170 JURIDICA INTERNATIONAL 27/2018
The Group Discussion ‘Practical
Possibilities of Taking Living
Wills into Consideration’
This is a translation of a discussion held in the Estonian language on 31 May 2017. The group discussion
transcribed here, with explanatory footnotes provided by Mari Lõhmus, was led by Tarvo Puri, a notary
Helgi Kolk – attending physician and lecturer at the Department of Traumatology and Orthopaedics of
Tartu University Hospital, and President of the Estonian Association of Gerontology and Geriatrics
Teija Toivari – Nursing Director for the Tallinn Diaconal Hospital Hospice Department
Mari Lõhmus – oncologist with the Chemotherapy Stationary Department and consultant with the Pallia-
tive Care Service of the North Estonia Medical Centre
Liidia Meel – doctoral student with the School of Theology and Religious Studies at the University of Tartu
Rainis Int – notary in Tallinn
Tarvo Puri: Let’s talk about whether and to what extent anyone here in Estonia has had experience with
the topic of taking the patient’s wishes into consideration. Have these wishes been written down, are they
noted somewhere in digital medical ﬁ les, and are these topics discussed with a patient – and in what cases?
Helgi Kolk: The prerequisite for any kind of medical treatment is consent: informed consent of the
patient. How it is given or received is an entirely di erent issue. In a trauma unit, where the patients come
in with emergencies, they usually have no prior wishes registered. I deal mostly with elderly patients with
serious trauma, severe bone fractures. We often have to decide whether to even operate or how to proceed.
In reality, there is no-one to ask, because about a third of the patients we see have either a milder or more
severe form of dementia and are unable to make adequate decisions. Common practice in such cases is
to look for children and caregivers. We hardly ever encounter guardianship over people with dementia.
Guardianship can be implemented when serious but non-urgent decisions need to be taken in a hospital
setting. In reality, we have a really hard time ﬁ nding out about consent.
Mari Lõhmus: It’s everyday practice that patients and their loved ones are consulted with regard to
their wishes and will. This depends on the care plan. For us in oncology, however, the dimension of time
may be somewhat di erent: we have time to discuss and reﬂ ect on things, often discussing matters of treat-
ment and ceasing it. Decision cases in which the patients themselves have written down their wishes are
extremely rare. This information is hardly ever in health ﬁ les either. In day-to-day practice, we write down
patients’ decisions to voluntarily refuse treatment or to end it, so that we would have at least some sort of
legal grounds or decision to refer to, should that be necessary later.
Tarvo Puri: So there have been talks with patients on ending treatment under certain circumstances?
Mari Lõhmus: There comes a point with any patient when treatment has to be stopped. It is done less in
Estonia, but care plans are prepared further ahead in oncology abroad. As soon as it becomes clear that, while
the cancer is not treatable, there are numerous end-of-life care options at the moment of diagnosis, we start
discussing the options and talk about what to do when the options run out – what the patient’s wishes are in
such a situation. I think that is done more and more these days. But we don’t have a document in which the
patient’s wishes are written down or registered. There is no advance care plan*1 used in Estonia.
Instructions for future treatment and care.