A living will is better than nothing, but unfortunately they are written by lawyers and don't answer key questions. The number one cause of death in the United States is heart disease. The living will usually says "if two doctors certify that I am terminal within six months, don't use extraordinary measures." This has three main problems. One is that what constitutes an extraordinary measure? Two, doctors are usually somewhat in denial and aren't very good at saying when someone has only six months to live: for hospice people are often referred within days of death. Three: the most common cause of death is heart disease. Think about heart disease: if you are having a heart attack, the two doctors haven't a clue whether you are terminal in the next 6 months. Actually your heart could stop in the next 5 minutes and then they would be very comfortable saying that you are dead, but the real question is "Do you want a natural death?"

People say they want a natural death but when confronted with a form, they often are a bit squeamish. In the state of Washington we have a POLST form: Physician Orders for Life-Sustaining Treatment. This is much more helpful and practical than the living will and it is meant to augment it, not replace it. It has four questions. The first is "Patient has no pulse and is not breathing." This means that the person is dead. Does that person want an attempt at recusitation? Check recusitate or do not recusitate. I ask if people want a natural death and people agree that recusitation is not natural. Also, if someone is in their 70s or older, if the recusitation is successful (mostly not) they are likely to have some brain damage from lack of oxygen. People often say, "Well, bring me back if I'm going to be okay." I say that unfortunately our higher power has not provided us with a little pop up thing like roasting turkeys have that says "Done." We really don't know. We may have opinions, especially if the person is 40 and otherwise healthy versus 83 and has had a quadruple bypass and died three previous times. We have 8 minutes to bring someone back, so if you want to be recusitated, die in the emergency room. The odds are much better. Also, most of the security guards at Las Vegas casinos have brought back more people than I have, because they have the automatic defibrillators and they are quick to put them on when someone wins a jackpot, grabs their chest, and keels over. If someone asks what I would do if I were them, I do answer. It depends on age and health. As a doctor I want to bring someone back if they are reasonably healthy and there is a decent chance. I don't really want to do CPR on 90 year olds because it doesn't work and their ribs break. Ick.

I once was doing a form with an elderly couple. The husband had already had more than one heart attack and he had been recusitated from a cardiac arrest once already. I asked about a natural death and if he wanted to be recusitated again and he said, "No, I don't want that." His wife elbowed him, "Yes you do." He said, "I do? Why?" She said, "You have to stick around to take care of me!" He said, "Oh, okay. Yes, I do." He WAS taking excellent care of her: she had by then had "end-stage" emphysema since she had come to our clinic 12 years earlier. I asked the pulmonologist how that could be and she said, "Some people are just wrapped in cotton wool by their families and they can stay around for years." I don't mind if someone wants to be recusitated even if I think it's medically futile, because most people make sensible choices. If someone is really frightened of death, at a certain point no doctor can keep them around if the body has stopped working. There are really very few cases like comas or brain injury where someone can be kept alive on a machine. It is extremely rare.

I was discussing the choice with a woman in her 80s and her daughter and the 80 year old said, "I don't want to think about this." I said, "It may be uncomfortable to think about, but if you don't tell me and your daughter what you prefer, we would have to guess. We don't want to guess and we would probably err on the side of doing too much." She grimaced, but she did make the decisions. The POLST form and living will are only used when we can't ask someone, so a person who can talk can change their mind.

Question two is "Medical interventions", asking how much intervention you think you would like. There are four levels on our revised form. The most interventional is defibrillation (shock), intubation (ventilator) and CPR. Since I live in a rural area, I also have the luxury of asking whether people want to be transferred to a big hospital. I explain that I can use medicine for a heart attack, but I don't have a heart doctor or surgeon and I can't do stents or surgery or bypasses or anything besides medicines and oxygen. Sometimes being rural protects people who don't want much intervention, since the cardiologist and pulmonologist and gastroenterologist aren't down the hall. Who would refuse to be transferred? A man who had two previous heart surgeries said, "I don't want to wake up with that scar on my chest again. It hurts." A frail man in his upper 80s had pneumonia and a tricky heart and kidneys. We said that we were family doctors and a cardiologist and nephrologist and pulmonologist would no doubt do more and they could do some monitoring that we couldn't. He said, "Do the best you can for me here. I trust you and my family is here and I will either pull through or I won't." Four days later we told the family that he wasn't. If we protected his lungs and heart from too much fluid, his kidneys failed more, and if we helped his kidneys, he couldn't breathe. We changed to comfort care and he was surrounded by his family. I think that we all felt comfortable that we had given him the most respectful care possible and had honored his wishes. The second most interventional choice on the form is "All care above and consider oral/nasal airway, bag-mask/demand valve, monitor cardiac rhythm, medication, IV fluids." The least interventional is comfort care only: "Oral and body hygeine, reasonable efforts to offer food and fluids orally, medication, positioning, wound care, warmth, appropriate lighting and other measures to relieve pain and suffering. Privacy and respect for the dignity and humanity of the patient/resident. Transfer only if comfort measures fail." I like the thoroughness of the comfort measures.

