14). The role that patient's families, doctors, health aides, pastors, chaplains and administrators, health educators and others play is crucial. Few people have executed an advanced directive, much less appointed a healthcare power of attorney by the time they enter a hospital with a debilitating condition. An informed consent form only marks the fact that a conversation has taken place in a health facility. The process that needs to or ought to take place concerning a patient's wishes and ensure one's wishes are empowered are part of the process involved as one fills out the advanced directive for themselves. In California the state has consolidated statutes for advanced directives and added some rights and included the best features of past laws. A patient may appoint a power of attorney for health care, or use a form to state what one's wishes are, which includes the ability to use extreme life-sustaining measures in having one's life prolonged, and/or have pain relief. An agent may be appointed to make sure these directives are carried out. Advanced directives may also expressly allow the hospital and relatives to use extreme life-sustaining procedures.

To love a person is to learn the song in his heart and to sing it when he has forgotten it," is what Sue Rubin believes the ethics of advanced directives is all about (Rubin, 2001). In other words, when a patient may no longer be able to communicate their wishes, the advanced directive and the agent named in an advanced directive does it for them.

Value assessment in ethics is the first point of departure in the differences of opinion concerning end-of-life decisions. Intervention-based approaches are the most common way that end-of-life scenarios are viewed. When a person sees all the types of medical interventions that may be used during illness and chooses what one would do in certain situations, then records these in detail for their doctors and relatives to use in medical emergencies, it is hard to decide when the actual event occurs what the person may have meant. An procedure-based approach does not ask if there is a point at which the person does not wish to go below. The bottom line is not really visible in an intervention-based approach. The false illusion that one may control every medical procedure one is going to be subjected to before one draws their last dying breath is sadly evident in the intervention-based approach.

Value-based approaches are now becoming more acceptable. It is dynamic and changing, as one experiences life. To allow a patient to change one's directives from time to time is important, as people may make broad, sweeping statements in their directives, yet when one gets down to details, one might make exceptions for certain circumstances. Choking, for example, may not require DNR orders, yet some people have a standing order for DNR in every situation, while others say that they certainly would want to be resuscitated if they choked on a peanut. An incurable, progressive, degenerative disease where treatment only prolongs dying, on the other hand, may present a different scenario where a patient may wish a DNR order to be carried out (Rubin Video).

When one allows relatives to decide and interpret a patient's wishes and make decisions which go against what the surrogate decision-maker or the patient would have wished, it is wrong. For instance, according to Donald "Dax" Cowart, who suffered burns over most of his body as a young man, in 1970, and begged the doctors to stop treatment and allow him to die, he should have had his wishes honored. As an attorney, later, he fought for the right for a patient to determine his or her own treatment or to be allowed to die if they felt this was best. He saw the doctors who treated him against his wishes as being paternalistic and was an early spokesman for the concept of patient individualism and determinism (McGee, p. 1).

When a patient receives CPR or a life-sustaining procedure against the patient's wishes as expressed in an advanced medical directive, a hospital may be liable. Interns, aides and other personnel who meet an incoming patient with a life-threatening condition need to check to see if that patient has an advance medical directive that may preclude use of some procedures. In a study of the care received by 47 critically ill elderly patients who were received in a hospital,...

Two of these (11%) received CPR, in spite of the directions in their advanced directives. All other things being equal, the standard of care was not influenced by whether the patient had an advanced directive or not. The conclusion of the study was that an advanced directive does not alter the quality of care given to a patient, but that hospital personnel need to find out if a patient has a legal advanced directive upon admission and abide by it (Goodman, p. 704).
Many hospitals are now putting an ethics committee in place which is available to help patients and families discuss ethical issues regarding the care of a dying patient. If there is disagreement concerning the interpretation of authority in a patient's living the ethical or medical team should meet with the family to clarify what is at stake. Exploration of the family's rationale for disagreeing with the living will is done, examining whether any new concepts have interfered since the living will was put into place and whether or not the family members have different ideas of what should be done. Sometimes the impression of what is occurring is mistaken and a revised look at the patient's best interest is reviewed, given the patient's commitments and values, compared with those of the family. Perhaps the family disagrees with the physician in interpreting the advanced directive. In this case the family, ethical committee and medical team may meet to discuss the exact terminology used in the living will.

Dialogue between all parties involved is crucial, given that the patient cannot be consulted as to proceeding. If the family is simply disagreeing with the living will and wishing to go against it, if it is legally binding, it would be difficult for them to go against it. In this case, the ethics of the family's case is weak, in that they do not wish to honor the patient's last wishes. However, if new knowledge has appeared in the treatment of the patient's condition and in the judgment of the medical team and the family, it would benefit the patient and lead to a sustained, healthy life after treatment, then, as long as it may be interpreted as the patient's wishes in regard to the living will, treatment may be sought. However, if it was the wishes of the patient that their life not be sustained in any circumstances, there is no doubt that the wishes of the patient, no matter how much the family or medical team may disagree, must be abided by.

One study found that a family opposed to the advance directive inhibited the medical team from abiding by the living will (Weiler, p. 6). Because the doctors have to deal with families who are interacting with them moment by moment in the dying patient's behalf, they often give in to a family's decision, rather than going by the advance directive. It is the living that the doctor has to answer to, rather than the comatose patient in these situations. And doctors are not dispassionate. While many doctors know that a situation may be hopeless for the patient, when the family begs to allow the patient to live on, the doctor often errs on their side (Edwards, p. 5).

Medical health care personnel and families sometimes choose to ignore advance directives if they believe what is written is not in a patient's best interest or for religious or moral reasons. If the law is misunderstood, or if there is a question of professional responsibilities or medical ethics, families and medical professionals may not wish to honor it. "It is important for you to know if your doctor will honor your request. If not, you may need to choose another doctor who will honor your request" (Caring, p. 2). The Compassionate Care Helpline advises that people bring completed living wills to their doctor and ask if the doctor has any questions or concerns. They also advise discussing their views of end-of-life procedures with their families to make sure they understand their wishes, so debates and anxiety over what should be done will not arise when the time comes.

In conclusion, medical advance directives have actually only so much power when it comes to their being used during end-of-life scenarios. When a relative of a dying patient faces an emotionally charged scene where they have to choose whether their loved one lives or dies, the decision may often be based not on what the patient expressed in…