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End of Life Care This article was inspired by an online post by Susan Reynolds which first brought this law to my attention. |
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In January 2009, a law known as Reforma 39:Ley General de Salud was enacted for the purpose of establishing a legal basis for palliative care (pain relief and comfort care) for patients who are expected to live no more than 6 months. The law in Spanish with a side-by-side English translation is here. References to the law are shown throughout this webpage. The original health care law provides few patient rights once a person enters a hospital. It says that medical care must be given, and once it is commenced, it cannot be stopped by the patient. This new law modifies the existing law to allow patients to direct their terminal care. The law applies to terminally ill patients in each of two groups: 1) Those who are mentally alert and able to make informed decisions regarding their care. 2) Those who are not capable of making informed decisions. Here are some of the highlights of the law taken from a Google translation. It will be worth your time to read the entire law. This law adds an eighth title to the Ley General de Salud. It has four chapters. Chapter I Establishes the purpose of the law and provides definitions of several terms used in the law. Among these provisions are: Palliative Care: Is the total active care of those illnesses that cannot be cured. The goal is the control of pain and other symptoms, and psychological care, social and spiritual. (Chapter I, Article 166, Bis 1, III.) Pain management: All those measures provided by health professionals, designed to reduce physical and emotional suffering of a terminal illness product, designed to improve the quality of life. (Chapter I, Article 166, Bis 1, IX) Chapter II Establishes the rights of terminally ill patients. Among these provisions are: To voluntarily leave the health institution where they are hospitalized. (Chapter II, Art. 166, Bis 3, III). To receive clear, timely and sufficient information on the conditions and effects of their disease and types of treatments which can be chosen. (Chapter II, Art. 166, Bis 3, V) To ask the doctor to administer medication to mitigate the pain; resign or leave at any time, refuse to receive or continue treatment considered extraordinary; elect to receive hospice care in a private home (Chapter II, Art 166, Bis 1, VII - IX) A patient in a terminal situation while still able to make informed decisions, has the right to order the session of curative medical treatments and to change to a palliative treatment focused exclusively on the reduction of pain in the form and terms provided in this law. (Chapter II, Art. 166, Bis 5/6). The law allows patients to designate a person authorized to make medical decisions for them if they are unable to make their own informed decisions. (Chapter II, Art. 166, Bis 3, X); and for patients to express their wishes for end of life care in a written health care directive. (Chapter II, Art. 166, Bis 4). Relatives of terminally ill patients have the obligation to respect decisions the patient voluntarily takes in terms of this law. (Chapter II, Art. 166, Bis 10). In cases of medical emergency and there is inability of the patient in a situation terminal to consent, in the absence of relatives, legal representative, guardian or person trust, the decision to implement a medical procedure or surgical treatment necessary will be made by the specialist and/or by the Bioethics Committee of the institution. (Chapter II, Art. 166, Bis 11) Chapter III Powers and Duties of Health Facility. Among these provisions are: Provide palliative care for the type and extent of disease, from time of diagnosis of terminal illness until the last moment; create specialized areas to care for terminally ill patients; and provide training and updating of human resources in the field of palliative care and care for terminally ill patients. (Chapter III, Art 166, Bis 12, IV - VI) Chapter IV Rights, powers and duties of medical and health workers. Among these provisions are: Provide all required information to patient that the doctor feels necessary for the patient to make a free and informed decision about treatment and care. (Chapter IV, Art 166, Bis 15, I) Respect the decision of terminally ill patients in curative treatment and palliative care, once the doctor has explained in simple terms the consequences of the patient's decision. (Chapter IV, Art 166, Bis 15, V) Attending physicians may provide palliative drugs to a patient in terminal situation, even when doing so causes a lose of alertness or shortens the life of the patient, provided that these drugs provide palliative care with the aim of alleviating the patient's pain.. (Chapter IV, Art. 166, Bis 16). There are strict probations against using these drugs for euthanasia. (Chapter IV, Art 166, Bis 16) Preparing the End of Life Care Document The law allows you to prepare the document yourself. There is no requirement that