More on Advance Directives

           

Role of Advance Directives

            Some thirty or more years ago, people realized that hospitals and doctors could not appropriately know what treatments patients wanted, especially as they became older and sometimes lost their ability to voice those wishes. Advance directives and living wills were approved for use by every state government. These were supposed to allow those in the medical field to know what a patient wanted.  They were supposed to open up the lines of communication among the patient, family, and healthcare professionals. However, they did not nothing to address how very uncomfortable patients and families and, sometimes, healthcare professionals were to discuss such taboo subjects as death. 

Research with Advance Directives

            In reviewing every study involving the use of advance directives, the dismal results are always the same.  They simply do not work. Why? First of all, only about 20 percent of older Americans even have advance directives. That leaves the vast majority of older Americans, 80 percent, with no written instructions on the care they want to receive near the end of life. 

            In studies on the 20 percent of Americans that have advance directives, they are almost never followed. Why? Of the minority of people that have them, once they are completed, the papers go into hiding, perhaps a safety deposit box. Certainly, no place that a healthcare provider has access to, especially in an emergency. Then, the patients forget or never really think of the need to share this information with family, those members who would need to make critical medical decisions on their behalf. During a crisis or emergency, family members are often left in a quandary. 

What Happens With No Decision

            These families are left feeling unsure of any decision and by not making any decision; the default decision is full aggressive treatment. The loved one ends up intubated, with several tubes that they may not have wanted, in intensive care, until the family can discuss at length what mom or dad or grandpop would have wanted. 

            One day when walking onto the inpatient oncology unit I worked on, I found the staff disgruntled. An elderly patient, dying of end stage heart failure, was at the core of the dilemma. The elderly patient, like most elderly patients, had no advance directives. Although he was dying, his family had to agree to a DNR or Do Not Resuscitate order in order to let him go. Five times that day the family had signed the DNR form and then five times they rescinded their agreement. As more family members appeared, more arguments ensued. Some family members felt that they were ‘playing God’ by signing such a form. Other family members argued that he wanted to go peacefully. We called his doctor to come and hold a family meeting to discuss his options.  Finally, the family agreed, the DNR form was signed, comfort measures were started, and the patient died peaceably a few hours later. 

            But, who wants to put their family through such an ordeal?