This article will try to discuss issues related to Advance directives with particular reference to the situation in Asia. In terms of numbers the Chinese, Muslims and Indians form the majority of the population in Asia. The religion of most Chinese including the Japanese and Korean is Buddhism. On the other hand the Muslims led by the Indonesians practice Islam while the Indians practice Hinduism. All religions teach us to do good and “Thou Shalt Not Kill”. Most countries in Asia except for the Philippines have less than 10% Catholics. In Malaysia which has a population of more than 28 million the percentage of Catholics is only 4%. Advance Directives are relatively unknown in Asia.
What is an Advanced Directive?
An Advanced Directive is defined as a document with written instructions made by a person before he/she reaches the terminal phase of a terminal illness or a persistent vegetative state and incapable of asking decision about medical treatment when the question of administering the treatment arises. It is preferably a duly notarised document executed by a person of legal age and of sound mind upon consultation with a physician and family members. It directs healthcare providers to administer terminal care when the person executing such directive reaches the terminal phase of his terminal illness. Before I delve further into Advance directives it is important also to mention death/brain death, euthanasia, dysthanasia, orthothanasia, ordinary and extraordinary care and DNR or Do Not Resuscitate as they are all interrelated with Advance Directives.
From the medical point of view Death can be diagnosed and certified when the heart stops and spontaneous breathing stops (conventional definition) or when the brain including the brain stem stops functioning (Brain Death definition). With the advance in Resuscitation and setting up of Intensive Care Wards some patients whose hearts had stopped or failed and whose breathing was stopping or had ceased were successfully resuscitated. A small percentage of the successfully restarted heart beating ‘survivors’ could not be taken off life supports. This group was actually ‘dead’ (by the old definition) because if there were no artificial supports (breathing machines, etc.) or if they were taken off these supports, the heart and breathing would stop. Medical advance (efficient Resuscitation and Intensive Care Units) created this problem of supporting the ‘dead’ and not as many erroneously refer to as supporting ‘life’. The concept of Brain death evolved and intensive care spread and became universally established from the 1960’s. It is now accepted that a patient in the intensive care ward requiring artificial supports (breathing machines, supportive drugs, etc.) to maintain heart/breathing functions can be diagnosed as ‘dead’ if assessment and testing of the total brain function (including Brain Stem function) shows absence of such functions that is Brain Death. The concept of Brain death has to be accepted in hospitals that run Intensive Care Units/Wards. If one does not accept Brain death as a medical entity the situation can arise whereby the ICU beds are occupied by ‘dead’ people (cadavers) on artificial supports. This is a constant dilemma faced by doctors who run ICU wards if the concept of Brain death is not understood and accepted. To diagnose brain death two specialists run through bed side tests/testing the brain stem function independently and repeat the test after a specific interval before the final conclusion is made. In countries where Organ Transplantation Programmes have been started brain death must be accepted as otherwise the only Organs for successful transplantation will only be available from living donors.
By Euthanasia is meant any action or ommision which of itself and by intention causes death with the purpose of eliminating all suffering. The pity aroused by the pain and suffering of of terminally ill patients, abnormal babies, the mentally ill, the elderly and those suffering from incurable disease does not justify any form of Euthanasia either active or Passive. It is not a question of helping a sick person but the intentional killing of a person. Healthcare Personnel should always remain faithful to the task of giving service to the service of life and assisting it to the end. Human life is sacred–all men must recognize that fact (HUMANAE VITAE).
Dysthanasia is meant as the undue prolongation of life by futile therapy which ends in an undignified death. It is an abusive use of extraordinary or inappropriate technological means to prolong life and is usually costly and is done for fear of a malpractice suit.
Ordinary and Extraordinary Care ANH or Artificial Nutrition and Hydration is regarded as ordinary care and cannot be legitimately withheld even if death is imminent. In 2004 Pope John Paul 2nd during an International Congress on the Vegetative State stated that ” ‘The administration of water and food even when provided by artificial means always represents a natural means of preserving life, not a medical act. Its use furthermore should be considered in principle ordinary and proportionate and as such morally obligatory insofar as and until it is seen to have obtained its proper finality, which in the present case consist in providing nourishment to the patient and alleviation of his suffering.
DNR or a Do Not resuscitate Order is usually executed when death is imminent. Life sustaining treatment is withdrawn from a patient in a terminal condition or in a permanently unconscious state when a medical practitioner signs a do-not-resuscitate order on the request of the patient or his representative if the patient lacks capacity to do so. The life sustaining treatment typically withdrawn is cardiopulmonary resuscitation (CPR). A DNR is morally permissible only if one can judge that CPR is excessively burdensome for the patient taking into account his or her situation and physical and moral resources or that CPR imposes excessive financial burden on the family and community.
POLST or Physician Orders for Life Sustaining Treatment is causing alarm in Catholic Healthcare circles. POLST orders include a DNR order (do not resuscitate) and an AND Order (Allow Natural Death) which is to withhold assisted nutrition and hydration and another Order to withhold antibiotics. The POLST ensures that the patient’s wishes are followed.A patient can choose any one of the three following measures:
a/ First Choice–‘Comfort Measures only’ which means providing care to relieve pain and suffering
b/Second Choice—‘Limited Additional Interventions’ which includes comfort care but may also include IV fluids and antibiotics.
c/Third Choice–‘Full Treatment’ which includes comfort care, IV fluids, antibiotics, CPR, the type of breathing support, artificially administered nutrition and all other intensive medical care measures including transfer to a hospital.
