End-of-Life Choice, Palliative Care and Counseling

Choosing Options for Life-Sustaining Care: Advance Directive Will Ensure Your Wishes Are Followedby Sonja

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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.

“A talk with your doctor about your life goals, and what kind of medical care can help you attain these goals, is an extremely important part of health care for anyone with a chronic illness such as heart failure,” says Dr. Chittenden.

Providing an advance directive tells your doctors and emergency physicians what level of care you want, should you not be able to speak for yourself. It reflects your innermost values, especially what trade-offs you’re willing to make to stay alive. If length of life is most important to you, you may be willing to accept more technology than if quality of life and being at home are your primary desires,” Dr. Chittenden explains.

“Discussing these wishes and decisions with those closest to you is equally important, because one of them may need to make decisions for you in the event of an emergency,” she adds.

In addition to an advance directive, there are two measures you can take to ensure your wishes are respected:

1. HEALTH CARE PROXY

It’s important to designate a surrogate decision maker who’ll have the legal authority to make medical decisions for you, if you’re unable to make them for yourself. The situation may be temporary–when you’re under anesthesia, for example–or permanent. The person you choose might be a spouse, child, or trusted friend.

“Having a legal medical surrogate is very important, because if two family members disagree about what should be done for you, the legal surrogate has the final say,” says Dr. Chittenden.

In many states, all you need to do is ask your doctor’s office for a form, complete it, and have it witnessed by two people. In other states, you may need the assistance of a lawyer or notary. Ask your doctor’s office for direction.

2. A NEW TYPE OF LIVING WILL

Thirty-four states have adopted legislation encouraging people with life-limiting illness to fill out a form with their physician that directs their care in a medical emergency or other situation in which they’re unable to make decisions for themselves. It’s called a Medical Orders for Life-Sustaining Treatment (MOLST) form (or POLST, for Physician’s Orders). It’s more specific than a living will, which is often too vague to direct care in a meaningful way.

The MOLST form may document your preferences only about resuscitation, or it may also specify your wishes regarding hospitalization, dialysis, artificial nutrition, or hydration. The form serves as a medical order if an ambulance is called to your home or if you are hospitalized away from home. It should be completed with your physician following a discussion on the goals of your care. You may change your decision at any time and replace the form with an updated one.

DON’T WAIT UNTIL IT’S TOO LATE

Advance planning should be done while you are able to make and articulate your decisions. “You may never need these documents, but if you do, your wishes for life-sustaining care are more likely to be respected,” says Dr. Chittenden.