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On Living Wills and End-of-Life Decisions
A response to “Surrogate Decision Making; Reconciling Ethical Theory and Clinical Practice”
(Ann Inter Med. 2008 Jul 1;149(1):48-53)
Walter Roufail, MD
COMMENT:
This is a special article by Dr. Walter Roufail, long known as an outstanding doctor, and winner of numerous teaching awards at WFUSM. Less well known is that Dr. Roufail has served our profession as President of the Forsyth-Stokes-Davie County Medical Society, and as a member of the North Carolina Medical Board through most of the 1990s (President in 1995). He has always been known as a straight talker with the highest principles and an exemplary commitment to excellence in patient care. In this article, he takes issue with the convoluted language of medicine and provides us with some basic principles of patient care.
- K. Patrick Ober, MD, faculty advisor, OASIS
CONCLUSION: A rigidly hierarchical view of surrogate decision making oversimplifies a process that is complex, dynamic, personal, and even idiosyncratic and tends to deemphasize other ethically valid considerations, including morally relevant emotions, and virtues, such as mutual responsibility. Although the normative standards offer a framework for decision making, clinicians should not consider them definitive and patients and families should not be limited by them. Norms for surrogacy should fully account for a robust range of patients' concerns and interests to improve the quality of surrogates' decision making, ensure that clinical decisions more fully respect the patient's own sense of genuine interests, and increase physicians' confidence in caring for incapacitated patients.
This is probably the most obscure paragraph in the English language that I have read in a long time. If it is intended to help physicians, patients or their families make the ultimate decision of life and death, the “conclusion” has not only failed miserably but has added to the confusion and stress that invariably accompany that decision. I have read English translations of Kant and Nietzsche that make more sense. I have also noticed that any problem that is labeled “complex” has no viable solution—at least in the writer’s mind—and should either be individualized, which obviously negates the necessity of writing the article, or should be referred to a committee of some sort, which would ultimately make things worse.
The situation presented in that long article describes how persons who make such decisions for a patient who may or may not have left a living will usually have no idea about what medical decisions may have to be made to hasten the patient’s departure from this world. The next of kin or a designated health care power of attorney is usually entrusted with those decisions. How many of us have sat down with either one of these persons and said specifically:
- If I am on the ventilator for 72 hours and every time they turn it down I am unable to breathe on my own, please pull the plug.
- If I am in a coma for a week and it is deemed by my treating physicians to be irreversible, I do not want any feeding tubes or antibiotics or to be placed on a respirator.
- If I have dementia, do not recognize my family and friends, and have an overwhelming infection, do not offer me treatment.
- If I am “brain dead,” I want my organs to be transplanted.
- If there is any strong division of opinion among my family, please try to resolve it within the context of the law, which defines specifically the order of the next of kin. The presence of a chaplain, pastor, rabbi or priest has always been of great help to me in those situations.
Basically, it comes down to the trust that patients and their families have in their primary care physician and even in the short-time consultants. It does not take long to establish a bond with a family if you sit down with them and calmly explain the patient’s situation and his or her options.
Please do not prognosticate the hour and minute of death. You will be wrong 75% of the time. I always remember the innumerable occasions in times past when patients stated, “I am ready,” but never specified the Eastern Standard Time at which they would depart.
The magic words are: she or he is comfortable and not in pain. |