Why Advance Directives Don't Work for the Elderly

Let’s begin by defining what an advance directive is. All states recognize the legality of Advance Directives.

·         Living Will – A written document that specifies what types of medical treatment are wanted or not wanted, for example, CPR, use of a ventilator to breathe.  

·         Health Care Proxy – This designates an individual to make health care decisions if you are unable to do so.

·         Durable Power of Attorney – This allows a named individual to make bank transactions, apply for disability, write checks, and sign Social Security checks etc when you are medical incapacitated. (Medicine.net, 2008)

                                                               

A Typical ER Visit with an Elderly Sick Patient

An elderly, ill patient is brought in from home. The patient is sick, over 90 years old with multiple medical problems. Due to dehydration, as well as progressive dementia, the patient is unable to carry on a logical conversation. The family is asked if the patient has a living will or an advance directive, something in writing that tells us how aggressive she wants us to be in caring for her.

Occasionally, the family tells us, “Yes, she has one”. The next obvious question is, “Can we see it?” The family never has it with them and always asks surprised that we would even expect them to have it with them when bringing in an elderly, sick loved one to the emergency room. Then, we go on to ask, “What does the living will say? Does your mom want us to pound on her chest if her heart stops, breaking nearly every rib within a minute?” No, of course, that is not what we really say. What we really say is much more tactful than that. We try several times to “get it out of the family member” what aggressive treatment the patient actually wants. Meanwhile, we have already started aggressive treatment because no family member brought the living will/advance directives to the hospital.

“I Don’t Want that Responsibility”

            We now need to discuss what level of aggressive treatment this family wants or does not want for the loved one they brought into the ER. We ask, “have you discussed what your mom at the end of her life?” Again, most of the time, the family looks like a deer caught in the headlights of a speeding car on a dark night. “No, we haven’t yet”. Well, we need to do that now.  Most family members do not want to take on the responsibility of saying no to aggressive, painful treatment for their loved one. This is sad because we can make someone comfortable at the end of her life. We know how to do that. We also know how to prolong someone’s life yet we cannot give a 90 plus year old back the quality of life she had. So, the patient continues to suffer until the family decides they do not want to see their loved one suffer any more.