A living will is a document that states that one does not want medical intervention if the technology or treatment that keeps one alive cannot offer a reasonable quality of life or hope for recovery (see example of living will).

All states have legislation authorizing the use of legal documents such as living wills and durable powers of attorney for health care (sometimes referred to as health care proxy, surrogate, agent or attorney-in-factor), which together are known as advance directives. Forty-eight states recognize durable power of attorney, 47 states recognize living wills, and 23 states have statutes for surrogate decision making. It is thought that between 12% and 20% of the population have completed living wills or durable powers of attorney for health care (Maddox, 1995:26.)

Despite a growing acceptance of living wills, the issue is still complicated by emotion and questions of when a will should be invoked. Many persons are reluctant to take steps leading to a patient's death, and some are willing to withhold further medical treatment, but do not want to disconnect existing life support. Others cannot even distinguish living wills from "do not resuscitate" (DNR) orders-a situation that has caused the deaths of healthy and alert people who have not suffered cardiac or pulmonary arrest (Stone, 1994).

In 1994 Cugliari and Miller determined that 29% of New York state hospitals would not honor a patient's request to withdraw or withhold treatment (Cugliari and Miller, 1994). In another study by Almgren (1993) in which 140 nursing home directors of nursing were interviewed, it was discovered that the competency of the patient and type of nursing home ownership were the primary factors influencing decisions to withdraw nutrition from terminal patients--the fact a patient had signed a living will had little influence on these decisions. Furthermore, Miles and August (1990) have demonstrated that the courts have a gender bias in the forced implementation of living wills. Because men were perceived as more rational and women as unreflective, emotional, and immature; the courts accepted the treatment preference of 75% of the men but only 14% of the women. This pattern of bias had been discovered in many states and remains unchanged when one controls for the patient's age, condition, and treatment modality (Miles and August, 1990). Consistent with the research findings sited above, Donald Dilworth (1996:79) conducted his own research in five hospitals and reached the following conclusion:

Living wills do virtually nothing to reduce patient suffering, because doctors and hospitals ignore them. Some 80% of doctors either misunderstood or set aside the dying requests, and a program to help patients avoid painful life-prolonging treatments had no effect at any of five hospitals I studied. The cause of the problem is the medical culture that rejects death and promotes technology.

If considering a living will, one should check to make certain that such a will is legal in the state of residence. After the will is drawn up, make several copies of it and share it with physicians and other healthcare providers, family members, and friends. A copy of the will should also be given to one's attorney to be kept in his or her office. This is not something one should limit to a single copy, lock up in a safety deposit box, and keep a big secret. Share the news!

In December 1991 the federal government created the Patient Self-Determination Act that requires most hospitals, nursing facilities, hospices, home healthcare programs, and health maintenance organizations (HMOs) to inform patients at admission of their right to create "advance directives" relating to their care. According to Ken Wibecan (1992), the two most common of these directives are the living will and the durable power of attorney for health care. The latter names a surrogate decision maker with legal authority to consent (or refuse consent) for medical treatment should the patient lack competency for making such decisions.

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