INSIDE DIGNITAS
Covid-19 and Advance Directive / Living Will:
Is there a need for special provisions?

In the wake of Corona disease / Covid-19, much has been and is being written in the media about the necessity of an Advance Directive. In the following article, “DIGNITAS – To live with dignity – To die with dignity” explains the purpose of such a document and clarifies the question of whether special provisions are necessary in an Advance Directive in the case of an infection with Covid-19.

When it comes to medical instructions, many people are of the opinion that “my doctor will know what is good for me”. It is indeed gratifying to see that there is such confidence in the medical profession and in a functioning medical care system.

Others prefer to decide for themselves which medical treatments they are willing to accept and which not: for example, they do not wish to be connected to life-supporting machines in a hospital when in a coma and be kept alive artificially for a long time. They wish to give more life to their years rather than more years to their life by all means.

Planning ahead with an Advance Directive

Anyone who wishes to take precautions in this regard may establish an Advance Directive. This must be done at a time when there is no reason to doubt the person’s mental capacity but it is only applied when the person is no longer able to express his or her will because for some reason he or she has lost mental capacity.

It is therefore important to have an unambiguous text with clear-cut instructions. An Advance Directive should also name one or several individuals who are authorised to speak for the person who established it. This is strongly recommended so that these persons can bring the Advance Directive to the attention of third parties and enforce it, if necessary even against opposition.

Special question due to Covid-19

Dramatic news about medical treatment and its consequences in the case of contracting Covid-19 can lead to uncertainty. For those who refuse life support beyond a certain point and do not want to “wait for the end connected to machines and tubes”, the question arises whether they have to set up a special Advance Directive to refuse intensive care in the case of severe disease progression.

The good news is that a special “Covid-19 Advance Directive” or a corresponding addendum to an existing Advance Directive is not necessary. If the existing Advance Directive corresponds to one’s own current will, it does not need to be adapted with regard to a potential Covid-19 disease.

In addition, a person contracting Covid-19 is usually at first still able to discuss treatment options with the healthcare professionals; in the course of the disease, he or she can express his or her wishes regarding further treatment.

Validity of the Advance Directive

In principle, an Advance Directive is legally enforceable if it is drawn up in writing, dated and signed and does not violate legal provisions. The Advance Directive of a self-determination organisation such as DIGNITAS places particular emphasis on protecting the patient from medical over-treatment. It is therefore clearly formulated and contains unambiguous instructions, which also provides security for doctors and nursing staff*.

Advance Directives, including freely available templates, are sometimes unclear or even contradictory in their wording. If there is reason to doubt whether the Advance Directive is based on free will, doctors and nurses will not comply with it. What was intended to be prevented may actually occur: medical (further) treatment. In addition, ambiguities lead to time pressure and an emotional burden put on doctors and nurses, and of course on relatives, as in these cases they will discuss, weigh the options and attempt to establish the patient’s presumed will. Sometimes an “ethics committee” is also consulted; however, these committees are sometimes staffed by conservative and religiously bound moralists and not always ideologically neutral.

Talking to each other

In addition to writing an Advance Directive that may be described as “hard worded” and fully corresponds to one's own will, it is highly recommended to discuss one's own wishes regarding “last things” with loved ones and also to talk about one’s personal wishes in case of contracting Covid-19.

In this way, they will be more confident in their actions in the event of a sudden loss of capacity of judgement with concurrent Covid-19 disease and will be able to inform the doctors clearly about the individual’s personal treatment wishes.

Planning ahead and self-determination

The consequences of Covid-19 disease can be severe and it is encouraging to see more media coverage regarding the Advance Directive and other tools for planning ahead. However, this is often done in a dramatising way, and recommendations from“experts” sometimes overshoot the mark: for example, the idea of a mandatory “Covid-19 Advance Directive” was brought up and discussed. In addition, there are recommendations for extensive Advance Directives, packaged as laborious “Advance Care Planning” and sold with mandatory consultation.

Caution is advised. A mandatory Advance Directive contradicts freedom of choice and self-determination. An Advance Directive is a simple and efficient tool in itself for planning ahead, whilst “Advance Care Planning” for a charge tends to unnecessarily complicate things, making it more difficult to get access to protection from undesired medical treatment.

In principle, everyone is entitled to the maximum possible medical treatment. It is up to each person to decide individually how far this should go for him- or herself: those who write an Advance Directive set the limit themselves; those who prefer not to write an Advance Directive leave the decisions to others.

* Members of the Swiss association “DIGNITAS – To live with dignity – To die with dignity” as well as members of the partner association DIGNITAS-Deutschland e.V. are entitled to receive a template for a legally binding Advance Directive for the duration of their membership; the Advance Directive must be respected by doctors and nursing staff in hospitals; if necessary, DIGNITAS provides members with direct support by a lawyer to enforce the provisions. Since Advance Directives are closely related to the law of the country in which they are issued, legal support for their enforcement can only be guaranteed for the territory of Switzerland and Germany, respectively.

Newsletter 2020-2-3-e