by Stewart B. Segal, MD
Believe it or not, “Doc, did I kill my …?” is a common question following the death of a loved one. Case in point; Patient D (someone’s father) was 80 when he had his first heart attack. It was a big one requiring heroic measures but D pulled through. While in the cardiac intensive care unit, Patient D developed aspiration pneumonia requiring intubation (breathing machine). Signs of a profound stroke became evident. Patient D worsened; and, due to his history of smoking, it became apparent that he would not be able to breathe on his own. The chances of Patient D recovering and living a meaningful life lessened every day. Patient D had no advanced directives. His only living relative, his son (Mr. S), had never discussed end of life issues with his dad. It was up to his son to decide what to do if Patient D suffered another heart attack, infection or other adverse event. It was up to his son to decide whether his father lived or died. Ultimately, patient D was allowed to die a natural death; heroics were stopped. Two months after Patient D was buried, his son asked that horrible question.
Advanced directives (AD) are a legal document, executed by an individual and presented to the hospital and his doctors in advance of the onset of illness. The AD directs the level of care to be given should the patient no longer be able to speak for himself. ADs are critical documents, both for the patient and his loved ones. They talk for you when you no longer have a voice. No wife or child should ever have to make the kind of decisions made by Patient D’s son.
ADs are often purchased from attorneys or over the internet and are boiler plate, fill in the blank documents. Realistically, they need to be highly customized, explaining the individual’s philosophy of life and death, as well as directing how care should proceed and when it should be terminated. An AD should be a fluid document, changing with the passage of time. What makes sense for a healthy, married 55 year old father of three does not necessarily make sense for a chronically ill, widowed octogenarian. ADs should be reviewed on a yearly basis and discussed with the family doctor, as well as the family.
This year, Medicare provides an “Annual Wellness Visit”. As originally passed, the law included physician payment for a discussion of advanced directives. Unfortunately, Medicare chose to eliminate this vital benefit. Regardless of expense, discussing end of life issues and advanced directives is an essential for everyone, young and old.
DOC, DID I KILL MY FATHER? No Mr. S, you did not. Your father and I had talked over the years and I am confident that he would have wanted the “Do Not Resuscitate” order given and that he be allowed to die with dignity. His written Advanced Directive clearly delineated how he wanted to be treated and when he wanted that treatment to be stopped. You simply honored your father’s wishes. He was foresighted enough to have taken care of things he did not want you to have to do. He is at peace and he wanted you to be at peace as well.