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Frequently Asked Questions About Advance Health Care Directives

“A love which accepts life as a gift also accepts the given limits on our lives; it never abandons those who are close to death” (Faithful for Life: A Moral Reflection, A Statement of the U.S. Bishops, 1995).

1. What is an advance health care directive?
2. What is a living will?
3. What is a durable power of attorney for health care?
4. What is ARNP?
5. What is life-sustaining treatment?
6. What is medically administered nutrition and hydration?
7. What is ethically proportionate life-sustaining treatment and care?
8. What is ethically disprortionate life-sustaining treatment and care?
9. What is a general example of the terms "ethically proportionate and disproportionate?
10. What is cardiopulmonary resuscitation and what is a Do Not Resuscitate order?
11. Is a Do Not Resuscitate order morally acceptable?
12. Who makes the judgment that life-sustaining treatment and care are ethically proportionate or disproportionate?
13. Is there a greater moral obligation not to withdraw life-sustaining treatment and medically adminstered nutrition and hydration once begun than to forgo these all together?
14. What is palliative care?
15. Who may act as my Health Care Agent?
16. May I name more than one Health Care Agent?
17. Is My Health Care Agent required to follow my wishes?
18. Can my Health Care Agent act when I am not suffering from a lack of capacity to make my own health care decisions?
19. Can treatment be given to me over my objections?
20. If I choose not to complete Section A of the DPAHC, can my Health Care Agent rely on the Three Beliefs document to guide the Health Care Agent in making health care decisions for me?
21. If I choose not to complete Section B of the DPAHC, can my Health Care Agent rely on the Three Beliefs document to be guided in making decisions for me regarding the withdrawing or withholding of medically adminstered nutrition and hydration?
22. Can I modify my advance directive?
23. How can I revoke my advance directive after it has been executed?
24. Can I strike references to an ARNP having any powers?
25. Should I discuss the DPAHC with my specific wishes with my Health Care Agent?
26. Why is it recommended that Section A of the DPAHC on "Life-Sustaining Treatment" not be completed?
27. Is the donation of organs after death morally acceptable in Catholic teaching?

1. What is an advance health care directive?

An advance health care directive is a legal document that allows a person (the “Principal”) to state his or her decisions and intentions about what kind of health care he or she wants when the person is not capable of making health care decisions. This document helps to ensure that health care decisions on behalf of the Principal are made with a consent that is informed by the Principal’s intentions.

2. What is a living will?

A living will is one type of advance health care directive. In a living will, the Principal gives written instructions about the kind of life sustaining treatment that he or she wants or does not want when the Principal is not capable of making health care decisions. A living will does not ensure that the consent of the Principal is as well informed as it is with other types of advance health care directives. The living will cannot reflect advancements in medicine from the time it is executed, or know in advance all of the changing circumstances associated with a future illness. The Diocese of Manchester does not recommend that the New Hampshire Living Will be used. For more information see Three Beliefs or contact the Diocese.

3. What is a durable power of attorney for health care?

A durable power of attorney for health care (DPAHC) is another type of advance health care directive. The Principal designates someone (Health Care Agent) to have authority to make health care decisions on his or her behalf when the Principal is not capable of making such decisions. This document may also include specific instructions about the kind of health care that the Principal wants or does not want, including if and when life sustaining treatment should be provided. The DPAHC allows for more complete informed consent by both the Principal and the designated Health Care Agent. The Health Care Agent is better able than is a living will to account for advancements in medicine and to the changing circumstances of the Principal’s illness when making decisions on the Principal’s behalf.

4. What is an ARNP?

Here is the definition of an ARNP in the New Hampshire law: “Advanced registered nurse practitioner or ARNP means a registered nurse who is licensed in good standing in the state of New Hampshire as having specialized clinical qualifications as provided in RSA 326-B:10” (RSA 137-J:2 II).

5. What is life-sustaining treatment?

Life-sustaining treatment according to New Hampshire law means “any medical procedures or interventions which utilize mechanical or other medically administered means to sustain, restore, or supplant a vital function which, in the written judgment of the attending physician or ARNP, would serve only to artificially postpone the moment of death, and where the person is near death or is permanently unconscious. ‘Life-sustaining treatment’ includes, but is not limited to, the following: mechanical respiration, kidney dialysis or the use of other external mechanical or technological devices. Life sustaining treatment may include drugs to maintain blood pressure, blood transfusions, and antibiotics. ‘Life-sustaining treatment’ shall not include the administration of medication, natural ingestion of food or fluids by eating and drinking, or the performance of any medical procedure deemed necessary to provide comfort or to alleviate pain” (RSA 137-J:2 XIII).

