The right end-of-life paperwork

...The advance directive should be seen as a conversation starter, an idea generator, a philosophical tool. It is a guide for your loved ones to work with your doctors and make decisions that are based on your goals and values as the situation unfolds. Its purpose is to chart the broad strokes, to delineate the guiding principles. But it simply cannot be a detailed list of dos and don’ts.

The form asks that you choose between two general approaches to treatment — to prolong life or not to prolong life. There will be no confusion if you choose the first option — physicians’ default setting is to pursue every reasonable treatment, often until death. The problem is for those who would choose the latter.

Although the choice not to prolong life includes clarifying sentences — if the likely risks and burdens of treatment would outweigh the expected benefits, or if I become unconscious and, to a realistic degree of medical certainty, will not regain consciousness, or if I have an incurable and irreversible condition that will result in my death in a relatively short time — those conditions remain very subjective and can leave decision makers and doctors stumped. What does a relatively short time mean? Four days on a ventilator for someone with terminal cancer in excruciating pain might be a fate worse than death. But for someone else it might be a bridge to another six months of good life.

Emergency workers like E.M.T.s and paramedics are legally required to prolong the lives of dying patients unless they have a specific order from a doctor, which an advance directive is not. When called to the side of a dying patient, they do not have the time, the training, or the medical knowledge to try to parse the details of a patient’s case. It is understandable that health care personnel on the front lines — E.M.T.s, paramedics and even physicians like myself — err on the side of prolonging life in patients whom we don’t know... (continues)
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When a Medical Proxy Saves a Life

“I’m begging you,” pleaded my 93-year-old grandmother. “I want to quit while I’m ahead. I’m too tired. It’s been a good, solid run and I’m done.”

I was sitting in my cubicle in Midtown Manhattan trying to untangle the phone cord so I could hear every word of the argument she was making from her hospital room in Florida, where doctors were waiting to hear if they should go ahead with surgery to treat her sepsis, or take her to hospice, where she would most likely die of the infection by the end of the week... (continues)