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Monday, September 22, 2014

Write Your Living Will Now to Ease Burdens Later

A living will is a legal document that indicates what medical treatments and life-sustaining measures you want or don't want. If the time comes when you can’t make your own decisions, a living will can be valuable for your family and doctor and help ensure your preferences are honored.
Approximately 80 percent of Americans fail to share their wishes for their end-of-life care, leaving family members and doctors to decide what life-saving measures to perform. Not only can this result in family quarrels, but you may receive care that is more aggressive than you desire. For example, CPR (cardiopulmonary resuscitation), which has a low success rate, can be violent and leave patients in worse condition. Not only does it make sense to write a living will as you get older and become increasingly prone to chronic illness, but it is also wise to understand the treatment options and their risks. A living will is a legal document that indicates the types of medical treatments and life-sustaining measures you want or don’t want, such as cardiopulmonary resuscitation (CPR), feeding tube, and mechanical breathing (respiration and ventilation). In addition to a living will, people are also encouraged to have an advance directive known as a medical power of attorney (POA). (See “Assigning Medical Power of Attorney is Both Difficult and Easy,” October 2012, Senior Spirit).

A medical POA is a legal document that designates an individual—referred to as your health care agent or proxy—to make medical decisions on your behalf if you’re unable to do so. Like the POA, the living will becomes a tool to help your family and medical staff determine the life sustaining measures and medical treatments to pursue at the end of your life if you are unconscious or not capable of deciding on your own.

In addition to executing a living will and medical POA, it’s important to discuss your beliefs and wishes with family members and your doctor. If they know beforehand what measures you want taken—and, just as important, why—when the time comes, the process can be easier and less stressful for everyone. (For where to find forms, see sidebar.

Important Questions to Ask

When writing your living will, give serious consideration to the kind of treatments you want. Questions to ask yourself include:

  • How important is it to be independent and self-sufficient?
  • What would make me feel that my life was not worth living?
  • Do I want treatment to extend life in any situation?
  • Or only if a cure is possible?
  • How might my decision about life-sustaining treatment be different if I was 50, 70 or 90 years old?
  • Would the treatment lessen my suffering?
  • What kind of burdens and side effects will the proposed treatment impose?
  • What are the potential benefits and risks associated with CPR, a feeding tube, ventilation, etc.?

(Adapted from Mayo Clinic and American Hospice.)
Weighing CPR

When a person stops breathing or the heart stops beating, medical personnel administer CPR, which can consist of two stages: chest compressions (forceful pressing on the chest to stimulate the heart) and artificial respiration (mouth-to-mouth rescue breathing). In addition, personnel may use electric stimulation and special medicines to resuscitate a stopped heart. CPR can help keep oxygenated blood circulating through the body, which can help prevent brain and organ damage. Without CPR, a person is likely to become unconscious almost immediately and will die in 5-10 minutes.

However, when a patient has an advanced life-threatening illness (such as late stages of cancer) and is dying, CPR may not provide any benefits (Family Doctor). Additionally, the survival rate after CPR is only 15 percent, but it decreases to 2 percent for the frail and elderly (Allina Health). If successfully, CPR may result in a sore chest, broken ribs or a collapsed lung, especially in elderly patients with fragile bones. Though they may survive, those especially who are older and/or frail may have a drastically reduced quality of life, suffer from brain damage or other health complications, and may require ongoing medical support (e.g., ventilator).

Other Treatment Considerations

Other treatment considerations to consider when executing a living will include (adapted from the Mayo Clinic and American Hospice):

Mechanical ventilation. A person who is unable to breathe sufficiently may need to have a tube inserted down the nose or throat (referred to as intubated), or surgically through the neck, into the trachea. This connects to a ventilator (breathing machine), which breathes for the patient. However, for those with certain lung and heart diseases, the likelihood of resuming normal functioning after removal from the ventilator is low. Intubated patients can’t talk and may need medicine to keep them comfortable. Some patients who survive may need to be on a breathing machine in the intensive care unit (ICU) for a while. Bacteria in the tubing can result in pneumonia, and patient immobility can lead to psychosis, skin breakdown and progressive weakness.

Nutrition and hydration assistance. To keep a patient alive, medical professionals will automatically supply the body with nutrients and fluids intravenously or via a feeding tube. If you are seriously ill or close to death, life-sustaining treatment will not be stopped unless spelled out in your advance directives. Permanently unconscious patients can sometimes live for years with artificial feeding and hydration. If food and water are removed, death will occur in a relatively short time due to dehydration, rather than starvation. Such a course of action generally includes a plan of medication to keep the patient comfortable.

Admission to the ICU. The ICU is generally meant for a person who is reversibly critically ill and who desires full resuscitation should cardiorespiratory arrest occur. But patients can suffer from isolation, as visitors are restricted, and immobilization, as well as disruption by light, noise, diagnostic tests and therapeutic interventions, which are uncomfortable and potentially painful. A frail patient is prone to develop ICU psychosis.
Additional Considerations

 Including a do-not-resuscitate (DNR) order in your living will may only prevent CPR, not other life-saving measures. Some people add a DNI—do not intubate. An alternative that is gaining popularity is AND—allow natural death. An AND advises doctors to offer only comfort measures, because any other aggressive treatment, such as intubation, may only prolong suffering. AND also conveys a positive, and perhaps gentler, message to those who must decide whether to continue life-saving measures for their loved one.

If your illness is terminal, you can also request in your living will that you want palliative care, which focuses on quality of life and dignity by helping a patient remain comfortable and free from pain until life ends naturally.

Some living wills encompass more than just DNR or DNI requests by spelling out your thoughts about dying, which can be more helpful to your doctors, friends and family when deciding what kind of end-of-life care you want. One of the more well known is Five Wishes, which goes beyond medical issues to deal with personal, emotional and spiritual concerns. The downloadable form includes questions about how comfortable you want to be, how you want people around you to treat you and what you want your loved ones to know when you’re facing the end of your life.

Five Wishes was written by Jim Towey, who worked with Mother Teresa and was inspired by her care and concern for others. His organization, Aging with Dignity, is a national nonprofit that aims to affirm and safeguard the human dignity of individuals as they age and to promote better care for those near the end of life. He introduced the Five Wishes will in Florida in 1997, and a year later, to the nation. Today, Five Wishes meets the legal requirements in 42 states, and millions have used the form to specify their desires.


“Advance Health Care Directives and Living Wills,” Help Guide

“Advance medical directive facts,” Medicine Net

“Cardiopulmonary Resuscitation (CPR),” Family Doctor

“CPR and Advance Care Planning: What You Need to Know,” Allina Health\

“Download Your State’s Advance Directives,”
“How Misconceptions Among Elderly Patients Regarding Survival Outcomes of Inpatient Cardiopulmonary Resuscitation Affect Do-Not-Resuscitate Orders,” Journal of American Osteopathic Association

“Living wills and advance directives for medical decisions,” Consumer Health, Mayo Clinic

“Medical Issues to Be Considered in Advance Care Planning,” American Hospice Foundation 

“What Do a Living Will and Power of Attorney for Health Care Cover?” Nolo (Law for All) 

“What is a Living Will?” All Law

Write Your Living Will Now to Ease Burdens Later was featured in the  August 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors