Answering the "What
If" Questions: Advanced Directives - Part 1
Some of the most important
conversations are also the most difficult to have. What if something horrible suddenly happened
to you and threatened your health or your life?
What if you were in a tragic automobile accident? What if you suffered a
horrible stroke? What if you acquired a
disease like Lou Gehrig's (amyotrophic lateral sclerosis) that will, although
slowly, lead to complete paralysis including inability to breathe? What medical interventions would you want performed? Would you want prolonged life support? Would you want long-term artificial nutrition
through a feeding tube? Would you want
heroic and risky surgeries attempted to preserve your life? Have you talked to your family members about
your preferences? Surveys show that one-third of Americans say they've had
to make decisions about end-of-life care for a loved one. In many cases, these folks had to make
assumptions about what their loved one would want.
Many folks have a "Last
Will and Testament" to spell out proper distribution of their assets and
estate after they die. However, very few
of the patients I see have prepared documentation that spells out what medical
interventions they would want if they were unable to communicate their
wishes. This documentation is called an
Advanced Directive. They were created in
response to the increasing sophistication of medical technology that allows us
to keep critically ill patients alive in cases beyond what they may have
wanted. One of the pinnacle legal cases leading to Advance Directives involved
26-year old Nancy Cruzan, who suffered a car accident that left her in a permanent
coma, or persistent vegetative state.
Her parents petitioned to have her life support removed, and the US
Supreme Court upheld the Missouri Supreme Court ruling requiring "clear
and convincing evidence" of a patient's wishes to be removed from life
support. A written document from Nancy
would have been "clear and convincing evidence."
A few years ago, in Texas,
33-year old paramedic Marlise Munoz was found unresponsive (likely from a blood
clot that traveled to her brain) by her husband and rushed to the hospital
where she was ultimately declared brain dead, but Texas law held she could not
be removed from life support because she was about 4 months pregnant. She had no formal living will, but had told
her husband and family members multiple times that she would not want to be
kept alive on life support machines, and her family banded together to fight
for her wishes. It still took a long
legal battle for their case to be resolved and her life support removed.
In 1990 Terri Schivo collapsed in her home from a massive heart attack
which left her on life support in a persistent vegetative state. In 1998 her husband asked that her life
support and feeding tube removed, stating Terri would not want to live on life
support with a feeding tube. Her parents objected. The battle was tied up in the courts until
2005 when life support was finally removed.
Next week I will discuss in more detail the types of Advance Directives and
how they can help ensure your wishes will be carried out should something horrible
happen to you.
*** Dr. Matthew Bogard, Iowa doctor, is an emergency medicine doctor primarily at the Lucas County Health Center in Chariton, Iowa. Presently, he is Board Certified in Family Medicine by the National Board of Physicians and Surgeons and the American Academy of Family Physicians.
