Dr. Escabi: Advanced directives and living wills

I’ve been struggling with what to write for a few weeks, not because of a shortage of health topics, but rather trying to decide on what might be the most impactful — the most helpful.

Finally, maybe because of inevitable realities you think about when birthdays come knocking at your door, but more likely due to a conversation I was having with a dear friend, I settled on a difficult, but very necessary topic everyone should address — advanced directives and living wills.

One of the best things we can do for our loved ones is spare them the hardship of having to decide on life and death matters. In the event of an incapacitating accident or worsening of a longstanding medical condition, where a patient can’t make a decision or express his or her wishes for further care, it is left to the spouse or next of kin to make those decisions.

Sometimes, those people may not be available, or even if they are, the situation calls for the doctor to follow certain protocols for resuscitation or even intubation.

These may not be things you want, but if a provider or an emergency first responder doesn’t know it, they are obligated to do everything in their power keep you breathing and your heart pumping. On the other hand, you may be terminally ill with little prospect of survival, but want every possible type of care administered until the very end.

Advanced directives and living wills are documents that state that information. They let healthcare personnel know what your wishes are when you are not able to communicate. There are several different types. Advanced directives, living wills, Do Not Resuscitate (DNR) or Do Not Intubate (DNI) orders, are the main examples.

A living will expresses your wishes regarding medical care in the event you become unable to do so. It addresses issues like resuscitation (being brought back in the event you stop breathing or your heart stops beating), blood transfusion, intubation or any other potential medical decision. Decisions not included in this document may be left up to the healthcare provider or next of kin, depending on the situation.

Advanced directives are more detailed and typically have four basic parts: names the people involved in the conversation regarding the directives, like the patient, physician, relatives, etc.; the actual orders or wishes, which you could consider your living will; the name of a proxy or delegate decision maker for any other medical decisions not contained in the predetermined orders; and any additional pertinent information like organ donation or possibly type of desired long-term care.

Both a living will and advanced care directives need to be established by the patient while mentally able to do so.

DNR and DNI orders are probably the simplest. They only establish that a patient does not want to be brought back in the event of the heart stopping or not breathing (DNR), or wants to be brought back as long as there is no airway intubation for artificial ventilation (DNI). These can be enacted by the patient, or a next of kin or designated proxy. However, next of kin or proxies should only implement a DNR/DNI when they know the patient’s wishes or when the likelihood of the patient surviving after resuscitation is very low.

It is also important to know that these are not set in stone. A patient can change his or her mind at any time, provided that they are mentally able to do so.

So why do this? For many reasons, but mainly to spare loved ones the burden of making life and death decision in a time of distress. To spare them from having to wonder from that point on if they did the right thing if the outcome ends up being something other than what they hoped for. If nothing else, just to make sure your wishes are carried out when you are not able to express them directly.

Also, please don’t think this is something only older people need to think about. Any person over 18 years old should consider this issue because unexpected illnesses and accidents can happen to anyone.

Terrence Owens once said: “Life and death. At some point we're gonna leave this world. Do I know when? Absolutely not.” And precisely because we don’t know when our ride is over, we better have our affairs in order when it’s time to get off the train.