Triggers for Hiccups:

• Hot or spicy foods
• Strong fumes
• If you eat too fast, you can swallow air along with your food and end up with a case of the hiccups
• Pleurisy, pneumonia or damage to the area of the brain that controls the “hiccup center” may lead to more frequent outbreaks

How to Control Hiccups

• At Home Remedies
• Holding your breath,
• Drinking a glass of cold water or
• Eating a teaspoon of sugar
• May also try holding a paper bag to your mouth and breathing in and out for a few minutes
• Medical Treatment (For More Severe Hiccups not getting better with home remedies)
  Contact Doctor to get evaluated. He may prescribe medications to control them. Chlorpromazine (Thorazine) is usually the first prescription medication tried for hiccups, although drugs such as baclofen (Lioresal) and medications for convulsions such as phenytoin (Dilantin) have also been successful.
• Surgery to disable the phrenic nerve (the nerve that controls the diaphragm) is often the treatment of last resort.

While it is rare for hiccups to last more than a few minutes, if yours continue for more than a few days, the NLM says you should see a doctor.

Reference:

1. eMedicine - Consumer Health - Hiccups
2. NCEMI - Singultus (Hiccups)

• Before you eat, ask: “Do I feel hungry?”. If yes, then eat. But, if not, don’t kill your boredome with eating.
• Make simple subsitution in your diet. Eat an orange instead of an orange juice from concentrate. 
• Reverse the Meat-to-Potatoes ratio. Instead of steak with brocolli stalk as garnish, make vegetable and whole grains the centerpiece, and use meat, fish, or poultry as a side dish.
• Go lean. Choose low-fat frozen yogurt instead of ice cream; Baked potatoes instead of french fries; Order a sanwich of lean roast beef instead of pastrami p or choose turkey or chicken breast.
• Avoid Multi-Tasking. Turn off TV and phone on mealtime.
• Eat Calmly and quietly. Don’t discuss work, taxes, and day-to-day hassles at the dinner table.

Sources:

1. Health Magazine, April 6, 2006.
2. Know Your Eating Style, Health Magazine

It is thought to be caused by debris which has collected within a part of the inner ear. This debris are small crystals of calcium carbonate derived from a structure in the ear called the “utricle”. Normally, these particles are distributed evenly in the inner ear’s 3 canals. When you move your head, the calcium particles stimulate nerve cells inside the canals. These cells send your brain a signal telling it what direction your head is moving.

However, the particles can break loose and clump together forming a debris in one of the canals. When this happens, the nerve cells tell your brain that your head has moved more than it actually has. This incorrect signal results in vertigo.

How it is treated?

The most common manuevre to treat BPPV is Epley maneuver. It is usually performed in the doctor’s office. If done correctly, it has a very high success rate(approximately 85-90%).

The Epley maneuver is also called the particle repositioning, canalith repositioning procedure, and modified liberatory maneuver. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.

Epley maneuver steps (1):

• Have the patient sit upright on the gurney with the head turned 45° to the affected side (this was predetermined using the Hallpike test). Make sure the patient is sitting far enough back in the gurney so that the head will hang over the edge of the gurney when the patient is laid back. Make sure the guardrail on the opposite side has been lowered (the patient will eventually sit up so his or her legs overhang the edge of the gurney).
• Place your hands on either side of the patient’s head and guide the patient down with the head dependent (as in the Hallpike test).
• Rotate the head 90° to the opposite side with the patient’s face upward and be sure to maintain the head-dependent position (head is hanging over the edge of the gurney).
• Ask the patient to roll onto his or her side while holding the head in this position and then rotate the head so that it is facing downward (tell the patient to look to the ground).
• Raise the patient to a sitting position while maintaining head rotation (This author finds that sitting the patient up so that he or she is sitting with his legs hanging over the edge of the gurney is easier. This is why the side guardrails need to be lowered before the procedure is started).
• Simultaneously rotate the head to a central position and move it 45° forward.

You CAN WATCH the VIDEO here.

