, and health care professionals. Such a document
is a better springboard to effective communication than a document
that is cumbersome and difficult to understand. Along those lines,
the Five Wishes document is now available in 20 languages,
which is a positive step toward meeting Dr. Perkins’ recommendation
that advance directives should be available in commonly spoken
languages.
Dr. Perkins goes
on to advocate the use of advance directives that contain the
following seven elements:
1)
A requirement that the signer meet
basic decision-making standards – specifically, knowing the purpose
of the advance directive, grasping the choices presented and their
implications, and being able to decide on the basis of the signer’s
own values;
Ø
Five Wishes
was created with help from national legal experts, and it meets the
legal requirements for an advance directive in 40 states. In order
to execute the document, the individual must have the capacity to
understand the document and make these end-of-life care decisions
based on their own values and preferences. The signature section on
page 10 requires that the individual sign the document in the
presence of two witnesses, who must “declare that the person who
signed or acknowledged this form is personally known to me, that
he/she signed or acknowledged this in my presence, and that
he/she appears to be of sound mind and under no duress, fraud, or
undue influence.”
2)
Choices covering diagnostic
procedures, treatments, proxies, and organ donation;
Ø
Wish 1 (pages 4-5)
allows a person to designate a health care proxy, or a person who
will make health care decisions on their behalf if they are unable.
Wish 2 (pages 6-7) allows a person to indicate the types of medical
treatments they would want or not want in certain
situations. It is not enough to simply name a health care agent; it
is also important to provide some guidance regarding your
preferences for care and treatment. Five Wishes offers an
easy way to address all of these issues. It also provides space in
Wish 5 (page 9) for people to express their thoughts on organ
donation and other matters.
3)
A commitment to providing comfort care
always;
Ø
The importance of
comfort care is stressed throughout Five Wishes. Wishes 3
and 4 (page 8) specifically deal with issues related to dignity and
comfort. The following are examples of statements in this section
which patients can either elect or decline that deal with personal
care:
I do not want to be in pain. I want my doctor to give me enough
medicine to relieve my pain, even if that means I will be drowsy or
sleep more than I would otherwise.
I wish to have a cool most cloth put on my head if I have a fever.
I wish to have my favorite music played when possible until my time
of death.
I wish to have people with me when possible.
I wish to have pictures of my loved ones in my room, near my bed.
Along with Wish 5, this is the section of Five Wishes that
address the issues that many people say matter the most.
4)
An option to withhold artificial
sustenance (if consistent with patient interests);
Ø
Wish 2 (page 6) provides
space for an individual to describe their definition of life support
treatment in their own words according to their own beliefs and
preferences. This is where the individual can explain their
thoughts regarding food and water supplied by a medical device.
They can also describe situations where they would want or not want
such treatment.
5)
A recommendation that the signer
inform all physicians and medical proxies about his or her choices;
Ø
The section titled “What
to do after you complete Five Wishes” (page 11) advises
people to: “Talk about your wishes with your health care agent,
family members and others who care about you. Give them copies of
your completed Five Wishes.”
The Next Steps discussion guide
is also available to provide helpful tips on starting the
conversation with loved ones and health care providers.
6)
A requirement that the advance
directive be placed in the signer’s medical record;
Ø
The same section on page
11 goes on to suggest the following:
Talk to your doctor during
your next office visit. Give your doctor a copy of your Five
Wishes. Make sure it is put in your medical record. Be sure your
doctor understands your wishes and is willing to follow them. Ask
him or her to tell other doctors who treat you to honor them…. If
you are admitted to a hospital or nursing home, take a copy of your
Five Wishes with you. Ask that it be put in your medical record.
7)
And revocation procedures.
Ø
A revocation statement
is included in the signature page of Five Wishes, so that it
takes the place of any advance directive completed previously.
Instructions are also provided on how a person can change to Five
Wishes and how the document can be revoked.
In his
commentary, Dr. Perkins puts the spotlight on many of the challenges
experienced with traditional advance directives. He joins other
recent critiques of advance directives that share common themes:
- They promote
shifting the emphasis from the legal boilerplate documents to the
process and conversation;
- They emphasize
the importance of picking a good health care agent, rather than
just making advance medical decisions;
- They encourage
consideration of personal care preferences, comfort, and dignity;
- They criticize
the jargon used in standard documents and say that advance
directives should be easily understood and readable (Dr. Perkins
suggests a “conversational tone”);
- And they
stress the importance of good communication between patients,
families, and health care providers.
Put me in the
group that agrees with these critiques. These are the reasons that
we created Five Wishes, because the traditional approaches of
advance care planning needed improvement. Fortunately, Five
Wishes provides an alternative that meets all of Dr. Perkins’
recommendations, in a document that is the closest to a national
advance directive available.
Paul Malley is President of Aging with
Dignity, PO Box 1661, Tallahassee, FL 32302. Phone 850-681-2010,
Email
p.malley@agingwithdignity.org. |
