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ELIZABETH BRANDT did her family a favor. She told them how she wanted to die.
Brandt filled out an advance directive 15 years ago just after moving from Illinois to Fredericksburg to be near her daughter. The document sat in her safe until last year when Brandt fell and broke her hip for the second time.
The 87-year-old never really recovered from the fall, and finally, as she was near death at Mary Washington Hospital, her daughter, JoAnn Sowards, pulled out the advance directive.
"I think it was one of the most precious gifts a parent can give a child," Sowards said.
As Brandt's case illustrates, an advance directive, or living will, can speak for those who are terminally ill and unable to speak for themselves.
Kimberly Hayden, executive director of the Fredericksburg-based Hospice Support Care, said that many of her clients already have an advance directive when they call for help.
Many others, though, are uncomfortable with the idea. Sometimes, when Rosalie M. Sullivan, patient advocate at Mary Washington Hospital, asks about them, patients will tell her, "I'm not old enough for that," or "I just got better news from the doctor than I thought, so I don't need it."
"I'm delighted you got good news," Sullivan replies, "but you may want to think about expressing your wishes."
The advance directive has nothing to do with "what you want to do with your stuff," Sullivan said. Instead, it represents a chance for patients to plan their final days.
In Virginia and many other states, an advance directive is legally binding and doesn't require the help of an attorney or notary to fill out.
In one of its most popular forms--The Five Wishes--a person starts by naming someone to make health-care decisions for them if they are unable. Often this person is a best friend rather than a spouse or family member.
As The Five Wishes document says, "A spouse or family member may not be the best choice because they are too emotionally involved."
The patient also lists the kind of treatment they expect if they are seriously ill and close to death. Most important, they can decide on the use of life-support measures, such as a ventilator for breathing or tubes for food, water or antibiotics.
Patients also can request that their doctor issue a "do not resuscitate" order if they're opposed to using CPR when their heart stops.
Usually, patients don't want these aggressive measures if they artificially prolong the dying process, Hayden said. With the Virginia Advance Medical Directive, a document approved by the Virginia General Assembly in 1992, the patient says he or she wants "to die naturally."
But dying naturally doesn't mean dying in pain, Hayden said. Patients almost always ask to be pain-free and comfortable.
The Five Wishes document is even more specific, asking patients whether they want to die in their homes, the type of music they want, and whether they want friends to pray for them.
Hayden said some of her hospice clients have said that they want to be well-groomed, or they might insist that their pet always be nearby.
"Some have said to 'make sure I always have my glasses on even if I can't see,'" Hayden said.
Health-care institutions, such as hospitals and hospices, are required by federal law to inform patients about their rights to decide on the type of medical care they receive.
At Hospice Support Care, the advance directive is one of the first things that hospice workers talk about with a client. If death appears imminent, the hospice worker may sit with the family and help them fill it out, Hayden said. If the client appears to have time, the worker may leave the document with the family and discuss it later.
The advance directive also is useful if a family member lives in another part of the country and has not been involved in day-to-day care. Sometimes, this distance can lead to disagreements.
"These documents help settle it," Hayden said.
Sowards and her brother, Perry Brandt, did not disagree on the care of their mother. Still, the advance directive proved useful when Perry Brandt drove from Indiana to Fredericksburg to help with her care.
By then, Elizabeth Brandt had stopped eating and talking and didn't seem to recognize her family. She was conscious but not aware, receiving food, water and medicine intravenously.
"This was no longer my mother," Sowards said. "I started thinking, 'This isn't getting any better.'"
When Sowards and her brother read the advance directive, they could see that Brandt had made her wishes clear.
"My mother was not shy about saying what she wanted," Sowards said. "She didn't want to be kept alive artificially in any way."
Still, Sowards and her brother hesitated, as many families do.
"You're the one that's standing there, making God's choice of life and death," Hayden said.
They asked to talk with Dr. Rebecca Bigoney, co-chairwoman of the hospital's clinical ethics committee.
"We wanted to be assured that we were doing the ethical thing," Sowards said.
Bigoney told Sowards and her brother that they were doing as their mother had requested.
"It was all there in black and white," Sowards said.
Finally, they decided to make sure that their mother was comfortable but to end all other treatment. Brandt was transferred to the hospital's Palliative Care Unit and died there the next day. It had been about a month since she was first admitted.
The advance directive made clear what her mother's wishes were, Sowards said, and it freed the family from guilt for the decisions they made.
"This was what my mother would want, no matter how hard it was," Sowards said.
An advance directive expresses a person's wishes, but there is no guarantee that those wishes will be carried out. Sometimes, family members or medical personnel do not do as instructed.
For example, one of Hayden's clients wrote in her advance directive that she wanted to die at home. However, her son was not comfortable with that and insisted that his mother remain at the hospital.
At Mary Washington, when patients with terminal conditions ask that no life support be used, the hospital will honor their wishes.
Said Sullivan, "We will do our best to bring the family to an understanding what the patient's medical condition is and what our understanding of their wishes are."
To obtain a free copy of the three-page Virginia Advance Medical Directive, stop by either office of The Free Lance-Star, 616 Amelia St., Fredericksburg, or 616 Garrisonville Road, Stafford. You can also request a copy by sending an e-mail to newsroom@freelance-star.com. Please include your name and mailing address.