MX federal health legislation/palliative care/end-of-life

The author is a field researcher, not an attorney, with over 30 years experience working in developing countries which was great preparation for working on the Life Planning in Jalisco project here in Jalisco. This posting is intended for foreigners living in Jalisco, primarily in the Guadalajara/Lake Chapala area even though the law is a MX federal law.

This research has focused on 'what's correct' and not on 'who is correct.' Other local lakeside publications/presentations on this legislation have 'skipped' the part that the law applies only when one has been diagnosed as 'terminal' with expected less than 6 months to live. To the extent possible, my 'findings' for this project are documented with names of interviewees, on-line resources, etc.

This posting is part of a larger document called "Life Planning in Jalisco©," which is copyrighted material, dated December 2010. The material posted here can be used for personal use. For any other use, permission needs to be obtained from the author (use PM to contact author) to use the document 'as is' unless prior agreement has been made. The reason for doing this is to ensure that the content remains correct. The reason for this is that I've already found, unfortunately, that someone editing the information, without knowing the research behind it, does not know when s/he is making incorrect or misleading changes.

 What’s available from the MEXICAN FEDERAL LEGISLATION?
(Links can be found in other postings below to the legislation in Spanish/English and some further use of this material.)

In 2008, Mexican federal legislation was passed which supersedes Jalisco state law. The Reforma 39:Ley General de Salud (DOF 05/01/2009) sets forth palliative [pain & comfort] care to patients in terminal situations expected to live less than 6 months (Chapter I, Art. 166, Bis 1, IV).

Palliative care (pain relief or comfort care) is a comprehensive approach to treating serious illness that focuses on the physical, psychological, spiritual, and existential needs of the patient. Its goal is to achieve the best quality of life available to the patient by relieving suffering, and controlling pain and symptoms (see www.caringinfo.org, Reforma 39, Chapter I, Article 166, Bis 1, III.)

The legislation provides for patients to:

designate in ‘advance’ a person(s) authorized to make medical decisions for the patient if s/he cannot speak for him/herself in any way (Chapter II, Art. 166, Bis 3, X); and

express [his/her] will [health care directives] in writing before two witnesses (Chapter II, Art. 166). (The legislation makes no provision for a Notario to sign the document (Rafael Vargas, Notario 114)).

[i]The law "in Mexico is that medical care must be given, and once it is commenced, it cannot be stopped" (Carlos Garcia M.D./Lic Sergio A. Macias, Living Wills presentation (LCS), July 8, 2005). The new legislation added to the general health law now provides support to the requests of the patient, such as:

 "The patient in a terminal situation, of age and in full possession of his mental faculties, has the right to voluntary suspension of curative treatment and following the onset of strictly palliative treatment in the form and terms provided in this Act." "The voluntary suspension of curative treatment involves the cancellation of all medicinal products is to counteract the patient's terminal illness and the initiation of treatments focused exclusively on the reduction of pain or patient discomfort" (Chapter II, Art. 166, Bis 5/6).

 "[A person can] [v]oluntarily leave the health institution where he is hospitalized" (Chapter II, Art. 166, Bis 3, III).

What follows are selected excepts from the legislation regarding patient's rights:

 "The physicians may provide palliative drugs to a patient in a terminal situation, even if this results in losing alertness or shorten the life of the patient, provided that these drugs provide palliative [care] to alleviate the patient's pain" (Chapter IV, Art. 166, Bis 16).

 "The medical specialist .... shall respect the decision of the patient in a terminal situation with regard to curative treatment and palliative care, once it has been explained in simple terms the consequences of their decision" (Chapter IV, Art. 166 Bis 15, V).

Preparing the Document: “Health Care Designation for Medical Decisions and Health Care Directives”

You can chose to have an attorney or notario prepare the document and a notario sign the document, but the legislation does not require this. Since a notario is not required to sign the document, nor is an attorney required to prepare the document, you can prepare the document yourself if you choose to do so.

If you do the document without an attorney or a notario’s ‘letterhead’ or signature, make sure to keep the legal citation as it is noted in the sample document. This law is NEW in Mexico and does not exist in the state of Jalisco (and may not exist in any of the other Mexican states at the state level). Therefore, health care providers and hospital staff are not likely to be familiar with this type of document or the law.

It’s also a good idea to keep a hard copy of the legislation along with your health care designation and health care directives so that there is immediate legal backup for your documentation.

• Make sure to read the law in full.

• When you designate who will be authorized to make medical decisions for you, make sure those people know they have been designated, know what your wishes are, and make sure they have a copy of the Health Care Directive, or know where one is.

• Make sure to clearly state your health care directives of what care you want, or don’t want based on the language in the law.

• Take any questions to your health care provider for clarification in determining what you need to include in the document (make sure to take with you a copy of the legislation, in English and Spanish).

• Make sure to sign and date the document in front of two (2) witnesses.

