Advance Directive

Jan 22, 2013When Is Making the Decision to Be DNR Appropriate?

by James C. Salwitz, MD
KevinMD
January 22, 2013

Here is a little appreciated fact: Patients cannot order medical care; they can only accept or refuse it. Only a doctor can order medical treatment. In an extreme medical situation, the doctor can offer CPR, but it is the patient’s job to accept or reject. Any patient can refuse CPR. This refusal is known as Do Not Resuscitate or DNR, and for obvious reasons needs to be made ahead of time. The question is, when is making the decision to be DNR appropriate?

A further definition is needed. DNR (and its colleague, Do Not Intubate, DNI) is not the same as DNT, or Do Not Treat. A patient, at their discretion, may receive maximal medical care, including drugs, dialysis and surgery, and still be DNR. The DNR order in that situation is simply a line that the patient will not allow the doctors to cross. “Do everything you can to help me, but if it fails I do not want to end my life on a machine or with some gorilla pounding on my chest.”

On the other hand, a DNR can be a part of a hospice or palliative care program, so that all care is focused on comfort and not treatment. It is even possible, in very unusual circumstances, to receive hospice care without being DNR. A DNR order is like any medical decision, it can be changed if appropriate. DNR is not the same as “pulling the plug.”

How aggressive to be in receiving medical care is a personal decision. In order to make certain that our individual desires are followed it is critical that, as much as possible, these decisions be made ahead of time. This avoids panic, confusion, and guilt. In that spirit, let us review a few cases. More

Jan 22, 2013End-of-Life Care Rarely Discussed

by Kay Lazar
The Boston Globe
January 21, 2013

On an average day in Massachusetts, 144 people die. One is an infant. A few are children. Some are middle-aged, most are over 75.

These observations lead a 32-page report, released nearly two years ago by a state-convened expert panel charged with recommending improvements to Massachusetts’s lagging system for end-of-life care.

Since then, few of the panel’s recommendations have been implemented. Precious final days for many Massachusetts residents are still not spent the way they would have chosen — at home with loved ones — but in a hospital. And health-care providers do not routinely discuss end-of-life care preferences with patients, said Dr. Lachlan Forrow, director of ethics and palliative care programs at Beth Israel Deaconess Medical Center, and chair of the expert panel. More

Jan 19, 2013Movement Grows in Planning End-of-Life Strategy

by T.J. Greaney
Columbia Daily Tribune
January 9, 2013

Kathe Ward could see that her mother was slipping away.

Suffering from advanced Alzheimer’s, the 77-year-old passed her days in a nursing home bed, unable to speak, sit up or control her bowels. So Ward, a St. Louis registered nurse, asked a lawyer to draw up a document forbidding medical personnel from aggressively trying to prolong her life by using CPR, dialysis or a ventilator.

Known as an “advance directive,” the document signed by her mother, with Ward’s help clutching the pen, gave Ward power of attorney in health care for her mother.

“I felt like I knew her well enough to know she wouldn’t want to linger in the state she was in,” Ward said of her decision in 2005 to prepare an advance directive. “But I knew there was a possibility she could have lived in that state for another 10 years.”

In 2007, when her mother stopped breathing correctly and a feeding tube implanted in her stomach fell out, Ward relied on the legal document to help her make the wrenching decision to let her mother die despite some resistance from siblings. “Had it not been for me really taking the bull by the horns and saying, ‘We are not taking her to the hospital to put another tube in her stomach,’ then I think my sisters would have just said, ‘We want everything done,’ ” Ward said. “And it would have been much harder for them to let go. And it would have been prolonged.” More

Jan 11, 2013A Precious Gift for Those You Love

by Terrell B. Vanaken
Daily Republic
January 10, 2013

During the holiday season, we often think of giving in terms of tangible, often costly items.

There is, however, an extremely valuable gift that we can offer at any time of year, and which costs virtually nothing. It’s something all of us can offer to our family and loved ones. It’s the knowledge and understanding of what we would want done at the time of a health emergency, when we cannot make decisions for ourselves.

An advance directive, when properly completed, is a legal document that stipulates who should make decisions at a time when an individual no longer can. It also allows you to specify your wishes for medical treatment and just how aggressive medical personnel should be with your care.

At a minimum, an advance directive should name the primary person you trust most to make major health care decisions about your welfare. This person is called your “agent” for health care decisions. You may also name an alternate in case your first choice is unavailable for any reason.

An advance directive can be completed by any adult and is made legal by the signature of a notary public or the signatures of two qualified witnesses. Of course, as we grow older, a directive becomes more and more important, since the incidence of health care emergencies increases as we age.

Many critically ill patients and families who I have met in the hospital have never sat down and actually talked about their wishes before such a tragedy occurs. We all tend to avoid these discussions, but after a stroke, a heart attack or life-threatening event, your loved one may not be able to talk at all or understand these issues. More

Jan 10, 2013Choosing Options for Life-Sustaining Care: Advance Directive Will Ensure Your Wishes Are Followed

The Chicago Tribune
January 9, 2012

Mr. J. had an implantable cardioverter defibrillator (ICD) for advanced heart failure. Having survived one episode of cardiac arrest, in which he nearly died, he was at high risk for another episode caused by a rapid, unorganized heart rhythm called ventricular fibrillation. Should this happen, the ICD would shock his heart back into normal rhythm. But at his daughter’s wedding, the ICD fired nine times. Each time, it saved his life, but the painful episodes terrified him, and he asked that the ICD be turned off.

Dr. Eva Chittenden, associate director of palliative care at Harvard-affiliated Massachusetts General Hospital, met with Mr. J. to explore his decision further. He stated that he’d already been hospitalized five times within 12 months, and he felt this took too much time away from his family.

They discussed his personal values and what action he’d want taken if his heart stopped, and the ICD was no longer there to revive him.

After long talks with Dr. Chittenden and his family, Mr. J. chose a “Do Not Attempt Resuscitation/Do Not Intubate (DNAR/DNI)” order. The decision meant he could continue seeing his cardiologist and other doctors, remain on his medications, and return to the hospital for intravenous diuretics. But he would not be revived if his heart stopped.

Doctors wish all their patients would make their preferences known in advance, like Mr. J. did. More

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