Volume 9, Number 1, November 1997

Concerns About the New Alberta Personal Directives Act

Mark R. J. Addison, B.Sc., M.D., C.C.F.P.
Family Physician

Like almost everyone in Alberta who is interested in personal directives, I am grateful that we appear to be gradually proceeding toward a law confirming the validity of these documents, which some of us have used for years. I am however, concerned about several aspects of the Act.

By way of introduction, I will give you a very brief synopsis of my involvement with personal directives and my views on their role in health care. I am a Family Physician, in practice since 1977, with an interest in Geriatrics. My first eight years in practice included a heavy commitment to working in the Emergency Department at Foothills Hospital.

In 1988 I became Medical Director of a 500-bed, long term care facility. The first weekend of this new job confirmed my worst fears about communication between physicians and patients/families, when a life threatening illness occurred. During the following week I created a form to obtain a clear agreement between the physician and the patient/family concerning the management of a life threatening illness. I initiated mandatory annual conferences at our facility in part to sign these forms. Our clergyman, an American, told me this was an advance directive. At that time this was a concept used in the United States, but seldom in this country. While he was correct in some instances, the majority of people in long term care had significant dementia, and thus the agreement generally reflected a consensus between the physicians and patients' families. This is not a personal directive as defined in the proposed Alberta statute.

The Benefit of Having a Personal Directive

In my experience, the benefit of Personal Directives is that they formalize communication. The instructions given in a directive must be clear to the physician in order that the patient's wishes can be understood. Certainly the old days of "no heroic measures" in living wills is not appropriate, as an understanding of what this means is open not only to the interpretation of the physician but every family member and significant other involved. The person writing the personal directive must be encouraged to discuss the details of such with their physician and every immediate family member/close friend. This will minimize future problems in complying with their directive when it becomes effective.

Standardized Personal Directive Documents

Relating to the new Alberta Personal Directives Act, I feel the single most important problem is that the Act does not encourage Health Regions to produce a set of standardized personal directive documents. Hospitals will ask patients if they have a personal directive on admission and may ask them if they want one made. This will be unsettling to most people, as well as time consuming, as they will have to try and understand the nature of personal directives at a time of major stress. This will not work. I cannot imagine more than a very few people being able to draft a well thought-out directive at such a time.

Social workers will be required to try and resolve the anxiety, explain the legislation, and perhaps, help the patient write their personal directive. I predict a good deal of distress in the admitting department, as well as the need for many more social workers. I hope very few new personal directives will be written in these situations.

Directives must be thought out carefully, and discussion with the physician or other experienced facilitator should take place in order to ensure the makers' wishes are understood and acted upon accordingly. Communication remains the cornerstone of a personal directive. Family should be involved and principally, of course, the individual to be named 'personal agent' (if a family member).

Does the personal 'agent' need to be advised?

Through the years, I have had a surprisingly large number of people come to me expressing concern that they will be named as an agent for someone else, without their approval. Clearly the agent must understand the maker's requests and values and must feel comfortable with the family situation with which they would be dealing. For this reason, I think it is essential that the designated personal agent be required to sign the personal directive at the time at which it is made. This point should be included in the legislation, which is not the case at present.

It is also important to note that at the time of assisting an individual in writing a personal directive, physicians may remind patients of issues such as organ donation and the use of blood products. As well, familiarization to this concept would be enhanced by a standard approach made widely available in the community. Other jurisdictions do not prevent the development of standardized advance directives.

The general purpose of the Alberta Personal Directives Act, as far as I can see, is to group all non-financial directives under one law. The inclusion of other social instructions, such as a definite statement that the maker refuses to be placed in a nursing home, can create a major problem. This increases the likelihood that not all wishes expressed in a directive will be carried out. Yet, personal directives must enjoy the same confidence of the maker that people have when making a will . . . that it will be carried out. If these social statements are routinely disregarded, then the whole process of advance directives looses all validity. Other jurisdictions have not taken Alberta's approach.

Age Requirement

My final concern relates to the age requirement of the Act. Although I have not had the experience of using personal directives with children, I have encountered many very difficult family settings which preclude rational decision making. I was asked to speak to a group in June 1997, in Regina, about the Saskatchewan Advance Directive Act which may be proclaimed into law later this year. In Saskatchewan, individuals over the age of 16 will be able to write advance directives, whereas, the Alberta Personal Directives Act requires individuals to be 18 years of age. I believe individuals 16 years of age and over should be allowed to direct their own health care. I suggest that those caring for teenagers with life threatening illness be contacted for their suggestions on this.

While in some ways I am pleased to see some sort of legislation validating personal directives, I believe that this Act is awkward and will pose a number of problems when applied. Although there was consultation with those with experience in this field when the legislation was drafted, I understand that this was not widely accepted. Thus, we have a broad Act covering all of an incompetent person's life except fiscal matters. This may prove to be unfortunate.