A living will or advance directive is a legal document by which one can specify his or her personal preferences and desires regarding health care decision-making in circumstances in which one is not able to speak on one’s own behalf. In other words, a living will provides a formal record of a person’s wishes in situations requiring medical decision-making, in the case in which that person, who previously had the cognitive capacity to make her preferences known, has lost such capacity, temporarily or permanently.
For example, a 55-year-old man suffers a stroke (cardiovascular accident; CVA) and loses consciousness. EMTs are called and the man is taken to the local hospital. The man (we’ll call him Joe) is able to breathe on his own, but requires life-saving support measures including delivery of fluids and nutrients (artificial hydration and nutrition). Joe never enacted a living will, and these measures are undertaken. After 72 hours Joe regains consciousness, but it is apparent that the CVA has caused severe brain damage. He is unable to understand what is said to him and he is unable to articulate recognizable words. Such a condition is known as global aphasia. He also has suffered a deterioration of skilled movements (apraxia) and is unable to feed himself. Thus, Joe requires full-time nursing care and may require such care for months or years. Although functional improvement is possible, the potential for improvement is typically unknown and the possibility exists that Joe will be permanently severely impaired in terms of cognitive function and the ability to perform activities of daily living.
Of course, these circumstances are very difficult to think about and speak about. Most of us have loved ones, family members or friends, who have suffered such an illness. Our critical question is what would Joe have wanted in the immediate aftermath of his stroke, had he been able to speak on his own behalf. Would Joe have desired live-saving measures to be used, regardless of the outcome? Would he have desired to continue living despite the long-term, possibly permanent, loss of his cognitive abilities? Many people would respond affirmatively, desiring that all life-saving measures be used to preserve life at any cost. Others would wish to decline such measures in medically life-threatening circumstances, being concerned about an unacceptably untoward outcome, based on their beliefs and values of what constitutes a happy life. For these people, a living will provides a formal, clear statement, of what medical services they would wish to have done to preserve life and what they would wish not to have done.