The United States Congress has passed a law known as the Patient Self-Determination Act. This law requires hospitals to provide all adult patients with written information about their right to refuse unwanted medical treatment. We want you to know your rights and responsibilities as a patient at our hospitals. We want you to understand and participate in your medical care and hope you will take the time to read this information and take appropriate action.

This information is designed to help you understand:  

• your right to be informed as to your medical condition and your right to accept or refuse medical treatments, including your right to refuse life-sustaining medical treatments;
• what an advance instruction is and your right to have one;
• what a living will is and your right to have one;
• what a healthcare agent is and how to appoint such an agent by having a healthcare power of attorney; and
• our hospital policies regarding these issues.

Most of our patients are only at our facilities for a short time and then return home. However, there may come a time when you become seriously ill, and you and your family members may be called upon to make major decisions about the medical care you wish to receive. In these situations, we want you and your family to discuss your wishes concerning your medical care with your doctor.

An alert, competent adult has the right to accept or refuse any medical treatment being offered by his or her physician, including life-sustaining procedures. Such procedures would include being kept alive by a breathing machine, kidney dialysis, cardiopulmonary resuscitation ("CPR" - a medical procedure used when a person's heart stops beating or when he or she stops breathing), tube feedings of food and water, antibiotics, and other life-prolonging measures. North Carolina law specifically recognizes the right of an individual to a peaceful and natural death and the right of an individual to accept or refuse medical treatments, including life-sustaining procedures.

Even if you are currently alert and able to discuss your wishes, at some point in your life you may become unconscious, unable to speak and unable to let others know your wishes. If you are facing these difficult choices, you should talk with your doctor and family and clarify your wishes. In addition to discussing your wishes with your doctor and family, in North Carolina you may also plan for your future medical treatment in three types of written instruments: A healthcare power of attorney, a living will, and an advance instruction for mental health treatment. These documents are described below.

Healthcare Power Of Attorney
By having a healthcare power of attorney, you may appoint a healthcare agent to make healthcare decisions, including mental health treatment decisions, for you if and when you become unable to make decisions for yourself. Under North Carolina law any alert, competent adult (18 years of age or older) may sign a healthcare power of attorney and appoint a healthcare agent. The healthcare agent can be any adult, except the person's healthcare providers.

The North Carolina legislature has adopted a standard form for establishing a healthcare power of attorney and appointing a healthcare agent. The healthcare power of attorney becomes effective if and when the physician or physicians you designate determine that you are unable to understand, make or communicate decisions relating to your healthcare. Upon such determination, your healthcare agent has full power and authority to make healthcare decisions on your behalf.

The healthcare agent's power includes the ability to consent for or withhold consent for x-rays, anesthesia, medication, surgery, mental health treatment decisions, and all other treatments your physician may offer. The standard healthcare power of attorney also gives your healthcare agent the authority to direct that life-sustaining procedures that are artificially postponing your death be withheld or discontinued, if your physician determines that you are terminally ill, permanently in a coma, suffer from severe dementia (i.e., severe, irreversible dementia caused by advanced Alzheimer's disease), or are in a persistent vegetative state. A persistent vegetative state is a form of permanent unconsciousness where although the person has sleep/wake cycles, the person is at no time aware of himself or his environment.

The healthcare power of attorney form also has a section where you may limit your healthcare agent's power and make any special provisions or limitations you deem necessary. For example, you may include your own definition of when life-sustaining procedures should be withheld or discontinued, or you may add instructions to refuse specific types of treatments that are unacceptable to you for any reason. If you would like a standard healthcare power of attorney form, copies are available upon request.

Living Will
In addition to, or as an alternative to, signing a healthcare power of attorney, North Carolina law also allows you to express your wishes concerning a natural death by signing a living will. A living will is a document that protects your right to refuse life-sustaining procedures if you are terminally and incurably ill or in a persistent vegetative state. A living will is an important way by which you can let others know your wishes. It remains effective even if you later become unconscious, unable to speak, or unable to let others know your wishes. For a sample of a living will (also known as a Declaration Of A Desire For A Natural Death) which complies with the requirements of North Carolina law, click here.

Advance Instruction
Under North Carolina law, you may execute an advance instruction for mental health treatment. An advance instruction allows you to consent or to withhold consent for mental health treatment, including electroconvulsive ("shock") treatment, psychotropic medication, and admission and retention in a mental health facility. If you would like a standard statutory form for the advance instruction, copies are available upon request.