References:

1. Benign Positional Vertigo - eMedicine.com
2. Dizziness and Vertigo - Medlineplus.gov

We all have and need fat tissue in our bodies. When there is increased amount of fat in the body that’s when problem arises. The amount of fat is determined by individual’s Body Mass Index (BMI). Individuals with a BMI of 25 to 29.9 are considered overweight, while individuals with a BMI of 30 or more are considered obese. NOTE: Overweight may or may not be due to increases in body fat. It may also be due to an increase in lean muscle. For example, professional athletes may be very lean and muscular, with very little body fat, yet they may weigh more than others of the same height. While they may qualify as “overweight” due to their large muscle mass, they are not necessarily “over fat,” regardless of BMI. Obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass¹.  The amount of body fat (or adiposity) includes concern for both the distribution of fat throughout the body and the size of the adipose tissue deposits.

ASSESSING OBESITY:

Obesity can be assessed by Body Mass Index (BMI), Waist Circumference, and by Waist-to-Hip circumference Ratio (WHR). Body fat distribution can also be estimated by other techniques such as ultrasound, computed tomography, or magnetic resonance imaging.

1. Body Mass Index(BMI)
   BMI is a common measure expressing the relationship (or ratio) of weight-to-height. It is a mathematical formula in which a person’s body weight in kilograms is divided by the square of his or her height in meters (i.e., wt/(ht)2. The BMI is more highly correlated with body fat than any other indicator of height and weight. According to NIH Clinical Guidelines², all adults (aged 18 years or older) who have a BMI of 25 or more are considered at risk for premature death and disability as a consequence of overweight and obesity. These health risks increase even more as the severity of an individual’s obesity increases.
2. Waist Circumference
   Waist circumference is a common measure used to assess abdominal fat content. The presence of excess body fat in the abdomen, when out of proportion to total body fat, is considered an independent predictor of risk factors and ailments associated with obesity.Undesirable waist circumferences differ for men and women.
• Men are at risk who have a waist measurement greater than 40 inches (102 cm).
• Women are at risk who have a waist measurement greater than 35 inches (88 cm).
  NOTE: If a person has short stature (under 5 feet in height) or has a BMI of 35 or above, waist circumference standards used for the general population may not apply.
3. Waist-to-Hip Ratio(WHR)
   Waist-to-hip ratio (WHR) is the ratio of a person’s waist circumference to hip circumference, mathematically calculated as the waist circumference divided by the hip circumference. For most people, carrying extra weight around their middle increases health risks more than carrying extra weight around their hips or thighs. (NOTE: Overall obesity is still more risky than body fat storage locations or waist-to-hip ratio.)
• What waist-to-hip ratio is considered risky? For both men and women, a waist-to-hip ratio of 1.0 or higher is considered “at risk” or in the danger zone for undesirable health consequences such as heart disease and other ailments connected with being overweight.
• What is a good waist-to-hip ratio? For men, a ratio of .90 or less is considered safe. For women, a ratio of .80 or less is considered safe.

HEALTH EFFECTS OF OBESITY^2,3

Persons with obesity are at increased risk of developing serious medical conditions, which can cause poor health and premature death. Obesity is associated with more than 30 medical conditions, and scientific evidence has established a strong relationship with at least 15 of those conditions. Weight loss of about 10% of body weight, for persons with overweight or obesity, can improve some obesity-related medical conditions including diabetes and hypertension.

