We have been advised all our lives not to make any major decisions when we are not in a calm emotional state. if you are angry or upset, it is not a good time to go out shopping for a major item, a car, a house etc. Because in this state of emotional upheaval we are not likely to make good rational decisions. We are in a state of emotional irrationality.
As healthcare workers we see this phenomenon often with families of terminal patients. No wonder they have a hard time coming to grips with the reality and making what everyone else would see as rational , reasonable decisions. Because they are in a state of emotional irrationality!!
Our responsibility as physicians now becomes to help them see reason, give them time, give them reasons as to why a certain choice is right. Help them see the impact that emotion is playing. Guide them gently to a rational decision so they ultimately are comfortable with their choice.
You will need patience, caring and compassion to carry this out.
We all can be in this emotional place just as easily one day.
Thursday, November 12, 2015
Sunday, August 30, 2015
The Conundrum of Alzheimer's and other Dementias
People want to live and die on their own terms. We all wish to have control on our lives. When we think of death, it is the dying which is what most worry about . Of special concern is when we lose the capacity to make decisions and with time lose the capacity to understand what is going on as happens with Alzheimer's and other dementia of multiple causes.
This is a chronic illness of slow decline with an average life span of about 7 to 10 years. Some of course may last less and some more years. Initially the loss of function and understanding is mild , perhaps forgetting names and places. But it progresses to inability to drive, then to simple tasks, losing ones way , becoming very forgetful and eventually not recognizing family, difficulty in eating, swallowing, walking and becoming totally dependent on others.
Concern most patients have is that they do not wish to live with help of artificial means beyond the level they feel worthwhile.
Again, if families do not know their wishes then they are left with the uncompromising situation of making hard decisions. Thus it behooves us all to let our loved ones know of our wishes and what may be important to us in case we get dementia.
You may consider a wording similar to what I am suggesting here below to be added to your advance directives as your wishes in case of dementia:
"If my mental abilities have declined to a point whereby I am unable to communicate rationally ( or none at all), unable to recognize my loved ones, unable to swallow food or water safely ( or none at all), unable to care for myself AND it is unlikely that my condition will improve, then I wish all life prolonging treatments to be stopped (medicines, machines, pacemakers, artificial food and water etc.) and nature be allowed to take it's course.
BUT please continue any treatments necessary for my comfort so that I may not suffer."
This is obviously a very severe end stage dementia but you may wish to change the function level to any other as you wish.
Once you have it in writing or have at least talked with your family and physician about it, you have taken appropriate steps to control your destiny as well as possible.
This is a chronic illness of slow decline with an average life span of about 7 to 10 years. Some of course may last less and some more years. Initially the loss of function and understanding is mild , perhaps forgetting names and places. But it progresses to inability to drive, then to simple tasks, losing ones way , becoming very forgetful and eventually not recognizing family, difficulty in eating, swallowing, walking and becoming totally dependent on others.
Concern most patients have is that they do not wish to live with help of artificial means beyond the level they feel worthwhile.
Again, if families do not know their wishes then they are left with the uncompromising situation of making hard decisions. Thus it behooves us all to let our loved ones know of our wishes and what may be important to us in case we get dementia.
You may consider a wording similar to what I am suggesting here below to be added to your advance directives as your wishes in case of dementia:
"If my mental abilities have declined to a point whereby I am unable to communicate rationally ( or none at all), unable to recognize my loved ones, unable to swallow food or water safely ( or none at all), unable to care for myself AND it is unlikely that my condition will improve, then I wish all life prolonging treatments to be stopped (medicines, machines, pacemakers, artificial food and water etc.) and nature be allowed to take it's course.
BUT please continue any treatments necessary for my comfort so that I may not suffer."
This is obviously a very severe end stage dementia but you may wish to change the function level to any other as you wish.
Once you have it in writing or have at least talked with your family and physician about it, you have taken appropriate steps to control your destiny as well as possible.
Thursday, July 16, 2015
CHATAUQUA TALKS # 1…"Courageous Conversations on Death and Dying -The Time is Now"
I am at the Chautauqua Institute in Chautauqua NY for three weeks now. It is a wondrous place we frequent every year!
