Making Decisions About End-of-Life Care

For most of our lives, relationships between patients and doctors focus on maintaining good health and keeping disease and symptoms to a minimum. However, as the end of life approaches, patients and doctors need to have a shared understanding of health care preferences.

Several studies indicate that patients have not taken advantage of their right to determine their own end-of-life care. Less than half of severely ill patients have an advance directive in their medical record. Of those who do, only 12 percent received input from their physician in its development. About three-quarters of physicians whose patients have an advance directive are not aware that it exists.

An advance directive, also known as a living will, is a legal document that allows patients to provide instructions for medical care in case they become incapacitated and cannot make decisions. A medical power of attorney, or health care proxy, is a document that allows patients to appoint someone else to make decisions about their medical care if they are unable to do so.

In the United States, 80 to 85 percent of people who die are over age 65. Most die as a result of chronic conditions like diabetes, heart disease, emphysema or renal failure. Many experience a slow decline in health, punctuated by periods of more severe illness from which they usually recover. These patients may experience several life-threatening illnesses over the years before eventually facing death. Because of this uncertainty, it is important to begin discussions about end-of-life care before a medical crisis develops.

You can prepare for a potential crisis by talking about these issues with your family and friends. How do you want to be treated at the end of your life? Are there particular treatments that you want to receive or refuse? Consider your overall attitude toward life and the activities you enjoy. What is your attitude about independence and control and how would you feel about losing them? How do your religious beliefs and moral convictions affect your attitudes toward serious illness?

Advise your doctor that you have begun thinking about end-of-life issues and have a realistic discussion about your medical situation. Most people have an overly optimistic view of their chances of survival after receiving CPR or receiving mechanical ventilation. Make sure that your doctor is willing to follow your wishes.

Life support replaces or supports a failing bodily function. When patients have curable conditions, life support is used temporarily until the illness or disease can be stabilized and the body can resume normal functioning. Sometimes, the body never regains the ability to function without life support. A specific form of life support might be beneficial if it relieves suffering, restores functioning or enhances the quality of life. The same treatment might be undesirable if it causes pain, prolongs the dying process without offering benefit or leads to a diminished quality of life.

There is no legal or ethical difference between withholding and withdrawing a medical treatment in accordance with a patient’s wishes. It is legally and ethically appropriate to discontinue medical treatments that are no longer beneficial. In other words, if you are placed on a mechanical ventilator but you later decide that this treatment is no longer beneficial, the ventilator can be withdrawn. It is the underlying disease, not the act of withdrawing treatment, that causes death.

In selecting a medical power of attorney, choose someone you trust and who understands your decisions. Once you have made your decisions, work with your attorney to draw up the necessary documents.

Make sure that your doctor and your family have copies of your completed directives. Reassess your decisions over time. They might change as your life and health circumstances evolve.