Put an “Ironclad Strategy” in place, so others will honor your end–of–life wishes

Complete the Natural Dying Forms to create your “Ironclad Strategy” to ensure others will honor your wishes and to eliminate possible future conflicts.

Your Natural Dying—Living Will form is the fundamental component of the “Plan Now, Die Later—Ironclad Strategy.” Its strategy is simple: to be clinically clear and specific. The legal strategy illustrated above is optional. Another optional legal strategy can resolve the potential conflict if your “future demented self” forgets how to attain the goal of your Living Will. Other optional strategies strive to conform to the teachings of conservative religions—to reduce possible opposition.

Confidence in an effective plan can save lives. To explain: Most people want a timely and peaceful transition—after they reach Advanced Dementia. Lack of knowledge or confidence in any plan now leads some Early Dementia patients to act on their “Dementia Fear.” This is the realistic fear that others will force them to endure a prolonged dying in Advanced Dementia. The “Ironclad Strategy” makes it unnecessary for patients to hasten their dying so they do not have to lose years of precious living with loved ones that would be not just sad but also tragic—if the only reason they chose to die prematurely was because they were NOT informed.

One of life's greatest ironies is that the freedom to control WHEN
you die—can and often does—lead to deciding to live longer.

This statement expresses an important part of Caring Advocates' mission: a timely dying; that is, to live longer.

"Freedom" is based on two RIGHTS. Your legal "right" imposes an obligation on others that it be honored:
You have two rights: The right to be INFORMED and the right to expect others to HONOR your decisions. 

Here again, is our mission statement:

Caring Advocates’ clinical, legal, and pastoral professionals are dedicated to helping people attain peaceful and timely transitions. Our Plan Now, Die Later™ strategic approach to Advance Care Planning effectively reduces prolonged suffering. Confidence that others will honor their wishes lets patients decide to live longer.

Natural Dying Advance Directive

The Natural Dying Advance Directive is a pivotal form in the “Plan Now, Die Later—Ironclad Strategy.” This one-page form refers to the Natural Dying—Living Will and can also refer to, or incorporate three other forms. Depending on how you choose to sign it, this form can be a pure Living Will or a combined Living Will and a Proxy Directive (Durable Power of Attorney for Health Care), which is recommended.

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The form allows you to write in your first choice proxy's name and contact information; and the names of “other important professionals/organizations involved your care,” including your Comfort Care physician, counselors, attorney, relatives, friends, and organizations. This form also allows you to list any individuals whom you wish to disqualify from being able to make medical decisions for you when you no longer can make those decisions, yourself; for example, those who hold different religious beliefs or who may be greedy and not want to pay for treatment that may extend your life.

Note: for strategic purposes, the Natural Dying Advance Directive (NDAD) is physically combined with the Natural Dying Physician's Order (Natural Dying Physician's Orders, Form #5). Each form is on one side of the same sheet of heavy yellow card stock. Together these two forms provide legal durability of your Known Wishes (NDAD) and clinical authority of physician's orders (NDPO).

To be effective, the Natural Dying Advance Directive must be consistent with other forms that also express your end-of-life wishes. That is why the form asks you, “In the event of a conflict with other Advance Care forms, including a POLST/MOLST/POST, do you want this NDAD/NDPO to prevail–, regardless of when other forms are dated?” (We recommend you answer, “Yes.”)

To explain the use of other forms: Your State form may be convenient and you may like certain instructions included on other forms. The new POLST/MOLST/POST forms (Physician's Order for Life-Sustaining Treatment) are useful to discuss and to implement physician's orders during the last year of life since they can be revised from Full Treatment to Intermediate Treatment and to Comfort Measures Only. It is important to realize however that these forms do NOT generally include an order to refuse Manual Assistance with Oral Feeding and Drinking or allow you to consent to Palliative Sedation for unending, unbearable pain and suffering. You may feel you need both of these options if you want to avoid lingering in Advanced Dementia and unbearable end-of-life pain and suffering.

The Natural Dying Advance Directive includes the Natural Dying Physician's Orders, which Caring Advocates will send both to you and/or to your physician.

Designation of Proxies/Agents; Specifying Their Authorities

The Designation of Proxies/Agents; Specifying Their Authorities is a four-page form that you can attach to your Natural Dying Advance Directive. (A one-page supplemental page of explanation is included.)

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The form:
a) provides spaces to add your second and third choice proxies;
b) gives you the option to have your proxy's authority begin immediately upon signing the form (based on the included explanation);
c) lets you specify your proxy/agent's authority, which includes powers beyond those typically granted by other Advance Directive forms and which may someday be needed if you want to attain the goal of a timely, peaceful transition by Natural Dying; and
d) is for those people who prefer to use two qualified individuals to witness their signature - instead of having a notary acknowledge their signature. Some examples of these signature pages are also included with our Living Will Package-Books.