This year with the help of the Department of Religion I have been able to schedule weekly talks on end of life issues, mainly talking about advance care planning and the courageous conversations we need to have with our families, the three questions, as already described in this blog earlier.
The response has been overwhelming. I was expecting maybe 20 people initially but close to 100 showed up. Every week now we have 140 or more attendees.
Even though a fair number (70-80% or so) of the attendees have living wills or advance directives, there was an extremely positive response to the value added by the three questions which define your minimum acceptable levels for supporting life by artificial means, be it medicines or machines or artificial hydration and nutrition via IVs or tubes.
There is still a lot of confusion over CPR, DNR, Healthcare Agent (POA) and their ability to make independent decisions.
There is also a lot of interest in euthanasia and physician assisted suicide.
Many people voiced their concern over management of dementia in family members and were worried about what to do for themselves if they also suffered from the same in the future. They found that at least in setting the advance care plan, they had some control over their lives which was very reassuring to them.
This experience of teaching large numbers of lay people in the essentials of conversations and seeing their reaction and evaluations reaffirms my belief that one of the simplest and most important conversations is to address the three questions - as already covered in this blog on earlier dates.
If everyone in the US did this, end of life decisions would be much, much easier and the cost of healthcare even will go down by not doing unnecessary, futile treatments.
It has been a most gratifying experience both professionally and personally, and I wish to thank Maureen Rovegno at the Department of Religion for the opportunity, my wife Jean for her support and help with this endeavor and God for Chautauqua Institute!!
If you have never been here, it is time you came.
At least go visit it on ciweb.org.
This year with the help of the Department of Religion I have been able to schedule weekly talks on end of life issues, mainly talking about advance care planning and the courageous conversations we need to have with our families, the three questions, as already described in this blog earlier.
The response has been overwhelming. I was expecting maybe 20 people initially but close to 100 showed up. Every week now we have 140 or more attendees.
Even though a fair number (70-80% or so) of the attendees have living wills or advance directives, there was an extremely positive response to the value added by the three questions which define your minimum acceptable levels for supporting life by artificial means, be it medicines or machines or artificial hydration and nutrition via IVs or tubes.
There is still a lot of confusion over CPR, DNR, Healthcare Agent (POA) and their ability to make independent decisions.
There is also a lot of interest in euthanasia and physician assisted suicide.
Many people voiced their concern over management of dementia in family members and were worried about what to do for themselves if they also suffered from the same in the future. They found that at least in setting the advance care plan, they had some control over their lives which was very reassuring to them.
This experience of teaching large numbers of lay people in the essentials of conversations and seeing their reaction and evaluations reaffirms my belief that one of the simplest and most important conversations is to address the three questions - as already covered in this blog on earlier dates.
If everyone in the US did this, end of life decisions would be much, much easier and the cost of healthcare even will go down by not doing unnecessary, futile treatments.
It has been a most gratifying experience both professionally and personally, and I wish to thank Maureen Rovegno at the Department of Religion for the opportunity, my wife Jean for her support and help with this endeavor and God for Chautauqua Institute!!
If you have never been here, it is time you came.
At least go visit it on ciweb.org.
Sunday, May 24, 2015
Take the Load off the patient and family
Nothing is more difficult than deciding on stopping or refusing life sustaining treatments. It is even more difficult and almost impossible for many a family members because of the emotional connections. Just as a father once said to me, "I would not want to be like this but she is my daughter. How can I make this decision which may end her life?"
I would like to share the story of Sally ( not her real name) where we were able to take the load of decision-making off her and the family's shoulders to obtain a good result.
Sally, age 62, was very sick with end stage liver disease with fluid accumulation all over, severe jaundice with heart failure and breathing problems. Now, she was totally bed bound and barely able to eat but mentally quite alert and making her decisions. Her prognosis was very poor and she was hospice appropriate with life expectancy of less than 6 months. her quality of life was very poor. She could communicate but barely smiled. If she were to arrest and be resuscitated, she probably would not respond and at best be on a vent and clinically at a worse level than now. Doctors felt that a "Do Not Resuscitate " order in case of an arrest would be the right thing to do.
