If you were in a hospital bed, severely brain damaged and unable to speak for yourself, would you want distraught family members to guess or, even worse, debate your end-of-life wishes?

Several state legislatures have created Web-based applications to help families avoid this situation by making advance directives accessible to physicians. Advance directives are a set of specific care instructions, pre-established by individuals to help hospital physicians and emergency-care responders honor patients' medical demands in case of incapacitation.

Such demands include artificial ventilation and nutrition, and in some cases organ donations. The most common of these directives are the living will and the durable power of attorney for health care, in which an individual designates a medical proxy.

Because these directives are often stored by lawyers and family physicians who observe regular business hours, they become virtually useless in the event of an after-hours incident. In other equally counterproductive cases, advance directives are simply kept at home, relegated to a shoebox.

Although the Terry Schiavo case is the freshest in many minds, similar high-profile cases in the mid- to late-1980s prompted private organizations to not only look for ways to educate people on the importance of advance directives, but also make them easily accessible to health-care providers. The Internet rapidly became the medium of implementation.

North Carolina, Arizona and Montana have since followed these initiatives and adapted the concept to their own legal systems. Washington state, the latest to undertake online advance directives project, will look to its predecessors in the public and private sectors for best practices.

What Would Washington Do?

On March 17, 2006, Washington Gov. Christine Gregoire signed HB 2342, requiring the state's Department of Health (DOH) to launch the state's first electronic registry for advance directives.

"We're currently reviewing the applications already in place in other states," said Jennifer Tebaldi, director of policy for Epidemiology, Health Statistics and Public Health Laboratory, a division of the DOH. "Some of them developed their own database, some of them contracted it out," she continued, adding that under the bill, which allotted the project $324,000 for fiscal 2007, Washington has both options.

The state also is discussing ways to address Web-related security issues, such as privacy and access. Tebaldi explained that the system will be password-protected to deny unauthorized access. The challenge, however, will be to allow hospital staff to access the directives in all situations.

"We're thinking about the doctor, nurses or any other health-care providers who need access," Tebaldi said. "How are they going to do that if they haven't been given the password by the persons themselves?"

Dr. Jim Shaw, medical director and staff ethicist at the Providence Center for Faith and Healing at Sacred Heart Medical Center in Spokane, Wash., said physicians regularly face situations in which patients are brought in unconscious, and their families forgot to bring or don't have their advance directives.

"If there's another way of getting them, such as online, in a quick and reliable fashion, I think it will be accepted as a step forward," Shaw said. "In those places, where physicians are not used to accessing electronic medical records, they'll probably look at this as a pie in the sky. It's going to require a lot of education and a lot of people siding for it to make it worthwhile for people to check."

Some health professionals worry about the extent of their liability if the system is unavailable, and should families, dissatisfied with doctors' treatment choices, attempt to sue. Shaw, however, said he wasn't too concerned with such issues.

"That's a question that I think people will be reassured about as they learn more about the program. The default position is always to treat the patients in a life-saving way, and when

Corine Stofle  |  Staff Writer