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{\listname ;}\listid1279798278}}{\*\listoverridetable{\listoverride\listid1279798278\listoverridecount0\ls1}{\listoverride\listid1189953162\listoverridecount0\ls2}{\listoverride\listid510336152\listoverridecount0\ls3}}{\info{\title The living will}
{\author Peter Green}{\operator Chris}{\creatim\yr2009\mo3\dy29\hr20\min57}{\revtim\yr2009\mo3\dy29\hr20\min57}{\version2}{\edmins1}{\nofpages2}{\nofwords477}{\nofchars2724}{\*\company Hambleton & Richmondshire PCT}{\nofcharsws0}{\vern8283}}
\paperw11906\paperh16838\margl1797\margr1797 \widowctrl\ftnbj\aenddoc\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\hyphcaps0\formshade\horzdoc\dgmargin\dghspace57\dgvspace180\dghorigin1797\dgvorigin1440\dghshow1\dgvshow2
\jexpand\viewkind1\viewscale100\pgbrdrhead\pgbrdrfoot\splytwnine\ftnlytwnine\htmautsp\nolnhtadjtbl\useltbaln\alntblind\lytcalctblwd\lyttblrtgr\lnbrkrule \fet0\sectd \linex0\headery709\footery709\colsx708\endnhere\sectlinegrid360\sectdefaultcl {\header 
\pard\plain \s15\ql \li0\ri0\widctlpar\tqc\tx4153\tqr\tx8306\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\cs17 Peter Green Northallerton VTS
\par Care of older adults 9, Clinical ethics and value based medicine 3.3}{
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}
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\fs36\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {The living will
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par An advance directive is the generic term for an act whereby a person, whilst competent, specifically makes arrangements about his future healthcare decisions should he become incompetent. This maybe done by an instrument which has become known as a living
 will, or by a durable (or enduring) power of attorney (or a combination of both)
\par 
\par }{\ul What constitutes an advance decision}{?
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \fi-360\li720\ri0\widctlpar\jclisttab\tx720\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0 {A written document
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}A clear oral statement
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}A signed printed card
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}A smart card
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Note of a discussion in the patient\rquote s records
\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {(Answer: all of the above)
\par 
\par But }{\ul to be legally binding}{:
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \fi-360\li720\ri0\widctlpar\jclisttab\tx720\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin720\itap0 {Clear refusal of a procedure or research
\par {\listtext\pard\plain\f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Voluntarily made by a competent informed adult
\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {(Health professionals are generally bound to comply when the refusal specifically addresses the situation that h
as arisen. It maybe invalid if treatment options change after loss of competence and does not cover unforeseen circumstances)
\par 
\par A less common type of \'93living will\'94 is the }{\ul Advance Authorisation}{ and reflects positive preferences for certain positive interventions
\par (E.g. obligation to provide artificial nutrition or hydration if it is clear that is what the patient wanted) Advance authorisations can only cover normal practice and not be unreasonable.
\par 
\par N.B. Advance decisions are not for everybody, some people do not want to know the implications of future decisions
\par 
\par }\pard\plain \s1\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs24\ul\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Legal Position
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Advance decisions are covered by the Mental Capacity Act 2005 and came into force on October 2007
\par 
\par }\pard\plain \s1\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs24\ul\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Conscientious objection
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Some health professionals disagree in principle with patient\rquote 
s rights to refuse life-prolonging treatment. 
\par They are entitled to have their personal beliefs but cannot impose them on patients who do not share them. 
\par They should make their objection clear and sample and take responsibility for transferring care to another health professional who does not share their objection. 
\par If no other health professional is available they should not act contrary to a known advance refusal.
\par 
\par }\pard\plain \s1\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs24\ul\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\page Proxy decision makers }{\ulnone (Lasting power of attorney or LPA)
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Competent adults can nominate another person to make decisions on their behalf if/when they lose capacity

\par 
\par }\pard\plain \s1\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs24\ul\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {LPA
\par }\pard\plain \s15\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Written in statutory form
\par Nature and effect described
\par Signed by donor and attorney
\par 3}{\super rd}{ party witness (voluntary)
\par Registered with public guardian
\par 
\par }{\ul Provision of information
\par {\listtext\pard\plain\s15 \f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \s15\ql \fi-360\li720\ri0\widctlpar\jclisttab\tx720\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin720\itap0 {Idea
lly discussed with health professional
\par {\listtext\pard\plain\s15 \f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Foreseeable options and uncertainties need to be explained
\par {\listtext\pard\plain\s15 \f3\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Drafting an advance directive is considered normal good practice and not a service that can be charged.
\par }\pard \s15\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {N.B. conducting an assessment of mental capacity solely for the purpose of an advance decision is not a primary service and may attract a fee.
\par 
\par }{\ul Clinical note
\par }{500 000 people in UK have been diagnosed with dementia, about 1 in 20 people over 65 years have it.
\par 
\par 
\par }{\ul References
\par }{
\par Office of the public guardian/ assessing capacity: }{\field{\*\fldinst { HYPERLINK "http://www.publicguardian.gov.uk/mca/assessing-capacity.htm" }{{\*\datafield 
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\par 
\par Advanced decisions and proxy decision-making
\par }{\field{\*\fldinst { HYPERLINK "http://www.bma.org.uk/images/Advance%20statements%202007_tcm41-147189.pdf" }{{\*\datafield 
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\par 
\par The living will, Consent to treatment at the end of life, A working party report: Edward Arnold, 1988 Age concern for england
\par 
\par }}