Monday, December 29, 2008

are you ready to die?

i know that sounds a bit macabre, particularly in light of this joyous holiday season, but as the year unwinds, i think it's a question that everyone should consider, sooner rather than later. now, oddly enough, i'm not even talking about the spiritual component which is what you might expect around christmastime. i'm actually talking about the realm of living wills and advance directives.

let's talk about dnr's first. a dnr is a "do not resuscitate" order. that means, in the event of a respiratory or cardiac arrest, there will be no cpr--no intubation and hooking the patient up to a ventilator, no cardiac shocks, chest compressions, no "heroic measures" or any of the other things that occur in a "code" situation. now, in the event that you are a 90 year-old woman with metastatic breast cancer, severe dementia and so debilitated you haven't been out of your bed in the past year, the decision for you or your family to make you a dnr seems pretty easy.

however, in many situations, it's not as clear cut. i have had a number of patients who were made dnr or about to be made a dnr who ended up surviving and leaving the hospital alive. they subsequently led happy and productive lives, at least for some time after discharge.

but what if you were a 97 year-old and you developed a tear in your aorta which could only be corrected surgically? if you don't get the surgery, you will probably die. if you do get the surgery, you will probably die. would you rather die peacefully at home or on the operating room table? the answer seems to be easy, except in this case, the patient was michael debakey one of the most renowned surgeons in history. he actually pioneered the surgery that he now needed. i think i have linked to this article before but here's the link again to a fascinating article in the new york times a couple of years ago. he refused his surgery and wanted to die in peace. only after he became comatose, his wife begged his colleagues to perform the surgery and after a special ethics meeting, they agreed to proceed. he survived the surgery and lived for another couple of years, long enough to receive the congressional gold medal from president bush. the funny thing is, even though he intially refused surgery and was ready to meet his maker, after the whole ordeal he was happy his wife did what she did. if the famed dr. debakey can make a mistake regarding a dnr order, how is the average joe on the street supposed to know what to do?

that's why i feel like it's good to have a surrogate medical power of attorney or medical decision-maker. in some young patients, it's appropriate to withdraw care. in some much older patients, it's appropriate to continue fighting. i think if you have an advanced directive specifying exactly what you want or don't want done to you if you aren't conscious to make those decisions yourself, you may be potentially making a tragic mistake. would you always refuse being hooked up to a ventilator? some people specify that but what if it's just for a day or two while your lungs recover from a bad pneumonia? frequently, we have patients on ventilators only for a few days and they get better and eventually go home. however, if your advanced directive refuses this care, you could potentially succumb to a disease you shouldn't have.

the point is, each situation should be evaluated on its own, which is why i feel (at least right now) that it's best to have someone make the decision for you. hopefully that person has some type of medical knowledge or background which would make the communication and decision-making easier. naturally, one would assume that the spouse should be the one making these decisions and they probably should, but other times it might be more difficult. if your loved one is actively dying despite all medical care, it would be very difficult to tell the doctors to withdraw care. sometimes people want to make this decision on their own, sometimes they want some reassurance from someone else that this is the right decision. whatever is right for you or your family, if you don't have an advanced directive, make sure someone is designated to make those decisions. if not, what happens frequently is that family members disagree about the care and that itself eventually turns into a mess.

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