Death is Inevitable

Death is Inevitable
Tell me how to help

We all have one thing in common. Sooner or later we are all going to die. Most do not have the luxury of knowing when or what will end our lives. Way too many think death is just for the old and infirm and is personally way too far off to contemplate. Far too few plan for end of life issues, leaving family with hard choices.

Death that comes quickly is somehow easier. Those with long, slow death dealing infirmities put caregivers, loved ones and medical providers in tough ethical and moral conundrums. Do we treat aggressively, moderately, passively or not at all? Who gets to make the decisions for the incapacitated who can no longer make decisions on their own? What happens when medical judgments and religious beliefs clash? What happens when family members disagree about the course of treatment?

As a guardian for those with dementia or other incapacitating infirmities, I have experienced first-hand what happens when death comes before affairs are put in order and end of life wishes are made known. 

People who fail to plan for their eventual death or terminal illness exist in what is known as “full code” status. That means that first responders and medical providers must use all means necessary to keep the person alive unless certain guidelines are followed. This can result in invasive medical procedures that may compromise quality of life or cause pain to the patient. 

People who are competent can direct how they want to be treated when they are not able to direct how and what medical treatments are undertaken for them. This is usually accomplished by creating a written living will that outlines what steps can and cannot be taken. People can also designate through a written Health Care Power of Attorney who can make medical and end of life decisions for them if they become incapacitated. Hospitals have forms you can fill out and elder care and estate planning lawyers can also help. Taking the time to create these plans and then discussing them with your family and loved ones will save them and you from the chaos that can follow sudden life-threatening injury and illness. 

For those who courts have determined to be incompetent and fall under the care of a guardian, end of life decision making gets complicated. If the person has made their wishes known before becoming incompetent, guardians can honor those wishes as life winds down. 

One of the major issues is whether to administer cardio-pulmonary resuscitation (CPR) if a person suffers cardiac or respiratory arrest. If a person does not want to have this intervention, she can sign a “Do Not Resuscitate” (DNR) order and provide copies to their medical providers and hospitals, keeping copies at home and in vehicles for first-responders. We know from studies that CPR when performed on elderly patients in nursing or other residential care can cause pain and broken ribs. We also know that long term recovery in these patients is not significantly improved if CPR is administered. 

If no DNR order is in place, guardians can obtain one under certain conditions. First, the person must be 18 or older (known to be not pregnant) and have a terminal condition or a medical condition that could make such actions unsuccessful or repeated cardiac or respiratory failure would occur before death, or have a condition where resuscitation would cause significant physical pain or harm that outweighs the possibility of restored function for an indefinite period of time. Next, an attending physician has to provide written information on procedures that might be used and how the patient can revoke the DNR consent. A DNR form is then signed by the doctor and guardian.

DNR orders do not address the withholding or withdrawal of life-sustaining medical treatment from someone who is unable to make those decisions. Again, living wills and Healthcare Powers of Attorney can spell out your wishes before these decisions have to be made. Those without this advance planning, put guardians and loved ones called upon to consider them at a considerable disadvantage.

In order for a guardian to withhold or terminate life-sustaining treatment like hydration and artificial nutrition, three physicians have to determine the person to be in a “persistent vegetative state.” If the person expressed their wishes on the subject, the guardian must follow those wishes. If not, the guardian must determine if the proposed course is in the person’s “best interest.” Courts have held that continued life is in a person’s “best interest.”

In considering if treatment withdrawal is in the person’s “best interest,” guardians must consider what treatments will do to the person, life expectancy and prognosis for recovery with or without treatments, the various treatment options, the risks, benefits and side effects of each treatment and the opinions of those who have known the person for significant periods of time. If these considerations weigh in favor of withholding or ending treatment, then the guardian must notify all “interested parties” and give them time to respond. If no one objects, the guardian can withhold or end treatment. If there is an objection, the matter is brought before the probate court for decision.

These are complicated and difficult issues fraught with emotional overlays making it more than worth the effort to address them long before they get presented. Please have the conversations needed to make your wishes known to your spouse, children and extended family. Make your own decisions now about how you want to be treated in the event you cannot express your wishes. It will make it easier on those called upon to help you as your life ends.