End-of-Life Decision Making

Health Care Reform Slideshow

• Advance Directives
• Contents of an Advance Directive
• Appoint a Decision Maker
• What to Do With Your Advance Directive
• For More Information
• Synonyms and Keywords
• References
• Authors and Editors

Advance Directives

"Do everything you can to save my father." Doctors hear this a lot. It's the easy thing for family members to say, 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, saying that if the person becomes mentally incompetent, then he or she no longer wants artificial life-sustaining measures. 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, before then, the doctor can just ask the person about his or her preferences concerning treatment. If the mind is gone, the person can no longer ask to be allowed to die with dignity.

Why would someone not want CPR?

Most relatively healthy people would want CPR if their heart were to stop. That's because they can expect to recover, leave the hospital, and continue with their active lives for a reasonable period of time. Some elderly people who have become incurably frail decide that life is no fun any more. One of my cancer patients, for example, when asked whether he would want CPR, told me that he only wanted to have to die once. CPR would bring him back to life, and then he'd have to die again later. He knew that "later" would be pretty soon anyway.

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 do everything possible to save the life of the patient unless the patient or the patient’s family doesn't want certain specific measures to prolong life.

• 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.



• The problem here is that these people don't 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 would then not be locked into the wording of a particular advance directive document that might not apply to your actual situation.