Estate Planning: Ten Practical Steps to Improve Written Advance Directives in Powers of Attorney for Healthcare

1. Change the “No heroics” clause

Most power of attorney documents for personal care include a more or less standardized “no heroics” clause that commonly reads along the lines of: “in the event of a terminal incurable illness I direct that life-sustaining treatments be withheld or withdrawn”, or words to this effect. Such text has traditionally apparently been perceived to provide sufficient direction to those appointed as substitute decision-makers or to provide direction to the designated substitute decision-maker of default and healthcare team should the appointed person be unavailable, incapable or unwilling to act.

Unfortunately, what people understand this clause to mean and what it actually means in clinical practice may prove vastly different: too often, people fail to appreciate the narrow scope of the situations to which such a clause speaks and assume that the adjectives “terminal and incurable” provide clear descriptors of a state of health. The reality of whether an illness is terminal or incurable may, however, not be immediately evident.

Should life-sustaining treatments be imitated to determine that this is indeed (and unfortunately) the situation of the person in question? What of the treatments that need to be undertaken in response to acute illnesses that usually arise in the course of a chronic or end-stage illness which may be curable and survivable? Should life-sustaining treatments be carried out in such situations, or not? The current texts of such documents are too often completely silent on such issues, and yet most people will die from an acute deterioration on a background of chronic illness. Current boilerplate “no heroics” clauses would be significantly improved if they indicated whether such acute deteriorations should be treated with a goal of cure or stabilization of the acute illness (which would potentially and likely result in more co-morbidities the person would have to accept to live with) or whether the person would prefer palliative care in such circumstances.

An example of such changes to the “no heroics” clause would be:

“Should I have an underlying end-stage illness, I do not wish to undergo any resuscitation (CPR) nor have life-sustaining treatments initiated, even if my need for such treatments arises from an acute illness, trauma or an acute exacerbation of my end-stage disease, whether or not this acute illness/exacerbation may respond to such treatments if they were required.

If, in the situation of any acute illness or trauma, life-sustaining treatments would only serve to prolong my death, in the opinion of my physicians, I direct that these treatments be withheld or withdrawn.

If, in the opinion of my physicians, my death will occur whether or not resuscitation and life-sustaining treatments are initiated, I direct that these be withheld.”

Go to Step 2


The author wishes to encourage and engage in discussion regarding the directives she proposes here. Please take a moment to express your thoughts and critical commentary in the comments section below.

About the Author

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LAURA HAWRYLUCK received her MD in 1992 from the University of Western Ontario where she also served her Internal Medicine residency. She completed a Fellowship in Critical Care at the University of Manitoba in 1997 and received her MSc in Bioethics in 1999 from the Joint Centre for Bioethics and the Institute of Medical Science at the University of Toronto. From 1999-2001 she was Assistant Professor of Critical Care/Internal Medicine, Queen’s University, Kingston, Ontario. In March 2000 she was appointed Physician Leader of the national Ian Anderson Continuing Education Program in End-of-Life Care at the University of Toronto and is currently Associate Professor of Critical Care Medicine at the University of Toronto. In 2002, she was awarded the Queen’s Golden Jubilee Medal for contributions to Canada in recognition of her work in creating the Anderson Program and improving end of life care for Canadians. Dr. Hawryluck is co-author and editor of “Law of Acute Care in Canada” to be published shortly by Carswell, a division of Thomson Reuters.

Dr. Hawryluck is deeply involved in international humanitarian projects. She has worked with critical care and burn units in Indore India and Cote d’Ivoire on a variety of quality improvement and educational initiatives. She was co-creator and co-Director for RCCI of the first Doctorate in Medicine Program in Critical Care in the entire country of Nepal. She worked with the Nepal Medical Council as an international consultant to enact a Code of Ethics and Professionalism for all physicians in Nepal.

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