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What’s Up Doc column: Advanced directive allows patient’s wishes to be honored

Dr. Jeff Hersh
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Cape Cod Times

Columns share an author’s personal perspective.

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Life is a terminal condition; everyone who lives eventually dies. So medicine’s role is not just to treat and possibly cure diseases, but to improve the quality and/or quantity of a patient’s life. Although quantity of life is easy to measure, quality of life is a much more subjective concept. How to achieve the best balance of quality and quantity of life for a given patient is often not an obvious thing.

An advanced directive - instructions given regarding medical decisions for certain situations in case the patient is incapacitated - is a way for someone to address what they feel is an acceptable quality of life. Although things differ a bit from state to state, every state has laws regarding advanced directives.

Some examples:

• A living will is where the patient states in a general way their feelings about artificially prolonging life after a catastrophic event has occurred. Life-prolonging treatments may include having a respirator assist their breathing, have a feeding tube for nutrition, an IV for fluids or even dialysis if their kidneys stop working, among other possibilities.

• A do not resuscitate order (DNR order) says the patient would not like heroic measures (like we have all seen on TV during a “code blue”) to restart their heart or breathing.

• A medical power of attorney is where a patient appoints someone to make decisions for them in case they are unable to express their wishes themself.

An advanced directive does not mean the patient will not be treated - in fact, the opposite is true. It means they will be treated in compliance with their wishes, and it ensures they will not receive treatments they would not want. Their dignity will always be respected, and control of their pain will always be prioritized.

If someone elects to make an advanced directive it is vital that their family, friends and doctors know their wishes. For example, in an emergency, the decision to resuscitate a patient must be made in seconds - so if they wish to be DNR (do not resuscitate), the order will only be useful if the appropriate paperwork is available to the paramedics and rescue people who may respond to an emergency. Some people get bracelets (like the bracelets people with diabetes or other chronic illnesses have) to be sure their wishes are known in case of an emergency. Patients in nursing homes or assisted living homes should be sure the staff are aware of their wishes and have appropriate copies of the paperwork that delineates what those wishes are.

The concept behind the Hippocratic Oath is not “do no harm” (these words are not actually part of the Hippocratic Oath), but is really that “it may be better not to do something, or even to do nothing, than to risk causing more harm than good.” Therefore, honoring a patient’s wishes, as expressed in their advanced directive and/or as delineated by the person having power of attorney to speak for them, is the right thing to do, even in the difficult scenario where life support already initiated needs to be discontinued. Honoring these wishes is to act to avoid causing more harm (by continuing this unwanted care) than good (allowing the patient to pass away peacefully, comfortably, and with their dignity intact and their wishes respected).

When I was working in the COVID ICU recently, a terminally ill patient’s family made the very difficult, but loving, decision to respect her wishes and to discontinue life support (the patient had been placed on a breathing machine when she coded). Although the medical staff strongly support honoring the patient’s wishes, discontinuing life support is still an emotionally difficult thing to do. Knowing we were honoring her wishes, and being there to support each other, is how we were able to cope.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.