Health Break | Published July 11, 2005 | Written by Linda Lochbaum, MS, RN, CWOCN

Making The Hard Decisions For End Of Life Care

A few months ago during the Terri Schiavo case, we were all very aware of the importance of communicating our end of life decisions. Have you thought about what would happen if you were very ill and could not make decisions for yourself? Would your doctors know what you wished them to do? Would your family and loved ones know what you wanted? What are your options? It is best to have an advance directive, which provides guidance for medical and healthcare decisions. There are two types of advance directives: a healthcare proxy and a living will. Healthcare proxy is a document in which you name a person to make your healthcare choices when you are not able. This is your healthcare agent or power of attorney, who is legally obligated to make decisions that he or she thinks you would make for yourself. Thus, it is very important for you to be as specific as possible with your agent about what you want and do not want. This includes discussing your medical treatments and your religious and spiritual beliefs. Knowing that you cannot anticipate everything, be sure you are comfortable with your healthcare agent. Selecting an alternate, in case the primary agent is not available, may be advisable. Because the healthcare proxy grants medical decision-making power to a third party, legal experts state that the healthcare proxy is preferable to a living will for ensuring that a your medical wishes will be fulfilled. A living will is a written record you sign that guides your doctor and your family about your wishes. It is used as a guide for your care when you are no longer able to make your own decisions. When writing a living will, people usually address whether or not they would opt for specific treatments in order to attempt to remain alive, such as:

  1. Cardiac resuscitation – this is an attempt to save your life if your heart stops. This may not be very successful toward the end of life and may cause injury. Some people with terminal illness who chose this, later wish they had not.
  2. Mechanical ventilation – this is a breathing machine that forces air into your lungs when you cannot breathe on your own. To do this, a tube is placed into your nose, mouth, or throat and passed into your lungs. It is usually very uncomfortable, so high doses of sedatives are given. This is sometimes referred to as ‘life support.’ People who choose not to have this may not want to spend their last days in the hospital connected to the machine or may not want their family members to see them in this state.
  3. Artificial nutrition and hydration – this is a method of feeding you by placing a tube in your vein, in your stomach or in your intestines. People who do not want to be artificially fed may not want the discomfort of the tube or other associated procedures, knowing it will prolong life.
  4. Defibrillation – this is an electric shock that can restart the heart. The shock causes the body to jerk; you do not feel it because you are already unconscious.
  5. Certain medications – medications called pressors may be given to raise your blood pressure. Again, if you are very ill, these medications may not be beneficial and the effect may only short lived.
  6. Other aspects that you may consider are:
    1. Do you want dialysis for kidney failure?
    2. Do you want blood transfusions?
    3. Do you want any form of surgery or invasive diagnostic procedures?
    4. Do you want antibiotics?
It is okay to have both a living will and healthcare proxy. If you do have both, naming a healthcare agent should be your priority. It is very important to inform your doctor about your advance directive and discuss with the doctor your wishes. Many people give a copy to their doctor. Do you still have control? Yes, you have control over your care as long as you are able to make your decisions and communicate them. Your word supersedes anything you have written or shared with others. Advance directives go into effect when you are unconscious or too ill. When you recover, you make your own decisions again. So, consider carefully what treatments/medications/procedures you wish and share them with others by your advance directive. Linda Lochbaum is a registered nurse and clinical nurse specialist at Mount Nittany Medical Center.

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