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End-of-Life Decision Making

Advance Directives

"Do everything you can to save my father." Doctors hear this often. It's the way many families respond as they obviously do not want to lose a loved one, but it's not necessarily what their father would have said. That's why people need to think about advance directives (sometimes called living wills) for medical care and the appointment of a health care agent.

What are advance directives?

Advance directives are documents, written while a person is still able to make decisions, that express their wishes as it relates to life support in case they are not able to express their wishes in the future. These include cardiopulmonary resuscitation (CPR), respirators, and any other measures that the person cares to list.

Why does the advance directive only apply if the person is mentally unable to make decisions?

Because when the person is still mentally capable, the doctor can just ask the person about his or her preferences concerning treatment. This document gives the health care team guidance on the decision process only if the patient is unable to express their wishes.

Why would someone not want CPR?

Most relatively healthy people would want CPR if their heart were to stop. That's because if CPR is successful, they can expect to recover, leave the hospital, and continue with their active lives for a reasonable period of time. Some elderly or terminally ill people who have become incurably frail will decide not to have measures instituted that will either only extend their life in a vegetative state or be senseless in the setting of their medical condition.

Why would someone want CPR?

Some people might make the opposite decision. They might decide to have CPR and machines to support artificial breathing because they want to live as long as possible. If you make a decision like that, it will be respected by doctors and hospitals. The doctor is expected to make a reasonable decision about which measures might help and are reasonable. The input of the patient in this process is very important. Your personal and religious beliefs will influence these decisions.

  • If you check into the hospital for any reason, even if you're not in any life-threatening danger, federal law requires the hospital to ask if you want CPR. Whenever you become a patient at a facility that gets Medicare or Medicaid money, you must be offered a document to sign after selecting certain choices about what treatment you want if you lose your mental competence. But the paper doesn't indicate which choices would be the wise ones to make.
  • People often decide that they won't want CPR and respirators once they can no longer remember the names of their children (or their own name). But they often check off that they would still want antibiotic therapy, IV fluid therapy, and artificial feeding through a tube. They do this because they visualize themselves having an illness that might respond to IV fluids, antibiotics, and tube feedings. They want these treatments if they can recover and have a life in which they can meaningfully interact with their families and friends.
  • On the other hand, what if they visualize the time when they can't talk and can't understand conversation. If they were to think about the end stages of organic brain syndrome, also called dementia or senility, they might decide that they wouldn't want IV fluid, antibiotic therapy, or artificial feeding through a tube when they got to that stage of their lives. They might want the medical team to concentrate on comfort measures rather than life-prolonging measures. A person who is writing advance directives needs to plan for the end stage of life.
  • Another option is to refrain from writing advance directives that specify particular treatments but, instead, to designate a health care agent. The agent would be someone who will make decisions for you when you can no longer make them for yourself. Then, just tell your health care agent what your wishes would be in various situations. The person you name as your health care agent will then make decisions (once you are not able to make them) as per your previous instructions and guidance.

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