Monday, May 13, 2013

Making Decisions for Your Loved Ones

Making decisions for yourself is hard enough when it comes to thinking about end of life issues, but when families are forced to decide for their loved ones, the burden is just enormous!
It almost always involves withholding or withdrawing life prolonging treatments.
This happens frequently when one has lost the ability to understand or think clearly and thereby has lost the capacity for decision - making as a result of disease, trauma or old age and dementia etc.

There are five "standards" we could rely upon to help us with these difiicult decisions.
1- Substituted Standard - when patient's wishes are known, you follow their wishes in the decision-making.
This means either having a written advance directive or having had the difficult conversations earlier. Most of the families never get to do that and thus are totally in the dark.
Thus as I pointed out in an earlier post, having discussed the  "three questions" with the family is a gift one leaves behind.
Jack was 78 yrs old and very sick with heart failure,sepsis and  kidney failure, on the respirator , barely conscious in the ICU now for 6 days. Prospects for recovery were minimum.Wife wanted to continue going full press while the doctors and nurses felt more of a comfort only approach was appropriate.
Wife was not aware of any wishes. She was asked to go home and ask ALL family members if Jack had ever made any comments regarding how he may want to live or not at the end of life which may help us in decision-making.
The two sons clearly said that the father never wanted to be hooked to machines if he was not going to improve. Thus ineffective life prolonging treatments were stopped without guilt on anyone's part and Jack died in peace.

2- The Best Interest Standard - refers to doing what is in the best interest of the patient, looking at all the benefits and burdens of proposed treatments and management strategies.
3- Reasonable Person Standard - equates to what a reasonable person would do in this circumstance, a matter of discussion and debate
4- The Gold Standard - just like the golden rule; treat others as you would have them treat you.
In other words, what would you do if this was yourself.?
5- The Commonsence Standard  - The question I ask here of the families is as follows," If your loved one was to go to sleep and never wake up, in other words die, would you be ok with that? Will you be at peace?"
If the answer is yes, then the decision to stop life prolonging treatments is clear. This means that the patient 's present life is so poor that allowing natural death would be preferrable.
Alice at age 87 was slowly becoming feeble . Now , after two years of decline, she could not talk, just grunt, barely recognise anyone or smile and had lost the ability to care for self or eat normally.
Family was suffering by watching her like this. Although she was on a few cardiac meds only, they were stopped so her life would not be prolonged by any artificial means,  since it was not meaningful to her now.Comfort medicines were continued.She died a week later in peace.

Diificult as it is, there is help available at the hospitals with these tough decisions. One can make use of the Palliative Care Team services that are now a part of most hospitals.You may also call for the Ethics/Patient Care Advisory committee to help with difficult ethical dilemmas or conflicts.

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