I was asked to consult. I agreed with her physicians and talked to the patient about the reasons why a DNR might make sense and for her to give it some thought. She understood and wanted to think about it. Family was involved in the discussion and privately seemed to support the notion. The next day, the patient seemed quieter and voiced that this was a hard decision. At this point, I decided to take the load off her shoulders and suggested that I work with her family and help them decide what is best for her, knowing they had her best interest at heart. Her face relaxed and she quickly agreed. Thus, we took load off of her shoulders.
Now, working with the family, we told them that these choices are medical decisions. In such cases, there are treatments and procedures that are of no benefit to the patient. In other words, they do not help us get to the goals we want to achieve, namely to get her better. Instead, we would be prolonging the dying process and increasing pain and suffering, not just for her, but for all concerned. The family needed to look at this a medical decision, understand the reasons and not feel that this is only their decision. The family did not object. Thus we were able to take the load off family's shoulders too by making this a medical decision. All they had to do was show their understanding. In addition to the do not resuscitate/ allow natural death order, family and patient agreed to a hospice consult.
Our job as palliative care physicians and teams is to help patient and families make difficult decisions. We help them understand why their decisions makes sense so that in the end they can be at peace with their decisions knowing they did what was best for their loved one even though it was very hard.
I would like to share the story of Sally ( not her real name) where we were able to take the load of decision-making off her and the family's shoulders to obtain a good result.
Sally, age 62, was very sick with end stage liver disease with fluid accumulation all over, severe jaundice with heart failure and breathing problems. Now, she was totally bed bound and barely able to eat but mentally quite alert and making her decisions. Her prognosis was very poor and she was hospice appropriate with life expectancy of less than 6 months. her quality of life was very poor. She could communicate but barely smiled. If she were to arrest and be resuscitated, she probably would not respond and at best be on a vent and clinically at a worse level than now. Doctors felt that a "Do Not Resuscitate " order in case of an arrest would be the right thing to do.
I was asked to consult. I agreed with her physicians and talked to the patient about the reasons why a DNR might make sense and for her to give it some thought. She understood and wanted to think about it. Family was involved in the discussion and privately seemed to support the notion. The next day, the patient seemed quieter and voiced that this was a hard decision. At this point, I decided to take the load off her shoulders and suggested that I work with her family and help them decide what is best for her, knowing they had her best interest at heart. Her face relaxed and she quickly agreed. Thus, we took load off of her shoulders.
Now, working with the family, we told them that these choices are medical decisions. In such cases, there are treatments and procedures that are of no benefit to the patient. In other words, they do not help us get to the goals we want to achieve, namely to get her better. Instead, we would be prolonging the dying process and increasing pain and suffering, not just for her, but for all concerned. The family needed to look at this a medical decision, understand the reasons and not feel that this is only their decision. The family did not object. Thus we were able to take the load off family's shoulders too by making this a medical decision. All they had to do was show their understanding. In addition to the do not resuscitate/ allow natural death order, family and patient agreed to a hospice consult.
Our job as palliative care physicians and teams is to help patient and families make difficult decisions. We help them understand why their decisions makes sense so that in the end they can be at peace with their decisions knowing they did what was best for their loved one even though it was very hard.
Monday, July 7, 2014
"I never want to lie in a bed of affliction."
Here is a true story that illustrates how some comments made by a family member may help in the end of life medical decisions even when there is no written advance directive or a living will.
Mary (not real name) is 93 years old with mild dementia and heart disease with severe peripheral vascular disease. She is able to converse with her family about what she wants to eat, how she is feeling and whether she needs pain medicine or not. She does not understand the severity of her problems and is unable to make her own medical decisions and thus the family members are making all the decisions for her. She has mild contractures of her legs and lies in bed most of the time, but is able to get up with help.
