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End of life issues are the most difficult issues we face in medicine. Dealing with the finality of death often causes much consternation for patients and their families.
The difficulties that arise often stem from trying to make the "right" decision for the patient when they themselves cannot participate. When a patient can participate in making a decision regarding end-of-life care, then the burden of responsibility is not transferred to the family, removing that source of anguish.
This has led to an industry of Advance Directives, also known as Living Wills. For the most part, these documents are not helpful.
The problem with Advance Directives
Advance Directives do not help in decision-making, because they are usually far too vague. Almost all say that if two physicians have agreed that the person is in a persistent vegetative state that care should be withdrawn and the person should be allowed to die naturally.
That particular situation is extremely rare, despite the famous cases in the news. The directives cannot answer questions, are inflexible, and can be overridden by family members.
It is impossible to write a document that covers every single possibility in every potentially terminal situation. They are also often written years prior to their need, and then never changed to adjust to the changes in someone's health and goals as they age.
Is there a better way?
So, what should you do? As a physician, my strongest desire in end-of-life situations is to ask patients themselves what they do and do not want.
If a patient can make decisions, then they are the final arbiter and my task is much easier.
When the patient cannot make decisions, I do not want to talk to a piece of paper - I want to talk to a human being who knows the patient, who loves the patient, and who will make decisions in the best interest of the patient.
People can respond to changing situations, complications, probabilities, and can understand the overall thrust of someone's life and guide medical choices. A piece of paper cannot.
My recommendation is to find a person who you love and trust, and appoint them as your Durable Power of Attorney for Health Care. They will make decisions as if they were you.
This means you need to have a good conversation with them about the things that you do and do not want. I recommend using a form such as 5 Wishes (available at http://www.agingwithdignity.com/5wishes.html as a starting point for discussion. It is a gift you will give your family that will save them much heartache.
Other complications
It is important to think carefully about interventions such as CPR, mechanical ventilation, artificial nutrition and even intravenous fluids and antibiotics.
Most people that I ask say that a trial of CPR and mechanical ventilation would be acceptable to them if they could return to their prior state within a few days.
Most also say that they would not want to be on such support for weeks or months without a meaningful hope of recovery, although the decision as to when to terminate support is difficult as everyone has different definitions of "meaningful."
Realize that CPR and mechanical ventilation have abysmal success rates in the absence of correctable medical conditions, such as blocked heart arteries, abnormal heart rhythms or trauma.
Under the best circumstances (a young, otherwise healthy patient with a quickly correctable problem), CPR has a success rate of only around 20 percent. The number rapidly drops with age and other medical conditions. Elderly sixk patients who get sick enough that they pass away from their illnesses will still be elderly sick patients even after "successful" CPR and will often require it again in minutes or hours.
While modern medicine can keep very sick patients alive for some time, it can also drag out their dying process inappropriately.
Shifting focus from cure to comfort
There comes a time for many people that the burden and severity of their illnesses bring them to the point that the main focus of medical treatment should shift from cure to comfort.
This community is blessed to have the services of Hospice of the Foothills for such patients. Hospice programs are there for people with diseases (not just cancer, but heart disease, lung disease, and others) that are severe enough that death is expected within six months.
Ideally, patients would enter into the program early enough to take advantage of all Hospice has to offer. Hospice gives support to the patient and family before, during, and after the dying process.
Patient comfort and dignity are the primary goals, and medicines and supplies are provided to ensure relief from pain, shortness of breath, and anxiety.
One of the benefits of modern medicine is the ability to make anyone comfortable, regardless of their level of pain. On a personal note, having Hospice during my father's death transformed a very difficult and emotional process into a true blessing.
ooo
If you have questions you would like addressed in future columns, please e-mail me at Nicholas.BrowningMD@gmail.com. Dr. Browning is a hospitalist at Sierra Nevada Memorial Hospital.
The difficulties that arise often stem from trying to make the "right" decision for the patient when they themselves cannot participate. When a patient can participate in making a decision regarding end-of-life care, then the burden of responsibility is not transferred to the family, removing that source of anguish.
This has led to an industry of Advance Directives, also known as Living Wills. For the most part, these documents are not helpful.
The problem with Advance Directives
Advance Directives do not help in decision-making, because they are usually far too vague. Almost all say that if two physicians have agreed that the person is in a persistent vegetative state that care should be withdrawn and the person should be allowed to die naturally.
That particular situation is extremely rare, despite the famous cases in the news. The directives cannot answer questions, are inflexible, and can be overridden by family members.
It is impossible to write a document that covers every single possibility in every potentially terminal situation. They are also often written years prior to their need, and then never changed to adjust to the changes in someone's health and goals as they age.
Is there a better way?
So, what should you do? As a physician, my strongest desire in end-of-life situations is to ask patients themselves what they do and do not want.
If a patient can make decisions, then they are the final arbiter and my task is much easier.
When the patient cannot make decisions, I do not want to talk to a piece of paper - I want to talk to a human being who knows the patient, who loves the patient, and who will make decisions in the best interest of the patient.
People can respond to changing situations, complications, probabilities, and can understand the overall thrust of someone's life and guide medical choices. A piece of paper cannot.
My recommendation is to find a person who you love and trust, and appoint them as your Durable Power of Attorney for Health Care. They will make decisions as if they were you.
This means you need to have a good conversation with them about the things that you do and do not want. I recommend using a form such as 5 Wishes (available at http://www.agingwithdignity.com/5wishes.html as a starting point for discussion. It is a gift you will give your family that will save them much heartache.
Other complications
It is important to think carefully about interventions such as CPR, mechanical ventilation, artificial nutrition and even intravenous fluids and antibiotics.
Most people that I ask say that a trial of CPR and mechanical ventilation would be acceptable to them if they could return to their prior state within a few days.
Most also say that they would not want to be on such support for weeks or months without a meaningful hope of recovery, although the decision as to when to terminate support is difficult as everyone has different definitions of "meaningful."
Realize that CPR and mechanical ventilation have abysmal success rates in the absence of correctable medical conditions, such as blocked heart arteries, abnormal heart rhythms or trauma.
Under the best circumstances (a young, otherwise healthy patient with a quickly correctable problem), CPR has a success rate of only around 20 percent. The number rapidly drops with age and other medical conditions. Elderly sixk patients who get sick enough that they pass away from their illnesses will still be elderly sick patients even after "successful" CPR and will often require it again in minutes or hours.
While modern medicine can keep very sick patients alive for some time, it can also drag out their dying process inappropriately.
Shifting focus from cure to comfort
There comes a time for many people that the burden and severity of their illnesses bring them to the point that the main focus of medical treatment should shift from cure to comfort.
This community is blessed to have the services of Hospice of the Foothills for such patients. Hospice programs are there for people with diseases (not just cancer, but heart disease, lung disease, and others) that are severe enough that death is expected within six months.
Ideally, patients would enter into the program early enough to take advantage of all Hospice has to offer. Hospice gives support to the patient and family before, during, and after the dying process.
Patient comfort and dignity are the primary goals, and medicines and supplies are provided to ensure relief from pain, shortness of breath, and anxiety.
One of the benefits of modern medicine is the ability to make anyone comfortable, regardless of their level of pain. On a personal note, having Hospice during my father's death transformed a very difficult and emotional process into a true blessing.
ooo
If you have questions you would like addressed in future columns, please e-mail me at Nicholas.BrowningMD@gmail.com. Dr. Browning is a hospitalist at Sierra Nevada Memorial Hospital.