1. Arthritis (Osteoarthritis)
• Obesity is associated with the development of Osteoarthritis (OA) of the hand, hip, back and especially the knee.
• At a Body Mass Index (BMI) of > 25, the incidence of OA has been shown to steadily increase.
• Modest weight loss of 10 to 15 pounds is likely to relieve symptoms and delay disease progression of knee OA.
2. Birth Defects
• Maternal obesity (BMI > 29) has been associated with an increased incidence of neural tube defects (NTD) in several studies, although variable results have been found in this area.
• Folate intake, which decreases the risk of NTD’s, was found in one study to have a reduced effect with higher pre-pregnancy weight.
3. Cancers
• Breast Cancer
• Postmenopausal women with obesity have a higher risk of developing breast cancer. In addition, weight gain after menopause may also increase breast cancer risk.
• Women who gain nearly 45 pounds or more after age 18 are twice as likely to develop breast cancer after menopause than those who remain weight stable.
• High BMI has been associated with a decreased risk of breast cancer before menopause. However, a recent study found an increased risk of the most lethal form of breast cancer, called inflammatory breast cancer (IBC), in women with BMI as low as 26.7 regardless of menopausal status.
• Premenopausal women diagnosed with breast cancer who are overweight appear to have a shorter life span than women with lower BMI.
• The risk of breast cancer in men is also increased by obesity.
4. Cancers of the Esophagus and Gastric Cardiac
• Obesity is strongly associated with cancer of the esophagus and the risk becomes higher with increasing BMI.
• The risk for gastric cardiac cancer rises moderately with increasing BMI.
5. Colorectal Cancer
• High BMI, high calorie intake, and low physical activity are independent risk factors of colorectal cancer.
• Larger waist size (abdominal obesity) is associated with colorectal cancer.
6. Endometrial Cancer (EC)
• Women with obesity have three to four times the risk of EC than women with lower BMI.
• Women with obesity and diabetes are reported to have a 3-fold increase in risk for EC above the risk of obesity alone.
• Body size is a risk factor for EC regardless of where fat is distributed in the body.
7. Cardiovascular Disease (CVD)
• Obesity increases CVD risk due to its effect on blood lipid levels.
• Weight loss improves blood lipid levels by lowering triglycerides and LDL (“bad”) cholesterol and increasing HDL (“good”) cholesterol.
• Weight loss of 5% to 10% can reduce total blood cholesterol.
• The effects of obesity on cardiovascular health can begin in childhood, which increases the risk of developing CVD as an adult.
• Overweight and obesity increase the risk of illness and death associated with coronary heart disease.
• Obesity is a major risk factor for heart attack, and is now recognized as such by the American Heart Association.
8. Daytime Sleepiness
• People with obesity frequently complain of daytime sleepiness and fatigue, two probable causes of mass transportation accidents.
• Severe obesity has been associated with increased daytime sleepiness even in the absence of sleep apnea or other breathing disorders.
9. Diabetes (Type 2)
• As many as 90% of individuals with type 2 diabetes are reported to be overweight or obese.
• Obesity has been found to be the largest environmental influence on the prevalence of diabetes in a population.
• Obesity complicates the management of type 2 diabetes by increasing insulin resistance and glucose intolerance, which makes drug treatment for type 2 diabetes less effective.
• A weight loss of as little as 5% can reduce high blood sugar.
10. Gallbladder Disease
• Obesity is an established predictor of gallbladder disease.
• Obesity and rapid weight loss in obese persons are known risk factors for gallstones.
• Gallstones are common among overweight and obese persons. Gallstones appear in persons with obesity at a rate of 30% versus 10% in non-obese.
11. Hypertension
• Over 75% of hypertension cases are reported to be directly attributed to obesity.
• Weight or BMI in association with age is the strongest indicator of blood pressure in humans.
• The association between obesity and high blood pressure has been observed in virtually all societies, ages, ethnic groups, and in both genders.
• The risk of developing hypertension is five to six times greater in obese adult Americans, age 20 to 45, compared to non-obese individuals of the same age.
12. Infertility
• Obesity increases the risk for several reproductive disorders, negatively affecting normal menstrual function and fertility.
• Weight loss of about 10% of initial weight is effective in improving menstrual regularity, ovulation, hormonal profiles and pregnancy rates.
13. Low Back Pain
• Obesity may play a part in aggravating a simple low back problem, and contribute to a long-lasting or recurring condition.
• Women who are overweight or have a large waist size are reported to be particularly at risk for low back pain.
14. Sleep Apnea
• Obesity, particularly upper body obesity, is the most significant risk factor for obstructive sleep apnea.
• There is a 12 to 30-fold higher incidence of obstructive sleep apnea among morbidly obese patients compared to the general population.
• Among patients with obstructive sleep apnea, at least 60% to 70% are obese.
15. Stroke
• Elevated BMI is reported to increase the risk of ischemic stroke independent of other risk factors including age and systolic blood pressure.
• Abdominal obesity appears to predict the risk of stroke in men.
• Obesity and weight gain are risk factors for ischemic and total stroke in women.