Carolinas HealthCare System's Policy
Of course, a living will, healthcare power of attorney and advance instruction are useful only if your doctor, other healthcare professionals involved in your care, your designated healthcare agent, and your family know about them. If you already have a living will, a healthcare power of attorney or an advance instruction, it is very important that you give copies to your doctor.

Even if you decide to sign a living will or healthcare power of attorney indicating your desire that life-sustaining procedures not be used to artificially prolong your life, you will continue to receive customary medical and nursing care to provide comfort, to alleviate pain, and to maintain your dignity. In fact, under North Carolina law, no healthcare agent you appoint has the authority to withhold or discontinue care necessary to provide comfort or alleviate pain.

The principles described above have been included in a written hospital policy on the rights of adult patients to refuse unwanted medical treatment.

Our policy recognizes that an individual has the right to sign a living will, healthcare power of attorney or an advance instruction to express the person's desire for a peaceful and natural death and desire that life-sustaining procedures not be used. We recognize these rights, but in no way discriminate against a person based on whether the individual has signed a living will, healthcare power of attorney or an advance instruction.

Frequently Asked Questions
Q: How do I prepare a living will, healthcare power of attorney or advance instruction?
A: You can prepare a living will by completing the sample of a living will (also known as a Declaration of a Desire For a Natural Death) or a healthcare power of attorney or advance instruction by completing the form available upon request. The document should be signed in the presence of two witnesses who should not be hospital employees, family members or close relatives. The witnesses should sign in the spaces provided for them. The completed document should be notarized by a notary public. Our hospital patient representatives can assist you with the notarization of your living will, healthcare power of attorney or advance instruction and, if necessary, with obtaining witnesses.

When completing the living will, you will need to initial your specific wishes regarding life-sustaining procedures. The living will allows you to authorize your physician to withhold or discontinue life-sustaining treatments including tube feedings (called "artificial nutrition and hydration" in the living will) or allows you to authorize your physician to withhold or discontinue life-sustaining treatments other than tube feedings (called "extraordinary means" in the living will).

In addition, the living will allows you to make different choices depending on whether you are terminally ill or are in a persistent vegetative state. Instructions on completing the healthcare power of attorney and an advance instruction are included with the standard forms available upon request.

Q: How long are living wills, healthcare powers of attorney or advance instructions effective?
A: A living will is effective until it is cancelled by you. Many people suggest, however, that you review, initial and date your living will every few years. A healthcare power of attorney and advance instruction are effective until cancelled by you. If you do not cancel the healthcare power of attorney, but at some point in the future the court appoints a guardian for you, the healthcare power of attorney ceases to be effective. For this reason, healthcare power of attorney forms usually contain a provision by which you may nominate your healthcare agent to be appointed as your guardian, if in the future a guardianship proceeding is necessary. The court is required to consider your wishes when making its appointment of a guardian.

Q: Is it possible to change your mind after signing a living will, healthcare power of attorney or advance instruction?
A: Yes. If you change your mind, you can cancel your living will in any manner by which you are able to communicate your desire to do so. Your cancellation of the living will is effective upon communication of the cancellation to your doctor. You should destroy a cancelled living will as soon as possible.

You may cancel your healthcare power of attorney or advance instruction by signing a document which revokes the healthcare power of attorney or advance instruction, by signing a subsequent Healthcare power of attorney or in any manner by which you communicate your intent to cancel. However, your cancellation of either of these becomes effective only upon your communication of the cancellation to your physician and to your healthcare agent, if you have one.

Q: Is the living will the same as a last will and testament which leaves a person's possessions to others?
A: No, it is not the same. It has nothing to do with your worldly goods.

Q: Does a healthcare agent appointed with a Healthcare power of attorney have any power or authority over my property or financial affairs?
A: A healthcare agent's power is limited to healthcare matters and, except as necessary to provide for your healthcare, the healthcare agent does not have authority over your property or financial affairs. North Carolina does have another law by which you can name a person to act as your attorney-in-fact for financial matters. This type of power of attorney is called a general power of attorney. North Carolina law does allow you to combine a healthcare power of attorney with a general power of attorney and name one person to act as your agent on all matters.

Q: Does a living will or healthcare power of attorney mean that a patient has decided not to have cardiopulmonary resuscitation (CPR)? [CPR is used when a person's heart stops beating or when he or she stops breathing.]
A: No, a living will or healthcare power of attorney does not automatically eliminate the use of CPR. You and your physician should talk about this question together and/or with your family, if appropriate. If you have appointed a healthcare agent, your physician would talk about this question with your healthcare agent.

In addition to speaking with my doctor, who else would be helpful to me in discussing a living will, healthcare power of attorney or advance instruction? We always encourage patients to talk with family members, clergy and friends.