On the surface POLST appears to be a sincere effort to encourage individuals to plan and address their end of life care needs. However POLST has a detrimental effect on Catholic Moral teaching. It makes patient autonomy an enforceable right and gives all patients whether terminally ill or not total control of their end-of-life issues.It attacks the sacred value of human life by allowing individuals to hasten their own deaths on the basis of their personal intentions . exerted independently of Catholic healthcare ethical values.
History of Advance Directives
Advance Directives began to be developed in the US in the late 1960’s.In 1976 Barry Keene introduced the Bill in California and the latter became the first US state to legally sanction Living Wills. In 1992 all the 50 US States had passed legislation to legalize some form of Advance Directive.
Advance Directives generally fall into 3 categories: Living Will. Power of Attorney and Health Care Proxy.
This is a written document that specifies what type of medical treatment are desired should the individual become incapacitated.A Living Will can be general or specific. the most common statement in a Living Will is to the effect that:- If I suffer from an incurable irreversible illness, disease or condition and my attending physician determines that my condition is terminal, I direct that life sustaining measures that only serve to prolong my life be withheld or discontinued. More specific Living Wills may include information regarding an individual’s desire for such service as analgesia (pain relief), antibiotics, hydration, feeding, CPR (cardiopulmonary resuscitation) and the use of life support equipment including ventilation.
Health Care Proxy
This is a legal document in which an individual delegates another person to make health care decisions if he or she is incapable of making his/her wishes known.The health care proxy in essence has the same rights to request or refuse treatment that the individual would have if capable of making and communicating decisions.
Power of Attorney
Through this type of Advance Directive an individual executes legal documents which provide the power of attorney to others in the case of an incapacitating medical condition. The Durable Power of Attorney allows an individual to make bank transactions, sick social security checks, apply for disability or simply sign cheques to pay the utility bill while an individual is medically incapacitated.
Advance Directives in Asia
While the Western Countries like the US has legalized some form of Advance Directives, the latter is relatively unknown in Asia. Up to date only Singapore has passed its Advance Medical Directive Act (Chapter 4A) on July 1997. This is an Act to provide for and give legal effect to Advance Directives to medical practitioners against artificial prolongation of the dying process and for matters connected therewith. The Act permits only natural death and not euthanasia or abbetment of suicide. The Advance Directive does not affect palliative care. Any Person who makes a Directive shall register his Directive with the registrar of Advance Medical Directives. Also any person who has made a Directive may in the presence of a witness revoke the Directive in writing, orally or in any other way in which the patient can communicate. The Medical Practitioner responsible for the treatment of the person who has been certified terminally ill shall obtain the opinion of 2 other medical specialists as to whether they agree to with the determination that the patient is terminally ill. Terminal illness means an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery where a/death would within a reasonable medical judgement be imminent regardless of the application of life sustaining treatment and b/the application of extraordinary life sustaining treatment would only serve to postpone the moment of death of the patient. A few other countries in Asia are presently trying to promote Advance Directives in their country. In Hong Kong in 2006 the Law Reform Commission released their final report on ‘Substitute Decision making and Advance Directives in relation to Medical treatment’ and recommended the promotion of Advance Directives but not Legislation.Chinese family members often play a very influential role in relation to end-of-life decisions. The Chinese often view overt reference to death as taboo and would like to talk about death. A Wong et al study showed that 6%of those not engaging in Advance Directives did so because of family objections. In Japan terminally ill patients also rely on Family Members and Physicians for making end-of-life decisions (Kinoshita 2007). These cultural differences are common in Asian countries and may result in patient’s medical directive preferences be override. Current Korean Medical Law does not include categories for end -of-life care but the Law concerning emergency medical care states that “Physicians are not allowed to discontinue emergency care without appropriate reasons.
Therefore if ill patients are transferred to ICU they must be kept on ventilators until death, brain death or a judicial decision from a court of law (YS LEE 2009). In The Philippines in July 2004 an Act was presented to their House of Representatives to be passed. This Act was introduced by Rodriguez D. Davidas Declaring the Rights and Obligations of Patients and Establishing a grievance mechanism for Violation thereof and for other purposes. This Act shall be known as the Magna Carta of Patient’s Rights and Obligations. Advance Directive is included in this Act—Any Person of legal age and of sound mind may make an Advance directive for physicians to administer terminal care when he suffers from the terminal phase of a terminal illness.
Advance directives and the interrelated bio-ethical issues like Euthanasia and Brain Death have been described. Whilst Advance Directives are commonly used in the Western countries like US and are legalized, in Asia only Singapore has legalized it. Due to our cultural differences Advance Directives may not be popular in Asian countries as the Family Bond is very strong amongst Asian Families. Finally Advance Directives attacks the sacred value of human life by allowing individuals to control their own end-of-life issues independent of Catholic Healthcare Ethical Values.
Prepared by Dr. Freddie Loh Immediate Past President of AFCMA and Asian Representative to FIAMC.