TREATMENT GOALS

Treatment of the overweight and obese patient is a two-step process: assessment and management. Assessment requires determination of the degree of obesity and absolute risk status. Management includes both weight control or reducing excess body weight and maintaining that weight loss as well as instituting other measures to control associated risk factors. It is also important to note that prevention of further weight gain can be a goal for some patients. Obesity is a chronic disease, and both the patient and the practitioner need to understand that successful treatment requires a life-long effort.

Goals
The general goals of weight loss and management are:

• To reduce body weight.
• To maintain a lower body weight over the long term.
• To prevent further weight gain.

Specific targets for each of these goals can be considered. The initial target goal of weight loss therapy for overweight patients is to decrease body weight by about 10 percent. If this target can be achieved, consideration can be given to the next step of further weight loss.A reasonable time line for weight loss is to achieve a 10 percent reduction in body weight over 6 months of therapy. For overweight patients with BMIs in the typical range of 27 to 35, a decrease of 300 to 500 kcal/day will result in weight losses of about 1/2 to 1 lb/week and a 10 percent weight loss in 6 months. For more severely obese patients with BMIs 35, deficits of up to 500 to 1,000 kcal/day will lead to weight losses of about 1 to 2 lb/week and a 10 percent weight loss in 6 months.

STRATEGIES FOR WEIGHT LOSS AND WEIGHT MAINTENANCE^2,3

Recommendations for treatment are now focusing on 10 percent weight loss to help patients with long-term maintenance of weight loss. Health professionals including physicians, nutritionists, exercise physiologists, psychologists and bariatric surgeons help persons with overweight and obesity to determine the most appropriate treatment. The interventions listed below are intended to give an overview of each treatment option and does not take the place of medical advice from a health professional.

