Advance Directives Help Patients Make their Healthcare Wishes Known

The patient, a 78-year-old woman, was unresponsive with no hope of recovery as a result of a severe hemorrhage. Her daughter—her designated healthcare surrogate—consulted the family physician for advice.

The doctor reviewed the patient’s advance directives, which stated that she did not want to be kept alive if she could not recover. Reassured that she was following her mother’s wishes, the daughter authorized the withdrawal of her mother’s feeding tube. Another patient rejected a surgeon’s recommendation of cardiac bypass surgery. While still lucid with full mental capacity, the patient understood that—without surgery—he faced the risk of myocardial infarction, which could lead to stroke, coma and death. The family physician advised the patient to put his decision in writing and discuss his end-of-life wishes with his family.

Shortly thereafter, the patient had a heart attack. He was hypoxic and no longer capable of making medical decisions. The surgeon again recommended cardiac bypass, but the family—knowing the patient’s wishes—chose palliative care, instead.

The importance of written advance directives cannot be overstated. Physicians have seen first-hand the pain, anguish and cost that can result when patients no longer can confirm with their loved ones what kind of healthcare they want or which “heroic measures” they would accept.

The consequences of not making one’s healthcare wishes known have been made all-too-publicly clear over the past several decades in three dramatic cases:

• The 1975 case of Karen Ann Quinlan led to the establishment of advance directives and hospital ethics committees.
• In 1990, the case of Nancy Cruzan marked the first time a court ruled in favor of discontinuing PEG feeding based on a previous statement the patient had made to a friend. This and the Quinlan case led in 1991 to the passage of a Federal law known as the Patient Self-Determination Act (PSDA), which gives Americans the right to refuse any medical treatment, including ventilators and feeding tubes.
• More recently, the Florida case of Terri Schiavo demonstrated the importance not only of making your end-of-life wishes known, but of documenting those wishes, even at a young age.

“Physicians can play an important role in the execution of advance directives by encouraging their patients to talk about and document their healthcare wishes before a healthcare crisis arises,” says Paul Rozynes, M.D., medical director for VITAS Innovative Hospice Care® of Broward County.

“Discussing end-of-life choices can be uncomfortable,” adds Alan Marcus, DO, team physician for VITAS’ inpatient hospice unit at Columbia Hospital in West Palm Beach, “but it’s important for physicians to know what their patients want so they can care for their patients when they can no longer speak for themselves.”

Advance directives typically consist of one or both of the following:

• A living will—which outlines the patient’s wishes as to medical treatment should he or she become unable to communicate.
• A medical power of attorney—which appoints a trusted family member or friend to make decisions about medical care, if necessary.

“The existence of an advance directive can help family members come to peace with their decisions when their loved one is incapacitated, and it can help the physician write a ‘do-not-resuscitate order’ (DNR) with confidence,” says Paul Pugliese, M.D., associate medical director for VITAS Innovative Hospice Care® of Miami-Dade/Monroe.

Once advance directive documents are signed, it is important for all involved to know where the documents are. “Patients’ directives should travel with them, from home to nursing home to hospital, so all caregivers are aware of its location and what it contains,” says Rozynes.

In some cases, a patient’s healthcare surrogate or family members might disagree with the patient’s plan of care, even if advance directives exist. Hospice is uniquely suited to help in these cases, says Pugliese. “Because they are trained in palliative and end-of-life care, hospice physicians and nurses can help loved ones understand that continuing ‘extreme’ measures actually can harm the patient and cause greater discomfort and pain as death approaches and the body begins to shut down.”

“By asking patients what their wishes are and encouraging them to document those wishes, physicians can make sure their patients are in control of their own medical decisions—even at the end-of-life,” concludes Marcus.