Mary is admitted to the hospital with painful foot which has gangrene in two of the toes of her left foot. She also has signs of infection and is being treated with antibiotics. Doctors recommend amputation of the left leg below the knee to get rid of the gangrene and prolong her life. Family is asked to make a decision for her therapy.
Family members next meet with the Palliative Care Team (author included) to discuss options and see what would be the right thing to do for the patient. Mary does not have an advance directive or a living will and family says that they never had any end of life discussions with her. In further talking with them about the kind of life she wanted to lead, they do remember her always saying, "I never want to lie a bed of affliction."
With the help of this comment, the family later was able to decide not to have any surgery which may have given her a longer life but she would be definitely "lying in a bed of affliction".
Instead they opted to enroll her in hospice, keep her comfortable as long as God wished her to be here.
Family was at peace with their decision since they felt it followed her voiced wishes.
Mary (not real name) is 93 years old with mild dementia and heart disease with severe peripheral vascular disease. She is able to converse with her family about what she wants to eat, how she is feeling and whether she needs pain medicine or not. She does not understand the severity of her problems and is unable to make her own medical decisions and thus the family members are making all the decisions for her. She has mild contractures of her legs and lies in bed most of the time, but is able to get up with help.
Mary is admitted to the hospital with painful foot which has gangrene in two of the toes of her left foot. She also has signs of infection and is being treated with antibiotics. Doctors recommend amputation of the left leg below the knee to get rid of the gangrene and prolong her life. Family is asked to make a decision for her therapy.
Family members next meet with the Palliative Care Team (author included) to discuss options and see what would be the right thing to do for the patient. Mary does not have an advance directive or a living will and family says that they never had any end of life discussions with her. In further talking with them about the kind of life she wanted to lead, they do remember her always saying, "I never want to lie a bed of affliction."
With the help of this comment, the family later was able to decide not to have any surgery which may have given her a longer life but she would be definitely "lying in a bed of affliction".
Instead they opted to enroll her in hospice, keep her comfortable as long as God wished her to be here.
Family was at peace with their decision since they felt it followed her voiced wishes.
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.
Tuesday, October 2, 2012
The 3 Questions to Establish Minimum Living Standards at End of Life
There is a lot of confusion on how to manage the end of life well. It is a difficult subject to talk about with your parents or children, so most of us just avoid it. Eventually we get sick and are stuck in the ICU, unable now to make our decision and everybody we love is suffering with us not knowing what to do and not knowing what we would have liked done.
Here are three simple questions to help you achieve more control on your life.
If you get ill and your life is being prolonged by means of medicines and treatments, and the level of your existence is meaningful to you, then it is wonderful. But if the treatments are keeping you alive but at a level lower than what you would consider meaningful, then it is only delaying the inevitable and in the process making your life more painful and increasing suffering for you, your family and friends.
Thus if we could all establish that minimum level of existence for ourselves, doctors and hospitals would know when aggressive treatments are warranted and when just keeping the sick person comfortable would be the best thing to do.
This can be accomplished by simply answering "the 3 Questions" to establish:
1- the minimum mental functional level ( mental awareness level) that is acceptable to us with the help of life prolonging treatments.
2- the minimum physical level acceptable with the help of life prolonging treatments
and
3- the life prolonging treatments that are acceptable to us, or not; or acceptable for a period of time to see if we can get to our minimum acceptable level of living.
Some examples of lower mental awareness levels:
1- you can recognize your loved ones AND communicate with them
2- you can recognize others, but cannot communicate
3- you may focus on things but have no recognition
4- you are barely aware
5- you are unconscious
6- you have dementia, so can talk but have no idea what you are saying and what is going on.
Let's say you decide to pick example #1 , then in your advance directive you would write, "I want my life prolonged by life prolonging treatments as long as I can recognize and communicate with my loved ones, but I do not want my life prolonged artificially by means of any medicines or machines or artificial nutrition or hydration if I cannot communicate"
Also discuss your feelings about different levels of dementia and acceptance oflife prolonging treatments.
Some examples of lower physical function levels:
1- you need assistance with walking, bathing and dressing.
