Controlling Personal Health Decisions for the Oldest Old

Abstract

Public health practitioners help the oldest old (persons aged 75 years and older) prevent falls, protect against communicable disease threats, cope with arthritis and many other chronic ailments, and deal with the loss of loved ones and lifelong friends. Collectively, assisting the oldest old as they manage their health is a core objective of public health practice. Warren DeWitt (right), aged 76 years, moved into the Peters household in Gladesville, West Virginia, to help look after Maxine and Arden, both aged 90 years. At the time this photograph was taken (2000), Warren had lived with the couple for over a year, cooking, cleaning, and maintaining the grounds. His chores also included trimming Arden’s hair. Photograph by Ed Kashi. Printed with permission of Ed Kashi Photography. Available at http://www.EdKashi.com. When M.R.G suggested this theme issue at a Journal editors meeting, he had another set of health-related controls in mind—specifically, the legal documents that allow us to direct the course of our life when we cannot. When thinking about these controls, most people usually consider only the prospect of documents that address one’s final affairs after death, such as a last will and testament, a living trust, or an organ donor card. A will allows a person to control the distribution of his or her wealth and personal property in accordance with his or her wishes and minimizes the tax impact of those transfers. A living trust is an approach to distributing wealth after death, which is set up and funded during life to avoid the burden of probate. An organ donor card authorizes the gift of a decedent’s organs for the benefit of transplant recipients. Perhaps more important, though, are the legal documents that structure the control of one’s medical and financial affairs during a period of incapacity, whether preliminary to the end of life or as a consequence of a traumatic injury or disease. The most significant of these documents are the general durable power of attorney, which appoints someone to act as an agent for legal, financial, and sometimes health matters when the principal is unable to do so, and the advance medical directive, which is also known as a “health proxy.” A health proxy—which is often accompanied by a health care power of attorney—is a set of directions that advises family members and medical professionals about wishes for medical life-support and other intervention. Also applicable to periods of incapacity is a contract for long-term health care insurance, which provides coverage for long-term conditions not covered by or limited by more traditional health care insurance. Preparation of these documents has traditionally fallen to attorneys; accordingly, addressing the issues covered by these documents has not been a core objective of public health practitioners. Ironically—and often, tragically—the implications of not having these legal protections in place falls most heavily on health practitioners and family members. Without a general durable power of attorney or a health proxy for an incapacitated person, health providers may be placed in the uncomfortable position of choosing the type and duration of treatment, which are all too often life-and-death choices. Moreover, the court system—impersonal, bureaucratic, and expensive as it is—is often invoked to make decisions that can have unalterable impacts on the mental health of family members. We cannot understate the anguish felt by family members who argue with other members about treatment and financial matters, sometimes to the point of lawsuits and family disintegrations. Conversely, many of us have witnessed a sense of relief for the oldest old who have prepared these documents. Without question, possessing up-to-date legal documents advances the dignity and autonomy of the incapacitated and dying and enhances public health and clinical public health practice.