1. Dietary Therapy
• Dietary therapy consists, in large part, of instructing patients on how to modify their diets to achieve a decrease in caloric intake.
• Reducing calories moderately is essential to achieve a slow but steady weight loss, which is also important for maintenance of weight loss. Low calorie diet (LCD - 800 to 1,500 kcal/day) is to be distinguished from a very low-calorie diet (VLCD) (250 to 800 kcal/day), which has been unsuccessful in achieving weight loss over the long term.
• Successful weight reduction by LCDs is more likely to occur when consideration is given to a patient’s food preferences in tailoring a particular diet. Educational efforts should pay particular attention to the following topics:
• Energy value of different foods;
• Food composition: fats, carbohydrates (including dietary fiber), and proteins;
• Reading nutrition labels to determine caloric content and food composition;
• New habits of purchasing: preference to low-calorie foods;
• Food preparation: avoiding adding high-calorie ingredients during cooking (e.g., fats and oils);
• Avoiding over-consumption of high-calorie foods (both high-fat and high-carbohydrate foods);
• Maintaining adequate water intake;
• Reducing portion sizes;
• Limiting alcohol consumption.
2. Physical Activity
• Physical activity contributes to weight loss, both alone and when it is combined with dietary therapy.
• Physical activity should be initiated slowly, and the intensity should be increased gradually. Initial activities may be walking or swimming at a slow pace. With time, depending on progress, the amount of weight lost, and functional capacity, the patient may engage in more strenuous activities. Some of these include fitness walking, cycling, rowing, cross-country skiing, aerobic dancing, and rope jumping.
• Physical activity should be an integral part of weight loss therapy and weight maintenance. Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week
3. Behavior Therapy
• Behavior therapy involves changing diet and physical activity patterns and habits to new behaviors that promote weight loss.
• The aim is to change eating and physical activity behaviors over the long term. Such change can be achieved either on an individual basis or in group settings. Group therapy has the advantage of lower cost. Specific behavioral strategies include the following:
• Self-monitoring of both eating habits and physical activity—Objectifying one’s own behavior through observation and recording is a key step in behavior therapy. Patients should be taught to record the amount and types of food they eat, the caloric values, and nutrient composition. Keeping a record of the frequency, intensity, and type of physical activity likewise will add insight to personal behavior. Extending records to time, place, and feelings related to eating and physical activity will help to bring previously unrecognized behavior to light.
• Stress management—Stress can trigger dysfunctional eating patterns, and stress management can defuse situations leading to overeating. Coping strategies, meditation, and relaxation techniques all have been successfully employed to reduce stress.
• Stimulus control—Identifying stimuli that may encourage incidental eating enables individuals to limit their exposure to high-risk situations. Examples of stimulus control strategies include learning to shop carefully for healthy foods, keeping high-calorie foods out of the house, limiting the times and places of eating, and consciously avoiding situations in which overeating occurs (580).
• Problem solving—This term refers to the self-corrections of problem areas related to eating and physical activity. Approaches to problem solving include identifying weight-related problems, generating or brainstorming possible solutions and choosing one, planning and implementing the healthier alternative, and evaluating the outcome of possible changes in behavior (580). Patients should be encouraged to reevaluate setbacks in behavior and to ask “What did I learn from this attempt?” rather than punishing themselves.
• Contingency management—Behavior can be changed by use of rewards for specific actions, such as increasing time spent walking or reducing consumption of specific foods (44). Verbal as well as tangible rewards can be useful, particularly for adults. Rewards can come from either the professional team or from the patients themselves. For example, self-rewards can be monetary or social and should be encouraged.
• Cognitive restructuring—Unrealistic goals and inaccurate beliefs about weight loss and body image need to be modified to help change self-defeating thoughts and feelings that undermine weight loss efforts. Rational responses designed to replace negative thoughts are encouraged (580). For example, the thought, “I blew my diet this morning by eating that doughnut; I may as well eat what I like for the rest of the day,” could be replaced by a more adaptive thought, such as, “Well, I ate the doughnut this morning, but I can still eat in a healthy manner at lunch and dinner.”
• Social support—A strong system of social support can facilitate weight reduction. Family members, friends, or colleagues can assist an individual in maintaining motivation and providing positive reinforcement. Some patients may benefit by entering a weight reduction support group. Overweight patients should be asked about (possibly) overweight children and family weight control strategies. Parents and children should work together to engage in and maintain healthy dietary and physical activity habits.
4. Drug Therapy
• Drug therapy is recommended as a treatment option for persons with: 1) a Body Mass Index (BMI) > 30 with no obesity-related conditions or 2) a BMI of > 27 with two or more obesity-related conditions.
• Drug treatment should be used with appropriate lifestyle modifications.
• Drug therapy may be used for weight loss and weight maintenance.
• Patients should be regularly assessed to determine the effect and continuing safety of a drug.
• Three weight loss drugs, approved by the US Food and Drug Administration (FDA) for treating obesity, are Orlistat (Xenical), Phentermine, and Sibutramine (Meridia).
• Orlistat works by blocking about 30 percent of dietary fat from being absorbed, and is the most recently approved weight loss drug. Note: This drug may cause decrease in absorption of fat-soluble vitamins; soft stools and anal leakage.
• Phentermine, an appetite suppressant, has been available for many years. It is half of the “fen-phen” combination that remains available for use. The use of phentermine alone has not been associated with the adverse health effects of the fenfluramine-phentermine combination. Note: These drugs can cause Valvular heart disease, Primary pulmonary hypertension or Neurotoxicity.
• Sibutramine (Norepinephrine, dopamine, and serotonin reuptake inhibitor) is an appetite suppressant approved for long-term use. Note: This drug may cause Increase in heart rate and blood pressure.
5. Combined Therapy
• A combination of a diet (with lower calories) and increased physical activity is reported to produce more weight loss than diet alone or physical activity alone.
• A combination of behavior therapy and drug therapy could prove to be an effective treatment for obesity.
• Drug therapy appears to assist in the adherence to dietary therapy (low-fat, low-calorie diet), and may improve maintenance of weight loss.
6. Surgery
• Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI 40 or 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patent is at high risk for obesity-associated morbidity or mortality.
• Obesity surgery is used to modify the stomach and or intestines to reduce the amount of food that can be eaten.
• Much progress has been made to develop safer and more effective procedures used in obesity surgery today.
• Before surgery, patients should be informed about the risks and benefits.
• Patients should be motivated and committed to making a lifestyle change after surgery.
• A medical team, including behavioral and nutritional professionals, should be part of a life-long follow-up plan.

