Advance directives can be guide
Mary (not her real name) had advanced colon cancer that had spread throughout her body. She and her family had elected not to pursue further curative care, as her physician told her it was unlikely to prolong her life. Mary did not have an “advance directive,” so we sat down with her and her family to ask her what her wishes were. I gave her a copy of “Five Wishes,” a wonderful document that guided her through the questions necessary to help her make decisions. She and her family were so impressed with the document, they asked for copies of their own, so they, too, could fill them out “just in case.”
What is an advance directive, anyway? It’s an awkward term (that’s medicine for you) that tells your doctor and your family how you wish to be treated if you are unable to make medical decisions (If, for example, you are in a coma). Advance directives tell the medical team what to do, or not do, if you are critically ill. They also serve as a guide for your family.
A durable power of attorney is an important part of an advance directive. It designates who you want to be the decision maker should you be unable to speak for yourself. This does NOT give that person the right to control your financial affairs (that’s another document). We owe it to our loved ones to designate that person ahead of when they might be needed and to have the serious discussions with him or her. In a time of crisis, it’s hard for someone to step forward and say, “Mom wanted me to make the decisions,” especially if there’s another family member who is disputing that. If it’s in writing, then the estranged brother from California knows that little sis really is the person Mom wanted to call the shots.
We are all more familiar with the term “living will.” This document takes effect only when you are terminally ill. In a living will you select what kind of treatment you want, in what circumstances you want it, and what you don’t want.
For example, you might want antibiotics for an infection, even if you have terminal cancer, if you are expected to recover from the infection. But you might not want the antibiotics if you have been in a coma with that advanced cancer and the antibiotics will only postpone your death but not reverse the coma.
What about the famous (or infamous) DNR order? DNR means “do not resuscitate,” or perform CPR, in the event your heart stops or you stop breathing. If we believe the television show “ER,” then we expect CPR to be successful most of the time. But in truth, in the setting of advanced terminal illness, CPR is rarely successful, and the chances of leaving the hospital alive are virtually nil. In that setting I really prefer the term “allow natural death,” because that is really what we are talking about.
I’ve had many patients tell me they hope they die suddenly, in their sleep, so these difficult decisions won’t have to be made. But as health care advances, many of us will live to a frail old age and die of a chronic disease.
Even cancer has turned into a chronic disease in many cases. As I work with dying patients and their families, I have discovered that there is much to be gained in those last months: Financial affairs can be set in order, good-byes can be said, and reconciliations with estranged friends and families can be realized.
It’s easier to think about these questions before the crisis. And nothing is set in stone. Goals change, and minds change.
Don’t like what you decided before? Tear up the old document and fill out a new one. Take a look at “Five Wishes.” It’s an excellent document. You can preview it and order one, if you want, at www.agingwithdignity.org/5wishes.html.