2- you are mostly in bed but can go to bathroom with assistance
3- you are totally bedridden, but can still swallow and enjoy food
4- you are totally bedridden and unable to swallow.
Obviously, there can be many other permutations to these.
Let's say you pick number 3, then you would write in your advance directive. "I do not want my life prolonged by medicines, machines or artificial nutrition if I am totally bedridden. If I get sick, I do not want to be treated, but do give me any and all treatments to keep me comfortable"
3- The third question has to do with life prolonging treatments you may not ever want eg intubation and respirator, or CPR or dialysis or tube feedings etc.
OR you may be willing for extraordinary treatments for a short while, say a week or two to see if you can be rehabilitated to your lowest acceptable levels as you have established by answering questions 1 and 2.
So , you would write in your directive,"I am willing to try any treatments for a period of one week (or two or more if that is what you are willing to endure), but if I do not get to my acceptable levels as mentioned above, please stop and just keep me comfortable"
Now, if you were to either put these in writing or just have a clear conversation with your family and your physician, then when the time comes, you will be treated as you wish.
AND this will be the best gift you can give your loved ones, making your own decisions so they will not have the burden of making these hard decisions!
Creating a document:
All your wishes can be put in writing, signed and witnessed by two persons, not your power of attorney for healthcare.
This now is equivalent of an advance directive and to be followed in case you become ill. It does not need to be done in a lawyer's office.
Be sure to give a copy to your family, friends, doctors and lawyers.
EXAMPLES:
Here are a couple of real examples from a couple of my patients ( names are changed for privacy and confidentiality reasons)
EXAMPLE #1:
End of Life Wishes for Mrs JJ
1- I do not want my life prolonged by any means if I am unable to verbally communicate with my family even though I may be able to recognize them.
2- If I cannot get out of bed myself, please let me die in peace, do not extend my life by artificial medicines and machines.
3- Always make sure I am pain free and not suffering.
signed by JJ and witnessed by two not closely related
EXAMPLE #2:
End of Life Wishes for CC
1- Do not artificially prolong my life if I cannot recognize my family AND communicate with them.
2- You may treat my illness if I am able to recognize my family AND communicate with them BUT DO NOT artificially prolong this state by means of dialysis , respirator or artificial nutrition and hydration for more than a week!
3- If I am totally bedridden, please Do NOT treat any illness, but keep me comfortable
4- Artificial treatments are only acceptable if I can be rehabilitated to my goal as mentioned in # 2 above.
5- I do not want to be a burden to my family.
6- I want to die at home
7- If any questions arise, please contact my physician Dr A.
Signed by CC and witnessed by two
You can see how this is a simple way to control your destiny.
CPR: ( Cardiopulmonary resuscitation)
If you were to have a cardiac arrest and your wishes were known, then you would be resuscitated if you could be treated to reach your established minimum levels of existence, otherwise you would be allowed to die in peace. Thus you would control how you live and die.
It would be very helpful to have these discussions with the help of your physician, nurse etc. to address any and all questions you may have.
Please remember, you can always change your mind so this is not etched in stone.
If you already have an advance directive, you could add the 3 wishes to it. This establishes how you want to live that is meaningful to you, when you have lost capacity to make decisions anymore.
Here are three simple questions to help you achieve more control on your life.
If you get ill and your life is being prolonged by means of medicines and treatments, and the level of your existence is meaningful to you, then it is wonderful. But if the treatments are keeping you alive but at a level lower than what you would consider meaningful, then it is only delaying the inevitable and in the process making your life more painful and increasing suffering for you, your family and friends.
Thus if we could all establish that minimum level of existence for ourselves, doctors and hospitals would know when aggressive treatments are warranted and when just keeping the sick person comfortable would be the best thing to do.
This can be accomplished by simply answering "the 3 Questions" to establish:
1- the minimum mental functional level ( mental awareness level) that is acceptable to us with the help of life prolonging treatments.
2- the minimum physical level acceptable with the help of life prolonging treatments
and
3- the life prolonging treatments that are acceptable to us, or not; or acceptable for a period of time to see if we can get to our minimum acceptable level of living.
