Editing Advance healthcare directive (section)

===United States===
Aggressive medical intervention leaves nearly two million Americans confined to nursing homes,<ref>Wilkkes, JL. Nursing Home Nightmares. ''USAToday.'' August 20, 1996. 11A.</ref> and over 1.4 million Americans remain so [[medically frail]] as to survive only through the use of feeding tubes.<ref name="US Congress 1987">US Congress, Office of Technology Assessment. ''Life-Sustaining Technologies and the Elderly.'' OTA-BA-306. Washington, DC: US Gov't Printing Office. July, 1987.</ref> Of U.S. deaths, about a third occur in health care facilities.<ref>{{cite news |author=<!--Staff writer(s)/no by-line.--> |title=A third of Americans die in hospitals, study finds |url=https://www.reuters.com/article/us-death-usa/a-third-of-americans-die-in-hospitals-study-finds-idUSTRE5A34N220091104 |work=Reuters |date=4 November 2009 |access-date=10 March 2021}}</ref> As many as 30,000 persons are kept alive in comatose and permanently vegetative states.<ref name="US Congress 1987"/><ref>{{cite journal | author = American  | year = 1995 | title = Practice Parameters: Assessment and Management of Patients in the Persistent Vegetative State: Summary Statement | journal = Neurology | volume = 45 | issue = 5| pages = 1015–1018 | doi = 10.1212/wnl.45.5.1015 | pmid = 7746375 | doi-access = free }}</ref>

Cost burdens to individuals and families are considerable.  A national study found that: "In 20% of cases, a family member had to quit work", 31% lost "all or most savings" (even though 96% had insurance), and "20% reported loss of [their] major source of income".<ref>Covinsky, KE; Goldman, L; Cook, EF; etal. The impact of serious illness on patient's families. ''Journal of the American Medical Association.'' 1994;272(23):1839-1844.</ref>  Yet, studies indicate that 70-95% of people would rather refuse aggressive medical treatment than have their lives medically prolonged in incompetent or other poor prognosis states.<ref>Heap, MJ; etal. Elderly patients' preferences concerning life support treatment. ''Anaesthesia.'' 1993;48:1027-1033.</ref><ref>Patrick, DL; etal. Measuring preferences for health states worse than death. ''Medical Decision-Making.'' 1994;14:9-19.</ref>

As more and more Americans experienced the burdens and diminishing benefits of invasive and aggressive medical treatment in poor prognosis states – either directly (themselves) or through a loved one – pressure began to mount to devise ways to avoid the suffering and costs associated with treatments one did not want in personally untenable situations.<ref name="ReferenceA"/>  The first formal response was the living will.

In the United States, all states recognize some form of living wills or the designation of a [[health care proxy]].<ref>{{cite web|title=Living Wills, Health Care Proxies, & Advance Health Care Directives|url=http://www.americanbar.org/groups/real_property_trust_estate/resources/estate_planning/living_wills_health_care_proxies_advance_health_care_directives.html|website=ABA|publisher=American Bar Association|access-date=8 May 2017}}</ref> The term ''living will'' is not officially recognized under California law, but an advance health care directive or durable power of attorney may be used for the same purpose as a living will.<ref>{{cite web|title=Do I Need a Will?|url=http://www.calbar.ca.gov/Public/Free-Legal-Information/Legal-Guides/Do-I-Need-a-Will|website=State Bar of California|access-date=23 November 2017}}</ref>

In Pennsylvania on November 30, 2006, Governor Edward Rendell signed into law Act 169, that provides a comprehensive statutory framework governing advance health care directives and health care decision-making for incompetent patients.<ref>{{cite web|url=http://www.pamedsoc.org/MainMenuCategories/Government/LawsAffectingPhysicians/AdvanceDirectives/Act169facts.aspx |title=Facts on Act 169 (Advance Directives) - Pennsylvania Medical Society |publisher=Pamedsoc.org |access-date=2010-06-23 |url-status=dead |archive-url=https://web.archive.org/web/20110507102752/http://www.pamedsoc.org/MainMenuCategories/Government/LawsAffectingPhysicians/AdvanceDirectives/Act169facts.aspx |archive-date=2011-05-07 }}</ref> As a result, health care organizations make available a "Combined Living Will & Health Care Power of Attorney Example Form from Pennsylvania Act 169 of 2006."

Several states offer living will "registries" where citizens can file their living will so that they are more easily and readily accessible by doctors and other health care providers. However, in recent years some of these registries, such as the one run by the Washington State Department of Health, have been shuttered by the state government because of low enrollment, lack of funds, or both.<ref>{{cite news|title=Washington state ends living will registry |url=http://seattletimes.com/html/localnews/2015478485_apwalivingwillregistry.html |access-date=2011-07-24 |newspaper=The Seattle Times |date=July 1, 2011 |url-status=dead |archive-url=https://web.archive.org/web/20130927115714/http://seattletimes.com/html/localnews/2015478485_apwalivingwillregistry.html |archive-date=September 27, 2013 }}</ref>

On July 28, 2009, [[Barack Obama]] became the first United States President to announce publicly that he had a living will, and to encourage others to do the same. He told an [[AARP]] town meeting, "So I actually think it's a good idea to have a living will. I'd encourage everybody to get one. I have one; Michelle has one. And we hope we don't have to use it for a long time, but I think it's something that is sensible."<ref>Conolly, Ceci. "Obama takes personal approach in AARP speech," ''The Washington Post'', July 29, 2009.</ref> The announcement followed controversy surrounding proposed health care legislation that included language that would permit the payment of doctors under Medicare to counsel patients regarding living wills, sometimes referred to as the "infamous" page 425.<ref>[https://www.washingtonpost.com/wp-dyn/content/article/2009/07/28/AR2009072801444.html President Obama Holds a Tele-Townhall Meeting on Health Care with AARP Members], CQ Transcriptions, July 28, 2009.</ref> Shortly afterwards, bioethicist [[Jacob M. Appel|Jacob Appel]] issued a call to make living wills mandatory.<ref>{{cite journal | author = Appel Jacob M | year = 2010| title = When Any Answer is a Good Answer: A Mandated Choice Model for Advance Directives | journal = Cambridge Quarterly of Healthcare Ethics | volume = 19 | issue = 3| pages = 417–422 | doi=10.1017/s0963180110000253| pmid = 20507692| s2cid = 28350033}}</ref>