Living Wills and Advanced Directives

Living wills and advanced directives are legal documents which provide caregivers and family members' instructions as to the wishes of an individual when decisions must be made surrounding medical care, especially when the decisions must be made surrounding life support issues. Living wills allow the patient to have someone advocate for his or her care, especially when her or she is no longer able to do so. These documents can be used in cases of terminal illness but can be used when the patient is simply incapable of speaking for his or herself. Health care directives also apply when the patient has developed a position of permanent unconsciousness, like a persistent vegetative state or a come. In these cases, the living will can only be implemented when two physicians agree on the patient's prognosis. No living will is legally binding if the person completing them is considered incompetent to make decisions on their own, or if the patient is a minor.

It is a widely held theory that patients who have reached the end of the effective lives must be treated with consideration and compassion. This theory is almost universal in its application. The manner in which effectively dying patients are treated, however, is markedly different depending on the geographical location of the patient. For example, in the United States, the care of patients at the end of their lives has become care that actively involves the patient, or if the patient is unable to participate in the decision making process, those family members who hold power of attorney to make such decisions for them. In North America, there is a trend toward earlier abandonment of life sustaining therapies. In Europe, active euthanasia is common in the Netherlands and Belgium although it is practiced legally in only one European country. The overall incidence of the withdrawal of life sustaining measures in European ICUs is not known, although withholding and withdrawing life support is actively used by most European intensivists, shortening of the dying process remains rare. In the treatment of terminally ill patients in Japan, new surveys indicate that Japanese physicians tend to treat the patients more aggressively. An analysis showed that in Japan, patients wishes are often not taken into account while a greater weight is placed on the feelings of the family. The overall feeling in Japan is that to withdraw or withhold treatment is essentially to abandon the patient and heroic measures are usually undertaken in an attempt to prolong the patient's life until family members are present at the bedside to witness the time of death. The physicians in Japan who were interviewed regarding end of life care still seemed to feel that withdrawing or withholding any life sustaining treatment would be considered ethically or legally unacceptable. It is also important to take into account that medical costs in Japan may not be a consideration in end of life care. The Japanese health care system is such that all care to those over age 70 (or over age 65 and bedridden) is free, therefore the financial burden associated with terminal care common in Western counties will not be an issue to families of the terminally ill in Japan. There has been a trend noted toward over treatment of the elderly, although no specific data has been found which suggests any financial association with the provision or withholding of life sustaining care by Japanese physicians.