More Living Will Discussion

I will have to be careful here as I don't want to be entirely insulting, but, I came across a blog with a post giving advice on what to put in a Living Will. My opinion is that the person who wrote the piece has no knowledge of the purpose of a Living Will. I know both of my readers are probably tired of me bringing this topic up, again, however many of the patients in the population I treat are there precisely because they did not have a clearly written Living Will.

The blog poster suggests that everyone add "and with unanimous consent of my children" to the end of any Living Will they sign. Let me ask the question; who is the Living Will designed to benefit? Who is the Living Will directed toward? Seems like dumb questions doesn't it?

A Living Will is filled out so that those who care for the person who filled it out have guidelines (and specific criteria) as to the level and intensity of care the person who filled it out would like, in the event they cannot speak for themselves. Pascal seems to assume that the family of a patient has greater rights than the patient to decide what life-prolonging treatments are provided. A Living Will helps me as a provider to decide what the patient wanted in the event of a disabling illness or injury (and often spells out exactly what the patient wanted). What the family wants is many times irrelevant to what the patient actually wanted.

Let me give an example. Patient Q fills out a Living Will five years ago. Patient Q has paranoid schizophrenia but is still capable of making medical decisions. Patient Q is also 80 years old and has many other co-morbid conditions (illnesses he could drop dead from any moment). Patient Q's daughter has the Power of Healthcare Attorney (POA) for patient Q. Patient Q's Living Will clearly states his wishes as regards to whether he wants to be a full code or do not resuscitate patient (DNR). He chose DNR.

Patient Q's daughter calls me and states she wants her dad to be a full code. What should I follow? The Living Will signed and witnessed by the patient or his daughter? Fortunately the state has addressed this issue and allows me to continue with the patients wishes not the daughter's preferences, even though she is the POA. The family may not like this situation but I am not treating the family I am treating the patient.

What Pascal and others like him fail to take into account is that just because there may be a medical treatment available for a particular condition does not mean we have to provide that treatment. Let me rephrase that, just because a treatment may be available does not mean that it is wise or prudent to pursue it. My practice is replete with examples of patients who underwent medical treatments that the doctors assured the patient "we can fix that" and it turned out they couldn't fix "that."   

I am all for advanced life-prolonging care in many situations however I am less enthusiastic for taking extreme life-prolonging measures in someone who is 80 years old and has multiple co-morbidities. Does this make me a moral relativist? Absolutely not. Let's pose this question to someone who is 80 plus years old. When your heart stopped at what point did you think it was not Gods will to call you home? I pose this question to families all the time to get them to think about the bigger picture. I don't believe in the Life at Any Cost notion. There has to be some kind of quality to life not just quantity.

There is another aspect to the Life at Any Cost argument and that is one of being good stewards to what has been provided to us. There are not unlimited medical resources in this country and there are not unlimited health care dollars toward those resources. I have cared for many patients who are in a permanent vegetative state. Patients so removed from life they do not even respond to painful stimulation. Patients on ventilators with feeding tubes and contracted in pretzel like contortions.

Am I suggesting we remove these patients from the ventilator and let them die? No, I don't think that would be appropriate.  What I do think could be appropriate is educate our population to the realities of medical care prior to the individual having a crisis. I advocate patients and their families to talk about these things prior to whatever health crisis befalls them and clearly make their wishes known. Our population is one that is poorly educated to the realities of medical decision making.

Our society does not realize that medical decision making on the part of providers is often driven not by what is best for the patient but what is best for the patient's lawyer. Many hospitalists (doctors who treat only hospitalized patients) feel compelled to provide treatments that prolong breathing and metabolism but have nothing to suggest that the patient's life, thoughts, and dreams will be honored. There is nothing noble about lying unresponsive in a bed with tubes in almost every orifice crapping on yourself.

One should be careful in choosing who is going to be the POA for healthcare decisions should one become disabled. You don't want someone to be making decisions that you would not make yourself. Through experience I have seen that making "all" the siblings equal in matters of medical decision making is a very bad idea. There is always one of the siblings who wants everything done regardless of whether it will improve quantity or quality of life. I have seen adult children put their parents through the tortures of the damned with the end result of a prolonged painful undignified death not a dignified and natural end of life. And beware of the far far right Catholic fake Living Will masquerading under the name "Will to Live." I won't link to it as it is one of the worst written, deceptive and foul advance directives I have ever read.

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