Advance Medical Directives

What are advance directives for?

Given that decision-making related to present (or future) health problems so that it can be applied when the person is unable to decide for themselves is a right recognised by current legislation, advance directives serve to ensure that when the person who signs them finds that, for physical or mental reasons, they cannot express their wishes, they receive healthcare that respects their life plan and that the instructions and personal criteria set by them are followed.

It is always advisable to do so after receiving all the necessary information from your doctor or healthcare staff. It is advisable to hold a discussion between the person who wishes to make advance directives, healthcare professionals and the family, followed by careful consideration.

What can I decide?

Instructions may be included regarding whether certain medical treatments, sedation for pain, end-of-life care, etc. are desired or rejected. Should the legal provisions set forth in the legislation regulating euthanasia be met, the Advance Directive (AD) can additionally be designated as a formal application for euthanasia.

How can this be done?

You can leave a record of your advance medical directives by filling out an Advance Directive (AD) form, which you can request from your hospital or download from canalsalut.gencat.cat. Once completed, it is important to register the document so that healthcare professionals have access to it.

Do I need witnesses?

The pertinent legislation in force stipulates that the document must be formalised before a notary, in the presence of a healthcare professional or before three witnesses of legal age and with full legal capacity, at least two of whom must not be related to the grantor up to the second degree of kinship or have any financial ties to the grantor. Once formalised, it must be registered in the Register of Wills of the Department of Health.

If it has been formalised before a notary, the notary's office will automatically register it in the Advance Directives Registry. If it has been formalised by a healthcare professional or three witnesses, the AD can be submitted to any registry of the Generalitat or sent to the Department of Health.

Will I be able to change my advance directive if I change my mind?

The grantor may modify or revoke the AD whenever he/she deems it appropriate or necessary.

To this end, the same steps set out for rendering the AD valid must be taken.

Can I make one even if I am not ill?

Yes. It can be done in anticipation of the future when one is not suffering from any type of illness or disability.

Will my decisions be respected?

Both the family and healthcare professionals are bound to follow the instructions set out in the advance directive, provided that they do not contradict current regulations/legislation or the code of good practice.

Legal Framework

Law 2/2024 of 6 February, amending Law 21/2000, on information rights relating to health and patient autonomy, and clinical documentation.

Article one. Amendment to article 8 of Law 21/2000

Addition of letter c to article 8.2 of Law 21/2000, on information rights relating to health and patient autonomy, and clinical documentation. This additional letter has the following wording:

"c) to a healthcare professional in primary care, hospital care or social healthcare, preferably at the patient's referral centres".

Article 8. Advance Medical Directives

1. An advance medical directive (living will) is a document addressed to the attending physician in which a person of legal age, with sufficient capacity and of their own free will, specifies what actions should be taken if the patient is unable or incapable of personally communicating their wishes. In this document, the person may also appoint a duly authorised agent, who is the valid and necessary contact person for the doctor or healthcare team, to act on the patient’s behalf in the event that he/she is unable to express his/her wishes personally.

2. There must be reliable evidence that this document has been issued under the conditions mentioned in section 1. To this end, the advance medical directive must be formalised through one of the following procedures:

a) Notarised before a notary public. When notarised before a notary public, there is no need for the presence of witnesses.

b) Before three witnesses of legal age and with full legal capacity to act, at least two of whom must not be related to the grantor up to the second degree or have any financial ties to the grantor.

3. Advance directives that include provisions contrary to the legal system or good clinical practice, or that do not correspond exactly to the circumstances that the patient had in mind when issuing them, cannot be taken into account. In such cases, a reasoned note should be made in the patient's medical record.

4. If there are advance directives, the person who has granted them, their relatives or their representative must deliver the document containing them to the healthcare centre where the person is being treated. This advance directive document must be included in the patient's medical records.

Law 3/2021 of 24 March (Spanish Euthanasia Act).

Article 1. Purpose.

The purpose of this Act is to regulate the right of any person who meets the required conditions to request and receive the necessary assistance to die, the procedure to be followed and the safeguards to be observed.

Article 6.4. Requirements for submitting an assisted-death request.

... the assisted-death request may be submitted to the attending doctor by another person of legal age and fully capable, and must be accompanied by the advance directive, living will, advance directives or legally recognised equivalent documents, previously signed by the patient. If there is no one who can submit the request on behalf of the patient, the treating physician may submit the request for euthanasia. In this case, the treating physician is entitled to request and obtain access to the advance directive, advance will or equivalent documents through the persons designated by the health authority of the corresponding autonomous community or by the Ministry of Health, in accordance with Article 4(1)(d) of Royal Decree 124/2007 of 2 February, which regulates the Spanish Advance Directives Registry and the corresponding automated personal data file thereof.

Hospital Healthcare Ethics Committee: Dexeus University Hospital, Quirónsalud Hospital Barcelona, Center Médico Teknon and El Pilar Hospital

The Healthcare Ethics Committee (HEC) was established in 2013 and was accredited by the Managing Director of Regulation, Planning and Health Resources in 2015.

It is a consultative body with a multidisciplinary and pluralistic composition. The Committee serves both healthcare professionals, guiding their actions in conflicts of values, ideology and morals that may arise in the course of their work, and patients and citizens in general.

The main objective of the HEC is to promote a space for dialogue where, through reflective, collective and respectful analysis of the different branches of ethical thought, care practices can be enhanced within a framework of respect for human dignity and human rights. The functions of the HEC include:

a. Advising on difficult decisions regarding specific cases in healthcare practice that present dilemmas due to the defence of conflicting moral values.

b. Proposing analysis guidelines and recommendations for action.

c. Promoting ethical training activities.

d. Organising informative activities about the HEC, reporting on the tasks carried out and encouraging reflection and deliberation on conflictive cases.

The HEC acts in accordance with the content of the Universal Declaration of Human Rights and the principles and values of bioethics, taking special care to preserve patient autonomy and freedom of thought, belief and opinion.

You can contact the HEC by e-mail at: ceabarcelona@quironsalud.es