• Make sure to have the two (2) witnesses sign the document.

• Make sure to have the document translated into Spanish since the original legislation is in Spanish and Spanish is the official language of Mexico. (As a practical matter, many emergency services and health care professionals may not know English, which may make the document useless if it is only in English.)

• Keep the original document in a safe, but accessible, place. Keep a ‘Spanish/English’ copy in your car or with you at all times. If hospitalized, provide a copy when you are admitted.

• If you have a durable medical power of attorney (with health care directives) from outside Mexico (apostilled), or a durable medical power of attorney from another Mexican state (with health care directives), also consider completing the end-of-life document with the same or similar designees and health care directives. The reason for doing this is so that the documents reinforce each other.

Also consider keeping a copy of the health care legislation (in Spanish and English) with your Health Care Directives since the legislation does not yet appear to be well known even within the medical, or legal, fields.

Sample Document (Reviewed by the Law Firm of Vargas and Espinosa; discussed with Notario Macias, Lic Macias):
“Health Care Designation for Medical Decisions and Health Care Directives”

This Designation of Person(s) for Medical Decisions and Health Care Directives are written in accordance with the Mexican Legislative Decree Reforming and Adding to the General Health Law of Palliative Care (DOF 05 January 2009), Chapter II, Paragraph X and Article 166 Bis 5.

Person(s) authorized to make Medical Decisions
I, XXX, authorize xxxxxx to make medical decisions on my behalf if I am unable to speak for myself in any way. In the event that xxxxx is unable or unwilling, I designate xxxxxx, then xxxxx, then xxxxx, and then xxxxx, in this order.

Health Care Directives
The following are my directives if I cannot speak or communicate in any way. I write this in an alert state and mentally capable of making these decisions.

If the medical doctor who is in charge of caring for me states that my condition is terminal and irreversible, that I’m in a permanent vegetative state, or that I am in a coma with no reasonable belief this will change and that I’m expected to live less than six (6) months, follow these health care directives:
(follow the legislation as much as possible)

I DO WANT (FOR EXAMPLE) hospice care (Article 166, Bis 9).

I DO WANT (FOR EXAMPLE) treatment measures my physician believes will keep me comfortable and relieve pain though this may shorten my remaining life (Article 166, Bis 16). I also want fluids, but only if they will serve to make me more comfortable.

I DO NOT WANT (FOR EXAMPLE) any life sustaining treatments. This includes breathing and kidney machines, heart medications, blood transfusions, heart lung resuscitation, or administration of fluids and nutrition in any manner.

I DO NOT WANT (FOR EXAMPLE) any invasive diagnostic tests or procedures after my diagnosis.

Dated: January xx, 2011

Signature: ___________________________

Witness: ____________________________

Witness: ____________________________

Life Planning in Jalisco©, December 2010








Thank you very much for sharing your research.

Last year an acquaintance who had only IMSS insurance and had lung cancer received radiation and other treatments in Guadalajara. Then, when it was clear to her doctors and her that she was terminal, she received the "hospice" care and with some help from relatives, was able to die at home without pain.
This, IMO, is a good thing.

We all need to think about these things and make the necessary arrangements while we're still in our right minds. Well, as close to it as most people on this board are.......lol.

You bring up one really important point 'Gringal.' When someone is diagnosed as terminal, hospital Civil and IMSS (I've been told) are glad to send you home because someone else needs the bed.

This legislation becomes really useful if you have private insurance where they continue to make money from someone 'hooked' up for some period of time.

Last November (2009) someone I knew (around age 95 and a foreigner) was in a private hospital in Guadalajara. Who family asked to have her 'unplugged,' and they refused to 'unhook/unplug' and her family could not get her released (there were several reasons). The family did not have health care directives in place from NOB or Mexico. The woman died a few days later fortunately which resolved the situation.

I'm told that Mexicans who have gotten into this situation either cancel their credit card or inform their medical insurance to stop payment. That apparently works.

Filoli

The law can be found by clicking here. It's a PDF, and the first page is blank, so scroll down.

Thanks Rolly for the link.

When I clicked on the link, it comes up in Spanish only because it is the original published legislation. For people like me, who need the English version, I put the legal citation into google. When the link appears, I use the google 'translator,' which seems to do an ok job on the legislation.

Is there a better way to do this for those of us who need the English translation?
Thanks,
Filolil

For anyone wanting to use any of the information from Life Planning in Jalisco, which is copyrighted material, please PM me for permission.

Thanks,
Filoli

Here is the law in a side-by-side Spanish-English Google translation.
http://rollybrook.com/life_care_law.htm

Thank you for taking the time to research and to post this information. Always better to be prepared than to stick your head in the sand. Kudos!