REFERENCES:

1. National Research Council. Diet and health: implications for reducing chronic disease risk. Washington, DC: National Academy Press, 1989.
2. National Institute of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication No. 98-4083
3. American Obesity Association. http://www.obesity.org/
4. Nutrition.gov. An excellent resource, provides easy access to all online federal government information on nutrition, healthy eating, physical activity, and food safety, easily accessible in one place. *** excellent source
5. 10 Year Risk Calculator - online calculator
6. Interactive Menu Planner - NIH - online calculator
7. Tipsheet–Reading Food Labels
8. Create a Diet - Interactive tool to create online diet for health.

RECOMMENDED BOOKS

1. American Heart Association Low-Fat, Low-Cholesterol Cookbook, Second Edition : Heart-Healthy, Easy-to-Make Recipes That Taste Great
   American Heart Association; Spiral-bound; Buy New: $18.17
2. The Cholesterol Myths : Exposing the Fallacy that Saturated Fat and Cholesterol Cause Heart Disease
   Uffe Ravnskov; Paperback; Buy New: $14.00
3. 50 Ways to Lower Cholesterol
   Mary P. McGowan; Paperback; Buy New: $10.47

What is Alcohol Abuse?

Alcohol abuse is defined as a pattern of drinking that results in one or more of the following situations within a 12-month period:

• Failure to fulfill major work, school, or home responsibilities;
• Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
• Having recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk; and
• Continued drinking despite having ongoing relationship problems that are caused or worsened by the drinking.

What is Alcoholism?

Alcoholism is more severe pattern of drinking that includes the problem of alcohol abuse plus persistent drinking in spite of obvious physical, mental and social problems causes by alcohol. It includes four symptoms:

• Craving: A strong need, or compulsion, to drink.
• Loss of control: The inability to limit one’s drinking on any given occasion.
• Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.
• Tolerance: The need to drink greater amounts of alcohol in order to “get high.”

Source: “Alcoholism – getting the facts”, National Institute of Alcohol Abuse and Alcoholism.

For More Information:

• Susbtance Abuse and Mental Health Services Administration. The National Clearinghouse for Alcohol and Drug Information. 800-729-6686.
  www.health.org
• National Institute on Alcohol Abuse and Alcoholism
  www.niaaa.nih.gov
• Alcoholics Anonymous
  www.alcoholics-anonymous.org
• Al-Anon Family Group Inc. 888-425-2666
  www.al-anon.alateen.org

People use Living Wills or Advance Directives to direct their medical care when they become unable to do it for themselves. The purpose is to avoid conflicts, confusion, and lack of information about the patient’s preferences when a crisis arises. The Living Will can (1) guide the care, (2) name someone to substitute for you in decision making or (3) both.  The substitute decision maker is called “a proxy decision maker.”

Living Wills are legal documents. Despite that, it is probably best to make them with a doctor’s help because the legal part of making one can be much easier than the medical part. Indeed, the legal part is usually easy enough to do without a lawyer.

The medical part is about what you might want in the way of care when, due to  illness or injury, you are unable to do it yourself. It can direct many options in many situations. You may direct that doctors try all reasonable, life-saving care. You may direct that your doctors make you comfortable and ease your dying. You may direct that they make some attempts to save you but also restrict which ones or for how long. You may allow or forbid other things of interest to you (being in research).

You can state various choices for different medical situations. This is why it is best made with the help of a doctor rather than a lawyer. The doctor knows of situations the patient and the lawyer may not consider. For example, someone once told me that he flatly rejected tubes and machines in his living will. I asked if he ever heard of Guillan-Barre Syndrome. This is a disease in the nerves that leads to paralysis and may cause a person to stop breathing and die. But the disease is often self-limited.  If the person is on a ventilator for a few days, he may recover very well. The patient admitted that he would want the tubes and machines in that situation. Many lawyers do not know to question a person to avoid mistakes like this.