6. What is medically administered nutrition and hydration?

Medically administered nutrition and hydration in New Hampshire law means “invasive procedures such as, but not limited to the following: Nasogastric tubes; gastrostomy tubes; intravenous feeding or hydration; and hyperalimentation. It shall not include the natural ingestion of food or fluids by eating and drinking” (RSA 137-J:2 XV).

7. What is ethically proportionate life-sustaining treatment and care?

Treatment and care that have a reasonable hope of benefit for the patient (based on his or her condition, what the doctors expect, and how the patient responds to the treatment or care) are ethically proportionate. This type of treatment and care is also not excessively burdensome for the patient. For example, such treatment and care are not likely to cause serious medical complications and are not intensely distressful for the patient. This type of treatment and care also does not pose an excessive expense on the patient’s family or the community. A person is morally required to use this type of treatment and care.

8. What is ethically disproportionate life-sustaining treatment and care?

Ethically disproportionate treatment and care have no reasonable hope of benefit because, for example, they will not adequately achieve their purposes, or carry significant risk relative to the expected outcome, or because death is “imminent and impending” (this could be interpreted to mean that despite life-sustaining treatment and care, death could be expected to occur in a matter of days to approximately a week). Treatment and care are also ethically disproportionate if they will likely cause an excessive burden such as serious medical complications, or some other significant burden for the patient such as a distress that cannot be overcome, or they pose an excessive expense on the patient’s family or the community. A person is not morally required to use this type of treatment and care.

9. What is a general example of the terms “ethically proportionate and disproportionate”?

The meaning of these terms may be illustrated with the general example of maintaining health through diet and exercise. We all have an obligation to maintain bodily health, which may be partially accomplished by taking proper foods and fluids at the right time, in the right manner, in the right amount, by appropriate exercise, and so forth. Such actions are normally appropriate or “proportionate” for the individual and therefore are morally obligated. However, if certain kinds of food are too difficult to obtain, or to prepare, or if engaging in an exercise program is too difficult to maintain or to afford, this approach to maintaining health would be “disproportionate” and therefore morally optional.

10. What is cardiopulmonary resuscitation and what is a Do Not Resuscitate order?

New Hampshire law defines cardiopulmonary resuscitation as “those measures used to restore or support cardiac or respitory function in the event of a cardiac or respitory arrest” (RSA 137-J:2 VI). A Do Not Resuscitate order according to New Hampshire law is “an order that, in the event of an actual or imminent cardiac or respiratory arrest, chest compression and ventricular defibrillation will not be performed, the patient will not be intubated or manually ventilated, and there will be no administration of resuscitation drugs” (RSA 137-J:2 VIII).

11. Is a Do Not Resuscitate order morally acceptable?

Cardiopulmonary resuscitation is a life-sustaining treatment and as such should be morally evaluated as is any other type of life-sustaining treatment. In some circumstances resuscitation may be ethically proportionate and in other circumstances it may be ethically disproportionate. If it is judged that cardiopulmonary resuscitation will either not have any reasonable hope of benefit or will be an excessive burden, then a Do Not Resuscitate order is morally justified because it prevents what would be ethically disproportionate.

12. Who makes the judgment that life-sustaining treatment and care are ethically proportionate or disproportionate?

The patient, either directly or indirectly through a Health Care Agent, is ultimately responsible for the decision. Morally, the patient or Health Care Agent must take account of what the medical evidence indicates with the help of physicians and other health professionals. With this information, the patient or Health Care Agent must act to fulfill the obligation to conserve life with treatment and care that are appropriate for the particular condition of the patient, have a reasonable hope of benefit, and are not excessively burdensome.

13. Is there a greater moral obligation not to withdraw life-sustaining treatment and medically administered nutrition and hydration once begun than to forgo these all together?

No. There is no essential moral difference between forgoing treatment under the right circumstances and withdrawing treatment under the right circumstances. The judgment to forgo and the judgment to withdraw are evaluated by the same moral principles. Thus, just because life-sustaining treatment or medically administered nutrition and hydration have been initiated, there is no special moral obligation to continue them as opposed to not initiating them at all. The simple fact of initiating life-sustaining treatment or care does not make it morally more difficult to withdraw them under the proper circumstances.

14. What is palliative care?

Palliative care for the actively dying patient focuses not on cure but on providing relief from pain and the symptoms of disease through nursing or comfort care, and includes care for the psychosocial and spiritual needs of the patient.

