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Tuesday, December 17, 2002The problem is, living wills, as generally executed, are very limited in their scope. They are usually restricted to very specific circumstances; namely, when (a) the patient cannot express their own wishes, and (b) the patient is terminal. Part (b) is what usually keeps the Living Will from kicking in. Under Illinois' Living Will Act, a “terminal condition” is an incurable and irreversible condition such that death is imminent and the application of death delaying procedures serves only to prolong the dying process. "Imminent" has been defined by one court as "near at hand; mediate rather than immediate; close rather than touching; impending; on the point of happening; threatening; menacing; perilous." There isn’t a strict time line – i.e., less than 10 days – but one court has said that a week or less would be considered “imminent.” A death delaying procedure means any medical procedure or intervention which, when applied to a qualified patient, in the judgement of the attending physician would serve only to postpone the moment of death. Keep in mind that this becomes an issue only when the family can't agree among themselves what the intent of the living will is, or when the physician and family can't agree.This is why it’s important to have a heart to heart discussion with both your family - especially the person you’ve designated as the decision maker if you become incompetent, and with your doctor, about just exactly what you have in mind for your final days, and what you consider those final days to be. For some, the final days may be now. They may never, ever, want to be resuscitated, under any circumstances, even though their death isn’t knowingly imminent; even though they're fairly healthy. Others, although in the poorest of health, may want to be resuscitated, but not kept indefinitely on machines, or to forego intervention only if they have a clearly terminal and hopeless condition, like widespread cancer. This is also a reason that it's important to have a primary care doctor, or generalist, who knows you well, and who is willing to take an active part in all of your care. (Both DB and RangelMD have discussed the important role of the generalist recently.) It’s important to have a physician who can act as your advocate in the hospital, who knows you and your desires, and who can run interference between the specialists and your family (or you). I’m struggling with this issue with one of my patients, even as I write. He had a stroke a few weeks ago and went to a rehab center to recuperate. While there, he aspirated (something he ate or drank went down the wrong way.) He developed pneumonia. He was taken to the emergency room in severe respiratory distress and ended up on a ventilator. He has more than his fair share of medical problems - heart disease, a history of strokes, poor circulation in his legs - all mostly due to years of diabetes. He has a living will, but he made it clear to me every time we discussed it that he wanted intervention unless there was absolutely no hope. But, I had a hard time conveying that distinction to the intensivist taking care of him. He was upset that he had ended up on the ventilator. I’m still having a hard time getting him to understand that this is what the patient would have wanted. He only sees a guy with endstage diabetes. He hasn't seen him within the context of his family, and his beliefs. He doesn't understand that my patient, as ill as he is, still feels he has a lot of living to do and doesn't want to miss out on any of it if he can help it. posted by Sydney on 12/17/2002 07:24:00 AM 0 comments 0 Comments: |
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