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The Art of Living Well and Dying Well Are One (Epicurus)

From the Patient Advocate

By Deborah Bickel

I have been present for many deaths throughout my medical career. At first they were hospital based and often brutal and drawn out. Most were in emergency rooms or intensive care wards and had the quality of a desperate fight against the inevitable. When I worked in rural Guatemala and Africa most deaths occurred at home. Here in San Miguel de Allende I have been present again for several passings at home. But whether death occurs in a mud hut or a lovely home, the quality of one’s last days and hours of life will be incomparably better when spent with loved ones in familiar surroundings. Most North Americans know this as well, and several recent polls confirm that the majority of us prefer that our lives end at home surrounded by those whom we love and by the treasures of our life. Unfortunately, data compiled by the Centers for Disease Control and Prevention reveals that only thirty percent of Americans actually manage to remain in their homes during their last days.

When preparing health directives with clients, I ask each to consider where it is they wish to end their days. Virtually all are clear about wanting it to be at home, but very few have thought to add this important fact to their medical directives. Still, a client of mine in his late nineties had added this to his medical directive but was told by his popular SMA physician that it would not be honored, as “it is just too difficult at home.” For whom? For the physician, of course. Understandably, managing a home death could mean more work—and involve a good deal more emotion—for the physician, but had this been discussed earlier perhaps a different MD might have been arranged for.

Fortunately, this is unusual in San Miguel. I have been struck by the high quality and compassionate care many of my clients have received in their homes. There are excellent nurses and care providers in San Miguel. Good palliative care at home is not difficult to organize and costs are far less than similar care would be in hospital or in the north. I urge you to put thought into the last part of life whether or not you are certain you will remain in Mexico. In this way your wishes will be clearly known and legal and you can put it behind you.

The following is a summary of the law concerning advance directives in the State of Guanajuato. If you travel outside the state, your directive remains binding, but the law stipulates that you must have it with you.

Medical directives created in the US or Canada are not legal in the state of Guanajuato. For and individual desiring an Advance Directive the following must be done:

• Complete the legal advanced directive form in English or Spanish.

• Designate a representative living in San Miguel (a patient advocate or close friend).

• Familiarize your attorney with your document, making certain that he or she understands the Advance Directive process (preferably someone bilingual unless you are fluent and comfortable managing everything in Spanish.

• Sign the document in the presence of a Notario Publico and your attorney. Be certain that the attorney and his or her Notary (Notario Publico) are reasonably priced and committed to being available when needed.

Note: If you are fluent in Spanish and do not want to use an attorney, some Notarios may be willing to work without an attorney.

Deborah Bickel is a PA MPH Patient Advocate.


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