Editing Advance healthcare directive (section)

==Living will==
[[Image:Refusal of treatment form.jpg|thumb|left|Refusal of treatment form]]
The living will is the oldest form of advance directive. It was first proposed by an [[Illinois]] attorney, [[Luis Kutner]], in a speech to the Euthanasia Society of America in 1967<ref>Benzenhöfer, U, Hack-Molitor, G (2009). Luis Kutner and the development of the advance directive (living will). Frankfurt (Main). [http://publikationen.ub.uni-frankfurt.de/frontdoor/index/index/docId/34515].</ref> and published in a law journal in 1969.<ref>{{cite journal|last1=Kutner|first1=Luis|title=Due Process of Euthanasia: The Living Will, a Proposal|journal=Indiana Law Journal|date=1969|volume=44|issue=4|pages=534–554|url=https://www.repository.law.indiana.edu/ilj/vol44/iss4/2/|access-date=22 March 2018}}</ref> Kutner drew from existing estate law, by which an individual can control property affairs after death (i.e., when no longer available to speak for himself or herself) and devised a way for an individual to express their health care desires when no longer able to express current healthcare wishes. Because this form of "will" was to be used while an individual was still alive (but no longer able to make decisions), it was dubbed the "living will".<ref>{{cite journal | author = Alexander G.J. | year = 1991 | title = Time for a new law on health care advance directives | journal = Hastings Center Law Journal | volume = 42 | issue = 3| pages = 755–778 }}</ref> The U.S. [[Patient Self-Determination Act]] (PSDA)<ref>Patient Self-Determination Act U.S.C.A. 1395cc & 1396a, 4206-4207, 4751, Omnibus Budget Reconciliation Act of 1990, P.L:.b 101-508 (101ST Cong. 2nd Sess. Nov. 5, 1990) (West Supp., 1991).</ref> went into effect in December 1991 and required healthcare providers (primarily hospitals, nursing homes, and home health agencies) to give patients information about their rights to make advance directives under state law.<ref>Docker, C. Advance Directives/Living Wills in: McLean S.A.M., Contemporary Issues in Law, Medicine and Ethics," Dartmouth 1996:182.</ref>

A living will usually provides specific directives about the course of treatment healthcare providers and caregivers are to follow. In some cases a living will may forbid the use of various kinds of burdensome medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. The living will is used only if the individual has become unable to give informed consent or refusal due to incapacity. A living will can be very specific or very general. An example of a statement sometimes found in a living will is: "If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued."

More specific living wills may include information regarding an individual's desire for such services such as analgesia (pain relief), antibiotics, hydration, feeding, and the use of ventilators or cardiopulmonary resuscitation. However, studies have also shown that adults are more likely to complete these documents if they are written in everyday language and less focused on technical treatments.<ref>{{cite web|last=Tokar |first=Steve |url=http://pub.ucsf.edu/today/cache/feature/200710312.html |title=Patients Prefer Simplified Advance Directive over Standard Form - UCSF Today |publisher=Pub.ucsf.edu |access-date=2010-06-23 |url-status=dead |archive-url=https://web.archive.org/web/20090207185025/http://pub.ucsf.edu/today/cache/feature/200710312.html |archive-date=2009-02-07 }}</ref>

However, by the late 1980s, public advocacy groups became aware that many people remained unaware of advance directives<ref>{{cite journal | author = Damato AN | year = 1993 | title = Advance Directives for the Elderly: A Survey | journal = New Jersey Medicine | volume = 90 | issue = 3| pages = 215–220 | pmid = 8446299 }}</ref> and even fewer actually completed them.<ref>Anthony, J. Your aging parents: document their wishes. ''American Health.'' May 1995. pp. 58-61, 109.</ref><ref>{{cite journal |vauthors=Cugliari A, Miller T, Sobal J | year = 1995 | title = Factors promoting completion of advance directives in the hospital | doi = 10.1001/archinte.155.17.1893 | journal = Archives of Internal Medicine | volume = 155 | issue = 9| pages = 1893–1898 | pmid = 7677556 }}</ref> In part, this was seen as a failure of health care providers and medical organizations to promote and support the use of these documents.<ref>{{cite journal | author = Johnston SC | year = 1995 | title = The discussion about advance directives: patient and physician opinions regarding when and how it should be conducted | journal = Archives of Internal Medicine | volume = 155 | issue = 10| pages = 1025–1030 | doi=10.1001/archinte.155.10.1025| pmid = 7748044 |display-authors=etal}}</ref> The public's response was to press for further legislative support. The most recent result was the Patient Self-Determination Act of 1990,<ref>''Omnibus Reconciliation Act of 1990'' [including amendments commonly known as The Patient Self-Determination Act]. Sections 4206 and 4751, P.L. 101-508. Introduced as S. 1766 by Senators Danforth and Moynihan, and HR 5067 by Congressman Sander Levin. Signed by the President on November 5, 1990; effective beginning December 1, 1991.</ref> which attempted to address this awareness problem by requiring health care institutions to better promote and support the use of advance directives.<ref name="American Bar Association 1991"/><ref>''Omnibus Reconciliation Act of 1990''.</ref>

Living wills proved to be very popular, and by 2007, 41% of Americans had completed a living will.<ref>Charmaine Jones, With living wills gaining in popularity, push grows for more extensive directive, ''Crain's Cleveland Business,'' August 20, 2007.</ref> In response to public needs, state legislatures soon passed laws in support of living wills in virtually every state in the union.<ref name="American Bar Association 1991">American Bar Association. ''Patient Self-Determination Act: State Law Guide.'' American Bar Association Commission on Legal Problems of The Elder. August 1991.</ref>

However, as living wills began to be better recognized, key deficits were soon discovered. Most living wills tended to be limited in scope<ref name="Annas, GJ 1210">{{cite journal | author = Annas GJ | year = 1991 | title = The Health Care Proxy and the Living Will | journal = New England Journal of Medicine | volume = 324 | issue = 17| pages = 1210–1213 | doi=10.1056/nejm199104253241711| pmid = 2011167 | url = https://scholarship.law.bu.edu/faculty_scholarship/1297 }}</ref> and often failed to fully address presenting problems and needs.<ref>{{cite journal | author = Hashimoto DM | year = 1983 | title = A structural analysis of the physician-patient relationship in no-code decision-making | url =https://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=6845&context=ylj | journal = Yale Law Journal | volume = 93 | issue = 2| pages = 362–383 | doi=10.2307/796311| jstor = 796311 | pmid = 11658880 }}</ref><ref>Hastings Center. ''Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: a report by the Hastings Center.'' [[Briarcliff Manor, NY]]: Indiana University Press. 1987.</ref> Further, many individuals wrote out their wishes in ways that might conflict with quality medical practice.<ref>{{cite journal | author = Campbell ML | year = 1995 | title = Interpretation of an ambiguous advance directive | journal = Dimensions of Critical Care Nursing | volume = 14 | issue = 5| pages = 226–235 | doi=10.1097/00003465-199509000-00001| pmid = 7656765 }}</ref> Ultimately, it was determined that a living will alone might be insufficient to address many important health care decisions. This led to the development of what some have called "second generation" advance directives<ref name="Annas, GJ 1210"/> – the "health care proxy appointment" or "medical power of attorney."

Living wills also reflect a moment in time, and may therefore need regular updating to ensure that the correct course of action can be chosen.