It is best to focus your document by what you value about life rather than by the equipment you want to avoid. For example, avoid “I never want a ventilator.” Instead say, “I never want to be kept alive by a breathing machine if I am permanently unconscious.” This is just an example. You may have the exact opposite desires. For example, you may want to be kept alive even if you are permanently unconscious or need a breathing machine far into the future. Write it as you prefer it.

The term “Living Will” has come to have many synonyms. They make a “word-salad.” Synonyms and closely related words include

• “Advance care planning”
• “Advance directive”
• A kind of power of attorney,
• Proxy directive
• Instruction directive
• Combined Directive
• Guardianship

These will be explained below. Most refer to a document that a person makes when they are able to think well and make decisions. When patients are incapable of a thoughtful choice, they lack decision-making capacity.  Sometimes people also call such patients “incompetent” (but officially incompetence must be declared by a judge). The document is the patient’s way to direct the medical care that that patient should get when they are incapable of reasonable decision making. If it is valid, it has the force of law.

The legal idea behind Living Wills is that people have a right to chose or refuse care when they are “competent.” They are not supposed to lose their rights after becoming incapacitated . Thus, they need a way to direct the exercise of their rights when they cannot do it. That is the “Living Will”.

Thus a Living Will should describe your thinking about when you want and when you reject kinds of care in different circumstances.  Some states set very high standards of evidence before allowing a patient to forgo care. Hence, your directive should be as clear as possible.

Above I listed many terms related to all this. Next I will define them and suggest some strengths and weakness of each kind.

The general name for a document of types 2-6 is Advance Directive.

There are many different printed forms for them. This is because many interest groups have made their own form to fit their values. Religious organizations, hospitals, citizens’ groups, propose forms consistent with their moral perspective, and some states require a particular form.  New Jersey, for example, does not.  It created a sample that is optional. See the complicated brochure and sample forms at the following link: http://www.state.nj.us/health/ltc/advance_directives.doc

As each state may have different formalities, this part of the process of making one has some legal aspects. They should be tailored to the state in which you live when you make it. You can also post your advance directive on the Internet! See http://www.uslivingwillregistry.com/register.shtm

Currently no one is required to make an advance directive. If you do make one, you may keep its existence or contents confidential, even from your proxy or your family members but that is usually unwise.  The whole purpose is to avoid conflict, confusion, and lack of information about the patient’s preferences when a crisis arises. Rival family members may resent one another about the choices you made. Give them all a chance to adjust to the content of it and discuss it with you.  That is why secrecy about it can be counter-productive.

Stating your values:
Minimize mentioning what equipment you want to reject. So too avoid refusing certain medical procedures. Instead state your values. For example in writing it, have one of the following statements in mind to shape how you word your directive:

1. “to me my life is worth sustaining no matter what my condition,” 
2. “to me my life is not worth sustaining unless I can experience affection or pleasures,”
3. “to me my life is not worth sustaining unless I can remember large aspects of my own story” (as tested through discussion with me) 
4. “to me my life is not worth sustaining unless I can reason about my situation/future”

Some wording is useless or worse.  One form says, “Do not treat me if there is no medical probability of benefit.” There are two reasons that this will not do the job most patients would want. First, many doctors will not say that there is “no probability” until it is extremely late in the course of dying—possibly much later than the patient intended.  Second, most of us cannot tell what you count as a benefit, etc.

In making a proxy-directive you appoint someone who will speak for you and make decisions based on your comments and history. Name several persons. Prioritize the list. Get consent of those you select, and give them copies of the document. 
Combined-directives contain both (1) what an instruction directive has and (2) names someone to interpret and apply the values of the patient if they are not clear in the particular case. This type of Advance Directive has the most power and flexibility. 

Here is a sample Advance Directive (PDF file) structured by specific patient values. Other value-sets would have very different samples or models.