Guide to Death with Dignity in North Carolina -
North Carolina Medical Society, 1991

Introduction to the Advance Care Documents

It is becoming increasingly difficult to die peacefully, whether in North Carolina or anywhere else in the United States today. If you had the choice, you would probably wish to live a long, healthy and happy life and then die suddenly in your sleep.  For a few people, death does come quickly: they have a massive heart attack or stroke or accident, and it's all over in a matter of minutes.  But most of you will face a quite different end to your life.  You may become ill and deteriorate over weeks or months or years, or a sudden catastrophic illness may occur.  In either case, you may become unconscious or otherwise unable to make decisions that are made for you during your final days.

As an alert, competent adult, you have a right to make decisions concerning your own health care.  You can decide to go ahead with certain treatments or operations or you can decide that you would prefer not to undergo them.  The trouble arises when you are no longer alert and competent and can no longer make such decisions.  Most of you will pass through that stage toward the end of your life, so you need to make your wishes known now about how you wish your health care managed at that time.

Medical technology has progressed so far in this country that it's often possible to keep people alive well beyond the point where their life has meaning and quality.   Patients who can't communicate their wishes regarding their medical care can be kept alive by heart-lung resuscitation, breathing machines, artificial feeding and other methods.  Many people see this as postponing death rather than sustaining life.

In earlier times, not only were there fewer heroic life-saving technologies, but also most patients had a personal family physician who knew their wishes concerning life-sustaining measures and would be available and able to ensure a peaceful death with dignity.  Today, a personal physician who knows your wishes is still the best safeguard against care you do not want.  But many patients don't have a personal physician or, if they do, that physician may not be present when needed for these decisions.  For these reasons, it has become very important for you to write down your wishes and/or appoint a person to make your health care decisions for you when you cannot make them.

You may have heard of a living will, a legal document in North Carolina that safeguards your right to determine the kind of care you'll receive at the end of your life.  The living will is one of several advance care documents by which competent people instruct their family, physicians, friends, lawyers, clergy and others important in their lives about their wishes for medical care should they become unable to speak and decide for themselves.  A health care power of attorney is another such advance care document and it, too, is a legal document in North Carolina.  When you execute a health care power of attorney you name a person to make your health-related decisions for you when you no longer can.  Both the living will and the health care power of attorney can be strengthened by the addition of a medical directive. A medical directive is a list of treatment options and medical or surgical procedures you may or may not want done to you when you are very ill.  If you incorporate a medical directive into your health care power of attorney it also has the force of a legal document.

This information is offered to help people who want to die with dignity.  It explains what advance care documents can do and discusses the shortcoming of each.   It is the result of the cooperative efforts of most of the people who could be involved in helping you during the last months of your life:  physicians, nurses, emergency medical personnel, clergy, ethicists, attorneys, and representatives of nursing homes, hospices, home health agencies and hospitals.  We all want you to be able to decide for yourself what you do and do not want done to you when you are no longer able to speak for yourself.  We also want you to know that your wishes will be carried out.

Copies of a living will, a health care power of attorney and a medical directive are shown. Examine them carefully.  Talk about them with your family and physician and perhaps with your friends, attorney and clergy. 

Adapted from the Guide to Death with Dignity in North Carolina © 1991 North Carolina Medical Society

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Advance Care Documents

Step 1 -- The Living Will

North Carolina has a law (the Right to a Natural Death Act) that says you can execute a living will and it will be honored by the health care personnel taking care of you.   When you execute a living will you state that you do not want your life to be prolonged by extraordinary means or by artificial nutrition and hydration in the event you have a terminal and incurable condition or are in a persistent vegetative state.   People who are terminally and incurably ill are those who will die soon, for example, people in the last stages of cancer or heart disease.  Those in a persistent vegetative state are most often accident or stroke victims who are in a condition in which their eyes open, they can move, they react to pain, but they cannot respond purposefully to the world around them: they are not aware.  Nor are they dying.

A living will is simple to fill out and only requires the signature of two witnesses (who are not related to you) and a notary public.  It is a good starting place for people who want to control the end of their life.  You write and sign a living will when you are at least 18 years old and mentally alert and competent; it becomes effective when you can no longer direct your health care.  This is the first and easiest step to ensure your death with dignity.

Living wills have limited applications. A living will executed in North Carolina may not be valid in another state since living will laws differ in virtually every state that has one.  Living wills don't apply to people who are in a coma or those with severe dementia, including people with Alzheimer's Disease. But because North Carolina law protects doctors, nurses and other health care personnel who honor your properly executed living will, it is a good first step toward seeing to it that your wishes are carried out even when you can no longer express them.  The second step, the health care power of attorney, is explained in the next section.

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Step 2 -- The Health Care Power of Attorney

There is a better chance that your wishes will be carried out if you discuss them in advance with your physician and your family.  It is also a very good idea to take advantage of a recent North Carolina law and name someone (known as your agent) to make health care decisions for you when you become unable to make them.  You accomplish this by executing a health care power of attorney.  Your agent can be anyone you choose: perhaps your spouse or adult child or a friend or attorney.  Your health care agent cannot be employed to provide health care to you and must be at least 18 years old.

A durable power of attorney is a document that people have drawn up to give someone else the power to handle their business affairs for them should they become unable to act for themselves.  A health care power of attorney does the same thing specifically regarding your medical care.  Your agent begins making your health care decisions for you when your physician determines that you are unable to make or communicate them yourself.

The law gives your agent considerable authority.  Agents can hire and fire health care providers; gain access to your medical records and other medical information about you; admit or discharge you from a health care institution; consent to or refuse tests, treatments or procedures; withdraw or withhold life-sustaining  procedures, including artificial nutrition and hydration, when you are terminally ill, in a persistent vegetative state, permanently in a coma or suffering severe dementia.  In short, agents are empowered to make all the health care decisions you could make for yourself if you were able.

The North Carolina health care power of attorney also gives you a place to add special provisions or specific limitations you want for your agent.  If you have religious reasons for not wanting a specific procedure done, for example, a blood transfusion, you could say so in that section of the health care power of attorney.  You could also attach a medical directive, which is explained in the following section, to your power of attorney. 

Like the living will, the health care power of attorney requires the signatures of two witnesses who are unrelated to you; it must also be notarized by a notary public.

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Step 3 -- The Medical Directive

Because neither the living will nor the health care power of attorney is perfect, there is a growing movement toward the use of medical directives.  With a medical directive you may specify in advance, while you are mentally alert and competent, certain situations in which you do or don't wish certain medical interventions done to you.  Of course, it's impossible to foresee all the situations that might happen to you, but stating your wishes for some situations will be a helpful guide for those who will be making decisions about your care.

The power to execute a medical directive comes from your virtually unlimited right as a mentally alert and competent adult to refuse medical treatment.  A medical directive is valuable evidence of decisions you made while you were competent for use in times when you are not competent.  A  medical directive form is included below.  By itself, the medical directive does not have the power of a legal document, but it is an important focus for discussions about your future medical care for you to have with your physician and family and agent.  It is evidence of how you feel about certain medical procedures, and all such evidence helps those who are trying to help you toward the end of your life.

If you wish your medical directive to have the force of a legal document, you may make it a part of the section on special provisions and limitations in your health care power of attorney and then attach the directive to the properly executed health care power of attorney form.

All three of these advance care documents have shortcomings.  In an ideal situation you would remain awake and alert and pain-free, giving all the needed directions for your own care.  No advance care documents can take the place of the alert and competent patient, nor can they absolutely guarantee that your wishes will be followed.

There is little question that the people involved in your medical care will do their best to abide by your wishes if you have gone to the trouble of filling out a living will and/or a health care power of attorney and /or a medical directive. Besides just filling out documents, though, it is crucial for you to discuss your wishes with your family and your physician.  What these steps taken together provide is clear and convincing evidence of your wish to die with dignity, the best possible way to assure today that you will die in that way in the future.

Where to Put Your Advance Care Documents

No advance care document will do you any good if it cannot be located when it's needed.   A copy should certainly be placed in your medical record in your doctor's office, and another copy should be in your home.  If you are receiving hospice care, home health care or are in a nursing home, a copy should be in the office of that agency or facility.

Certain people besides your doctor should also have a copy of your advance care documents: your spouse, your agent and your next of kin.  In addition, you may also want to give copies to your adult child or children, one or more close friends, your clergy or pastor, the nurse or home health aide who takes care of you or any other person you feel should have access to or know about the documents.