Hi Rolly,

I just saw your posting. Thanks. There's one line that needs to be corrected because it is misleading as 'changed.' I was advised by Notario Vargas to keep the choices of health care directives as close as possible to the legislation. And, in the sample document above, I stated to "follow the legislation as much as possible." What I give in the sample document is just a very few choices and NOT the only choices.

From the change you made, "include any of the following," suggests to the reader that all they need is to select one or all of those choices, and that is not the case. They really need to go back to the legislation and chose from all of the selections what they want and do not want.

I've worked very hard for correctness on this document because of what others have produced that have been incorrect and misleading. So, thanks very much for making the change to keep the information as correct and clear as possible.

Filoli

WHEN USING THE SAMPLE DOCUMENT ABOVE.....

This is Mexico, as well all know.
Keep this in mind if you decide to complete the sample document above on your own: as mentioned, the legislation does not require a notario or an attorney for preparing the document. If you decide, however, not to have a notario sign the document or to have it prepared by an abogado with his/her cover sheet, then you will want to make sure to INCLUDE THE REFERENCE TO THE LEGISLATION IN YOUR DOCUMENT and probably keep a hard copy of the legislation with the copy of your document.

WHY do this???
First, health care directives (living wills, etc.) are new as of 2008 in Mexico. So, no one is used to seeing this type of a document, let alone having a law in place giving an individual rights about their end-of-life health care. Many of the attorney/notarios lakeside had not seen the legislation before I hand-carried it to their office, and that was in 2010. The same was for the doctors lakeside. This may change in Guadalajara, or it mat NOT change???

The reason you are doing the documentation is to try and make sure to the extent possible that you are getting the treatment you want or don't want should you reach a point of being diagnosed as 'terminal'.

So.....make sure to include the legislation reference, and a copy of the legislation, with your end-of-life health care designation and health care directive.

The second reason for including the reference and the legislation is that the 'law of the land' (see reference above) IS that once medical treatment is commenced it has to be continued. This is currrent, not past. The focus has been 'formally' on curative care, not palliative care. [b] The 2008 MX federal legislation adds to the existing law for people in one particular situation in their life.

Comments? Questions?
Filoli

I followed Filoli's instructions to prepare my letter in Spanish.

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 puede tomar decisiones informadas con respecto a mi cuidado, yo autorizo a [nombre] 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 cómoda 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. Si estoy en estado de coma, no quiero recibir ningún tipo de nutrición. (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:

Paciente ___________________

Testigo ________________ ___

Testigo _______________ ____

Hi Rolly,

While you have good intentions, I just checked your website and you have used my information with from this website, with still some incorrect editing, without referencing where you got the information which was specifically from my posting on this website.

As mentioned in my original posting, this posting is part of a larger document which is copyrighted. I am the author and gave you permission to use the information 'as is.'

The general protocol is that if you copy someone else's work, which you have done, at the very minimum you reference their work by giving the author's name, the title of the work and the date. In a private email, I gave you my name, the name of the document and the date it was written. None of that appears on your 'end of life care' entry on your website.

What would you think if someone copied your book that you are promoting on your website, published it elsewhere (albeit incorrectly) as their own and did not acknowledge the author??? Not much integrity and not very professional.

filoli

There are none of your words in my post. I wrote it all myself. Everything I wrote is based on my reading of the law to which you have no copyright. In your posts here, you don't even give a link to the law. I found it myself, translated it, and made it available on my website. The only thing I took from your posts here was the fact that such a law exists, and that is not copyrightable.

In the beginning, you gave me permission to use your original post from this forum which I did with some edits to make it more readable. You objected to my edits, so I deleted the whole thing and started over from scratch being careful to avoid using any of your original language. Obvious the law is the same, but that is not your intellectual property -- it's public domain.

Your insistence that I use your work "as is" was not part of your original permission. You added that after you objected to my edits.

Obviously there are going to be similarities between your work and mine because they both deal with the same subject. Here s a link to the article on my website so others can decide if I have plagiarized your original post on this forum.

Since you seem especially upset that I did not credit you in my article, this morning I added this line at the beginning of my article:

This article was inspired by an online post by Susan Reynolds which first brought this law to my attention.

Rolly,
The point of the discussion with you in this thread was keeping the information correct, which was a struggle when you first began editing my material, especially since you had not participated in any of the background research.

Today (1/8/2011) I checked your website and saw your recent edits. I'm satisfied that the information you provided is sufficiently correct and not misleading. I think you have added to the quality of the material by providing the 'side-by-side' English/Spanish translation and the sample end of life care document (Health Care Designation and Health Care Directives) in Spanish. Thank you for sticking with the material to get your information to where it is now! I'm sure it will be helpful to those that use your website for information.

Filoli

(author, Life Planning in Jalisco, December 2010)

Maybe the best thing to do is to not list all the info but list a link to the info. Many people do this for my traffic laws brochure as I'm constantly revising and updating it and it serves 2 purposes, one to credit the author and the second to always have up to date information as the person is always going to the source.