Natural Dying Organ Donation Consent Form

The Natural Dying Organ Donation Consent Form is a two-page optional form (plus a one-page explanation) that you may attach to your Natural Dying Advance Directive.

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The form gives you two choices that few if any other Advance Directives offer:

A) You can implicitly allow your future physicians or institutions or State to define the “moment of death” for purposes of “procuring” your vital organs; versus,
B) You can voluntarily consent to donate your organs by using the same criteria you previously specified for Natural Dying.

The traditional alternative of the “Dead Donor Rule” sounds comforting to many: The medical profession will never procure your vital organs while you are still alive. What is the problem with that? The way they define “death.” Some experts consider it as a “politically convenient myth” that places you at risk for experiencing pain as they procure your organs. Abandoning the “Dead Donor Rule” is a growing and vigorously debated but still minority view.

These two alternatives are explained further on the supplemental page. Note: The Natural Dying Organ Donation Consent Form is NOT part of the “ironclad strategy.” You may therefore take extra time to think about your choice and decide later, when you are sure.

Natural Dying Physician's Order

The Natural Dying Physician's Order form confirms that you and your physician discussed and then you gave your informed consent based on your decision that these physician's orders did reflect your end–of–life wishes.

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There are two reasons why it is important that your physician also sign: the first is to verify that you gave your informed consent; the second is to confirm your physician's willingness to write relevant orders to fulfill your end–of–life wishes.
The NDPO form
a) lets you state your wishes to refuse Manual Assistance with Oral Feeding and Drinking, which you can choose to make irrevocable;
b) lets you write the names of institutions to which you do not want to be transferred/transported (if you doubt they will comply with your specific end–of–life wishes); and
c) allows you to give your consent to Palliative Sedation—if you refer to, and attach a Consent Form to Obtain Relief from Unbearable Suffering by Palliative Sedation

Note: Caring Advocates can send this form directly to your physician or to you, or both. Of course, it will be attached to your Natural Dying Advance Directive because this form is on the other side of the same sheet of yellow heavy card stock.

Consent to Relieve Unbearable Suffering / Palliative Sedation

The Consent Form to Obtain Relief from Unbearable Suffering by Palliative Sedation is needed if you DO want relief from endless, unbearable, end–of–life pain and suffering.

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You may attach this two–page form to your Natural Dying Physician's Orders form. The Palliative Sedation Consent Form lets you detail your specific wishes for this method of Comfort Care. You can discuss your completed form with your physician and then sign it to indicate your consent. It will then become part of your Physician's Orders, which implies your physician has agreed to provide Palliative Sedation, if you need it, someday. If your physician refuses to sign the NDPO that verifies that you wish to give your consent, then you must ask another physician if you want relief from unbearable, end–of–life pain and suffering.

Natural Dying Agreement

The Natural Dying Agreement form is a nineteen page form to which your Natural Dying Advance Directive may refer.

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The form
a) allows you to clarify WHY you want WHAT you want–in detail, and in your own handwriting;
b) demonstrates your conviction by agreeing to an irrevocable, bilateral contract with your proxy; and
c) empowers your proxy/agent to override “decisions” made by your “future demented self” if they would sabotage your goal of a timely, peaceful transition. This last authority is an important component of the “ironclad strategy” since it similarly empowers your proxy to overcome challenges by others who oppose your wish for Natural Dying.

Natural Dying Affidavit

The Natural Dying Affidavit is a four page form that has enhanced legal force based on your swearing an oath before a notary that its contents are true and correct.

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The form's content
a) summarizes your Known Wishes;
b) directs your proxy “to seek declaratory or injunctive relief to effectuate [your] originally expressed, competent wishes...”; and
c) directs your proxy to sue any entity who fails to honor your Known Wishes, or who accedes to requests by your “future incompetent self” to delay your Natural Dying.

Your proxy/agent may use this form only if necessary to motivate your future physician or institution to honor your Known Wishes. This form is designed to be used along with the Natural Dying Agreement.

Dr. Terman has accurately and respectfully presented the Catholic position(s). I agree with the values he holds most dear: To do everything possible to learn directly from the patient what she or he wants; and to appreciate that one of life’s greatest joys—to be heard and respected—is especially true for needy and vulnerable patients in the last chapter of their lives.

John Gillman, Ph.D., ACPE Supervisor of Clinical Pastoral Education; VITAS Innovative Hospice Care, San Diego, California