I know I said “nothing academic,” and this really doesn’t fall under that heading, but neither is it a witty entertaining story. This is about how we
in the hospital decide what to do with your life.

Say a 90 year old woman comes to ER with a stroke. There’s no family around, and the patient is unable to speak and/or is unconscious. She needs to be intubated very soon to save her life. She can’t speak for herself, and we can’t find family. We don’t know for sure if she’s chronically ill or still plays tennis, or is just generally healthy but old.

What do we do?

We intubate. If there is no directive to guide us in the patient’s wishes, we have to do the medically prudent thing. Now, what if we were able to get our hands on a living will stating that no heroic measures be taken? We most likely would not intubate, but there are many variables involved.

I think there is much confusion about “advance directives.” I think this because whenever I admit a patient to my unit, I’m required by law to ask them if they have an advanced directive, and provide information to them if they do not. At least 90% of the time I am answered by a confused look. “Advance wha?” It becomes only marginally clearer when I clarify by saying “healthcare durable power of attorney” and much clearer when I say “living will.” Regardless, most people have not actually filled any of them out.

There is a major difference between a living will and healthcare durable power of attorney (DPOA). In most cases you don’t need an actual laywer in order to fill either of them out. And I do so hope that my own peer group in their 20’s are still with me here, because 2 of the biggest cases involving end-of-life decisions involved patients that were our age – Karen Ann Quinlan and Nancy Cruzan. Typically, though, these situations deal with those who are older than us. This includes our parents, ya know?

A living will is something that is filled out by the patient who is competent to make decisions at the time. It is a document that speaks only for itself and because of this, is restrictive. It is much better than having nothing at all. It is also typically only consulted once the patient has a serious medical problem: coma, persistent veggie state, etc.

A DPOA, however, can be consulted at any time the patient is unable to participate in making health care decisions. The main advantage of this document is that you’ve named someone to act on your behalf, thereby making it less restrictive. There are a few catches to this, though. One is that you must designate someone to do this for you, and then actually talk to them about what you want done. The document typically contains the usual “does/does not want life-sustaining measures,” but doesn’t take into account every single possibility of every situation. This is where it becomes handy to have another human being who knows you try to help us figure out what you’d want. The other catch to this is the emotional component. Think that your spouse would be the best candidate for the job, seeing as how they probably know you better than anyone? Think again. I’ve seen numerous situations where the spouse is too burdened and too emotional to make such a decision, even if it is spelled out right there for them. The guilt is overwhelming and their minds are flooded with what if’s.

Children (age 18+) are a better choice, but not by much. The best choice is an impartial person that you trust and who knows you well. Gee, how many of those do you have in your life? This is very hard for all concerned. But also quite necessary.

What happens when there is lots of family, but no documents to guide them? One child says, “Dad wouldn’t want to be kept alive like this!” and another says, “We can’t give up on him yet!” Ouch. This one’s hard. Laws are different from state to state, but the general hierarchy for decision making is this:

1. Guardian or agent/proxy of DPOA
2. Spouse
3. Children over 18
4. Parents
5. Sibling over 18
6. Close friend or relative (not recognized everywhere)

Note that in the case of children deciding, the eldest has no overriding decision making ability, except in cases where they are the only one over 18. If dad is wasting away on a vent with a feeding tube, and the kids making the decision do not agree, dad stays on the vent until he dies or some agreement has been made otherwise. However, the spouse can make a different decision from the children, because he/she has the higher authority. And a mere friend takes precedence over them all if said mere friend is the proxy of DPOA.

DPOA’s can be revoked or changed at any time by the patient, provided that they are competent to make decisions. The patient never gives up flexibility or control over their options until they reach the point that they are simply not able to do so anymore. For example, they have become unconscious or they are beginning to rant about picking those pennies off the ceiling.

LW’s and DPOA’s, unless specified otherwise, do NOT mean “do not treat.” We have had many patients with DNR (do not resuscitate) orders in ICU receiving antibiotics, tests, nutrition, and treatments of all kinds.

A very good resource for this topic is this article. It’s long and informative without being too jargonish.

I hope this was helpful in scratching the surface. Keep in mind that I’m no lawyer, laws vary around the country, and misunderstandings of the written word are common. Each case is different.