you use a lawyer to prepare it. Here is what you need to do: Read the law so that you understand what provisions you can invoke. Before designating someone who will be authorized to make medical decisions for you, discuss your wishes to be sure the person is willing to act faithfully on your behalf. Provide a copy of your health care directive and the law. Your health care directive should clearly state what care you want or don’t want. It must be based on what is in the law. It would be wise to include references to the paragraph in the law that supports your directive, as I have done in the sample directive below.. If you have a question about exactly what medical directives to include or how to word the directives, discuss it with your doctor. Take a copy of the law with you to be sure the doctor understands its requirements. Your care document must be in Spanish since Spanish is the official language of Mexico. Sign and date the letter in the presence of two witnesses. Then the witnesses will also sign it. Give a copy to your primary care doctor. When you are hospitalized, provide a copy to the medical staff. Have a copy of the health care law attached to your health care directive in case your care giver or hospital staff is not familiar with the law. While this revision of the health care law was officially announced in January 2009, there is ample evidence that it is not widely know in the medical community; so you may have some educating to do with your care givers. That is why it is important for you to have a copy of the law with your directive. The official PDF file can be downloaded here. [Note: This link will open with what appears to be a blank page; it's not. Scroll down.] The following is an example of a health care directive:
TO my doctor, hospital or other health care professionals who may be in attendance when I am unable to express my wishes: When it is determined that my condition is terminal and irreversible and that I’m expected to live less than six months and that I am unable to make informed decisions regarding my care, the following health care directives shall define my care as authorized by Titulo Octavo de Ley General de Salud, a copy of which is attached. When I am comatose or otherwise unable to make informed decisions regarding my care, I authorize [name] to make medical decisions on my behalf in addition to my directives listed below. If [name] is unable to serve, I designate [name]. [Include any of the following example paragraphs or others as you may want and/or as your doctor may recommend: Be sure your directives concur with the law which should be shown where possible. If you include instructions that are beyond the scope of the law, your care giver is not obligated to follow them although he may voluntarily accommodate your wishes.] I want to receive drugs or other treatments that will keep me comfortable and relieve pain even though this may shorten my life. (Chapter IV, Art 166, Bis16) I do not want any extraordinary life sustaining measures. This includes being connected to any machines, heart resuscitation and intravenous fluids. (Chapter IV, Art 166, Bis17 and 18) When practical, I want to receive palliative care in a private home. (Chapter II, Article 166, Bis 3 IX) This decision should be made by my designated representative in consultation with my doctor. I write this while I am mentally capable of making these decisions. (Chapter II, Art 166, Bis 4)
Date: __________
Witness
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Here is a Google translation of the example letter. A mi médico, hospital u otros profesionales de la salud que pueden estar presentes cuando no estoy en condiciones de expresar mis deseos: Cuando se determina que mi condición es terminal e irreversible y que soy una esperanza de vida inferior a seis meses y que soy incapaz de tomar decisiones informadas con respecto a mi cuidado, la atención de la salud directivas siguientes definir mi atención de lo autorizado por el Titulo Octavo de la Ley General de Salud, cuya copia se adjunta. Cuando estoy en estado de coma o no pueda tomar decisiones informadas con respecto a mi cuidado, yo autorizo a [name] para tomar decisiones médicas en mi nombre, además de mi directivas que figuran a continuación. Si [nombre] es incapaz de servir, designo a [nombre]. Deseo recibir medicamentos u otros tratamientos que me mantendrá cómodo y aliviar el dolor, aunque esto puede acortar mi vida. (Capítulo IV, Art. 166, Bis16) No quiero que ninguna de la extraordinaria vida de las medidas de mantenimiento. Esto incluye estar conectado a ninguna máquina, la reanimación del corazón y los líquidos intravenosos. (Capítulo IV, Art. 166, Bis 17 y 18) Cuando sea posible, quiero recibir los cuidados paliativos en un domicilio particular. (Capítulo II, artículo 166 Bis 3 IX) Esta decisión debe ser tomada por mi representante designado en consulta con mi médico. Escribo esto ahora que estoy mentalmente capaz de tomar estas decisiones. (Capítulo II, artículo 166, Bis 4) Fecha:
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