Dan Onion, MD, MPH
Mt. Vernon/Vienna Health Officer
OK, this isn’t a very popular topic, but it is important, especially for the chronically ill and/or those us over age 75. If you aren’t in those categories, you may, nevertheless, be called on to help family members or friends, construct advance directives. As a geriatric consultant, I talk with many people about how to prepare for and manage serious illnesses and the mortality risks those illnesses carry.
Advance directives are directions written out by a person ahead of time, most often when chronically ill or elderly, to lay out what kind of medical interventions they do or do not want, should they suffer a life-threatening event, like a heart stoppage (cardiac arrest), or other organ failure. They direct physicians to use or not use cardiopulmonary resuscitation (CPR), kidney dialysis, or lung intubation and ventilation on a respirator. The odds of such interventions succeeding decrease with age and/or frailty. For instance, the chance of CPR succeeding is small to non-existent over age 75. One can direct ambulance and hospital staff to forego such likely futile treatments. Otherwise nowadays, the default is to use extreme measures if there is no explicit direction not to do so in an advance directives document, signed by the patient.
Hospitals and doctors’ offices have forms with check boxes to indicate whether or not you desire feeding tubes, CPR, or any of what are often called “heroic” measures. Advance directives can spare prolonged intensive care unit stays and the associated suffering with low likelihood of success. Instead, they can permit comfort care, often labelled palliative or hospice care.
Because the default is to “do everything”, which for many, has little chance of successful return to normal function, you should prepare ahead of time by letting your primary care clinician, the ambulance service and your local hospital know your desires. Send them copies of your advance directive forms, and also share them with your family so they can monitor conformance to them when the time comes.
There are a number of similar form choices for creating your own advance directives1, several have been designed in Maine. You should feel free to add or modify yours beyond the check boxes to include some specific directions; I append my own in a footnote2.
- 2If I am not mentally capable of participating in care decisions and facing any conditions listed below, please follow these guidelines as best you can.
- CPR up to age 75 unless I have a known terminal (under 1 yr) illness. No CPR over age 75 unless defibrillation possible within 3 minutes of loss of consciousness.
- No respirator support beyond 3 days, except in the case of trauma without brain injury.
- No IV maintenance fluids or feeding tubes unless recovery likely within 1 week and no terminal illness is present.
- Adequate pain control, preferably with a PCA system, or offer of pain meds regularly. But, if I am unable to request pain meds, I do not want others deciding to give them without direction from me. If I am medically paralyzed, then stop the paralyzing meds. If stroked out, work on ways to communicate with me (eye blinking etc.)
- If conditions don’t seem to conform to above situations and I am incapable of participating in care decisions, I authorize first my current POA, (NAME), and if he/she is not able to do so, then any or both of (NAMES), to use their best substituted judgment. My PCP (NAME), should, if possible, help them. If none of my named agents are reachable, my PCP himself can and should use his substituted judgment for me.