The third question is "Antibiotics". Three choices: no antibiotics unless needed for comfort, no invasive(IM/IV)antibiotics or full treatment. Who would choose no antibiotics? Sometimes someone with end stage cancer or a very disabling disease, like Lou Gehrig's. Someone with a terminal illness who is not going to get better and is ready.

The fourth question is "Artificially Administered Fluids and Nutrition." Three choices again: No feeding tube/IV fluids (provide other measures to assure comfort), no long term feeding tube/IV fluids (provide other measures to assure comfort), or full treatment. Most people choose the second. Most people would like nutritional support if they have a reasonable chance of getting better. An elderly frail person with pneumonia sometimes needs iv feeding, or after surgery or after a bad accident. Most people do not want long term feeding by iv or tube if they are in a coma or have severe brain injury to the point where they can't even eat.

I am very happy to have the POLST form and it is an excellent augmentation to the living wills. It is very comforting to families as well. If a widowed mother has discussed her decisions with me and signed the form, then it doesn't fall to her three children to make decisions about how much care to give. She has left them and me a map and guidelines and we try to follow them as best we can. We are not left with the fear that maybe we did too little and that we should have done more. The hardest decision with a loved one is when to stop intervening.

I want the POLST form to have one more section. Question five: "Memory loss". If you have lost your memory to the point where you no longer recognize family, you have forgotten personal hygeine and toilet training, you may not even be able to speak any more, do you still want other things treated? My answer is no, for me. Too many of our hospital patients are frail, elderly, demented and the hospital confuses them. They often call out or cry or scream at night because it is frightening to be in another place and they don't like having their blood drawn. Sometimes we have to drug them or use restraints in order to treat the pneumonia or urinary tract infection. I really wonder how ethical it is. The problem is that by the time they have lost their memory, they can't really say, "no, don't keep treating me." Except for one woman. I have one lovely woman who has been at our nursing home for more than 4 years. She realized that she was losing her memory and said to her husband, "I don't want any drugs, no ivs, no feeding tubes ever. And I never want to go to the hospital again." He visits her every day and talks to her. Sometimes she won't let me examine her on my routine visit, but that is okay. Once she ran a fever of 102 for two days and didn't eat or drink anything. I checked with her husband and he stuck with her wishes. The fever went away and she got better. I am so happy that she doesn't have to have medicines or any blood draws or anything that she doesn't want. Another woman told me that she'd gone to our hospital family group on death and dying. Her husband had lost his memory and was in a nursing home, having gotten to the point of not recognizing her and not remembering toilet training. She said that the group said, "He's not dead." and weren't very welcoming. She said, "They don't understand. He's left his body and all I have is the live shell. He's really gone and he left slowly, bit by bit. They don't understand that the part that was him IS dead."

I don't think that doctors are terribly good at doing POLST forms with people. For a while I thought it was because my partners were younger than I was. Then I moved to a clinic where two doctors had left and they were both older than me. They had lots of people over age 65 and practically none of them had POLST forms. I'm not saying that people under 65 should not have a form. They really should, especially if they care about that coma scenario. But I REALLY think that people over 65 should have a chance to address this. Our form is bright green and after it is filled out I scan it into the computer and then the owner is supposed to put the original on his/her refrigerator, where the ambulance crew knows to check for it. Someone still might end up with a ventilation tube temporarily, if they become unconscious in a public place and the crew has no guidance. They too have to err on the side of doing more rather than less. I theorise that doctors' discomfort with the POLST form stems from a mostly unconscious idea that their job is to "make people better." I have been interested in end of life issues since medical school and it occured to me that if I thought of my job as to "save" people or keep them alive, then I was going to have a 100% failure rate, because actually everyone dies eventually. Instead I thought that my job was to help as best I could with a good life and a good death. It is turning out that no two people define a good death in the same way. It is entirely individual. My job turns out to be partly about telling people and families when I think death is approaching and helping them define their good death.

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