15. Who may act as my Health Care Agent?

A Principal’s Health Care Agent need not be a family member, but can be any individual other than the Principal’s (i) health care provider, (ii) residential care provider, or (iii) any non-relative of the Principal who is an employee of either the Principal’s health care provider or residential care provider.

16. May I name more than one Health Care Agent?

A Principal may list more than one Health Care Agent. The Principal should specify whether the Health Care Agent’s authority has priority as given in the order in which their names appear on the DPAHC (i.e. primary Health Care Agent followed by alternate Health Care Agent), or whether the Health Care Agents are required to act jointly.

17. Is my Health Care Agent required to follow my wishes?

Yes. By statute, the Health Care Agent is required to make a good faith effort to determine the desires of the Principal, including the information provided in the Principal’s advance directive, the principal’s spoken or written desires, and the Principal’s known religious and moral beliefs.

18. Can my Health Care Agent act when I am not suffering from a lack of capacity to make my own health care decisions?

No. A Health Care Agent’s authority arises only when a determination has been made by the Principal’s physician or ARNP that the Principal lacks capacity to make health care decisions.

19. Can treatment be given to me over my objections?

No, unless the Principal includes in his or her advance directive an explicit statement that if the Principal is determined to lack capacity to make health care decisions and is objecting to treatment, treatment may be given over such objections. Absent such an express statement, treatment will not be given over the Principal’s objections, even if the Principal lacks capacity to make informed medical decisions.

20. If I choose not to complete Section A of the DPAHC, can my Health Care Agent rely on the Three Beliefs document to guide the Health Care Agent in making health care decisions for me?

Yes, so long as that direction is given to the Health Care Agent in Section C of the document. A Principal does not have to answer questions 1 or 2 of Section A in the affirmative in order to grant the Health Care Agent authority to act.

21. If I choose not to complete Section B of the DPAHC, can my Health Care Agent rely on the Three Beliefs document to be guided in making decisions for me regarding the withdrawing or withholding of medically administered nutrition and hydration?

No. By statute, if question 1 of Section B is not completed, the Health Care Agent will not have the authority to withhold or withdraw medically administered nutrition and hydration under any circumstances, even though the principles of the Three Beliefs document would permit the withholding or withdrawal of medically administered nutrition and hydration under certain circumstances.

22. Can I modify my advance directive?

Once executed, an advance directive cannot be modified. In order to make any changes to the document, an entirely new advance directive would need to be executed. Your Health Care Agent and physician or ARNP should be given signed copies of this document.

23. How can I revoke my advance directive after it has been executed?

An advance directive can be revoked (i) by a written document signed and dated by the Principal expressly stating the Principal’s desire to revoke; (ii) by an oral statement made in the presence of two or more independent witnesses; (iii) by intentionally destroying the existing document; (iv) by the execution of a subsequent advance directive; (v) by the filing of an action for divorce, legal separation, annulment or protective order; or (vi) by a court order (such as the appointment of a guardian).

24. Can I strike references to an ARNP having any powers?

Yes, by specifically stating that in the advance directive.

25. Should I discuss this DPAHC and my specific wishes with my Health Care Agent?

Yes. The Health Care Agent is required to follow your specific wishes and intentions when exercising his or her authority under the advance directive. While the written information in the Three Beliefs document is very detailed, and is incorporated into the attached DPAHC by the statements in Sections B and C, further personal discussion between the Principal and Health Care Agent will only better serve to ensure that the Health Care Agent is fully informed to carry out the directives of the Principal as completely as possible.

26. Why is it recommended that Section A. of the DPAHC on “Life-SustainingTreatment” not be completed?

For one reason, the law behind the DPAHC does not adequately define “near death.” As a result, Section A could allow withdrawing or withholding of life-sustaining treatment in situations where the treatment would have a reasonable hope of benefit and would not cause an excessive burden. Section A also allows the withholding and withdrawal of life-sustaining treatment for the sole reason that the Principal is permanently unconscious, which is inconsistent with Catholic teaching. Finally, it allows the Principal to mandate the continuance of life-sustaining treatment when in the particular situation this might not be morally required.

27. Is the donation of organs after death morally acceptable in Catholic teaching?

Yes, if informed consent is given and the donation is made only after death has been decarled by proper cardiopulmonary or neurological criteria. Organ donation after death is regarded as a “noble and meritorious act and is to be encouraged as an expression of generous solidarity." ¹⁶

¹⁶ Catechism of the Catholic Church , n. 2296