Some examples of lower mental awareness levels:
1- you can recognize your loved ones AND communicate with them
2- you can recognize others, but cannot communicate
3- you may focus on things but have no recognition
4- you are barely aware
5- you are unconscious
6- you have dementia, so can talk but have no idea what you are saying and what is going on.
Let's say you decide to pick example #1 , then in your advance directive you would write, "I want my life prolonged by life prolonging treatments as long as I can recognize and communicate with my loved ones, but I do not want my life prolonged artificially by means of any medicines or machines or artificial nutrition or hydration if I cannot communicate"
Also discuss your feelings about different levels of dementia and acceptance oflife prolonging treatments.
Some examples of lower physical function levels:
1- you need assistance with walking, bathing and dressing.
2- you are mostly in bed but can go to bathroom with assistance
3- you are totally bedridden, but can still swallow and enjoy food
4- you are totally bedridden and unable to swallow.
Obviously, there can be many other permutations to these.
Let's say you pick number 3, then you would write in your advance directive. "I do not want my life prolonged by medicines, machines or artificial nutrition if I am totally bedridden. If I get sick, I do not want to be treated, but do give me any and all treatments to keep me comfortable"
3- The third question has to do with life prolonging treatments you may not ever want eg intubation and respirator, or CPR or dialysis or tube feedings etc.
OR you may be willing for extraordinary treatments for a short while, say a week or two to see if you can be rehabilitated to your lowest acceptable levels as you have established by answering questions 1 and 2.
So , you would write in your directive,"I am willing to try any treatments for a period of one week (or two or more if that is what you are willing to endure), but if I do not get to my acceptable levels as mentioned above, please stop and just keep me comfortable"
Now, if you were to either put these in writing or just have a clear conversation with your family and your physician, then when the time comes, you will be treated as you wish.
AND this will be the best gift you can give your loved ones, making your own decisions so they will not have the burden of making these hard decisions!
Creating a document:
All your wishes can be put in writing, signed and witnessed by two persons, not your power of attorney for healthcare.
This now is equivalent of an advance directive and to be followed in case you become ill. It does not need to be done in a lawyer's office.
Be sure to give a copy to your family, friends, doctors and lawyers.
EXAMPLES:
Here are a couple of real examples from a couple of my patients ( names are changed for privacy and confidentiality reasons)
EXAMPLE #1:
End of Life Wishes for Mrs JJ
1- I do not want my life prolonged by any means if I am unable to verbally communicate with my family even though I may be able to recognize them.
2- If I cannot get out of bed myself, please let me die in peace, do not extend my life by artificial medicines and machines.
3- Always make sure I am pain free and not suffering.
signed by JJ and witnessed by two not closely related
EXAMPLE #2:
End of Life Wishes for CC
1- Do not artificially prolong my life if I cannot recognize my family AND communicate with them.
2- You may treat my illness if I am able to recognize my family AND communicate with them BUT DO NOT artificially prolong this state by means of dialysis , respirator or artificial nutrition and hydration for more than a week!
3- If I am totally bedridden, please Do NOT treat any illness, but keep me comfortable
4- Artificial treatments are only acceptable if I can be rehabilitated to my goal as mentioned in # 2 above.
5- I do not want to be a burden to my family.
6- I want to die at home
7- If any questions arise, please contact my physician Dr A.
Signed by CC and witnessed by two
You can see how this is a simple way to control your destiny.
CPR: ( Cardiopulmonary resuscitation)
If you were to have a cardiac arrest and your wishes were known, then you would be resuscitated if you could be treated to reach your established minimum levels of existence, otherwise you would be allowed to die in peace. Thus you would control how you live and die.
It would be very helpful to have these discussions with the help of your physician, nurse etc. to address any and all questions you may have.
Please remember, you can always change your mind so this is not etched in stone.
If you already have an advance directive, you could add the 3 wishes to it. This establishes how you want to live that is meaningful to you, when you have lost capacity to make decisions anymore.
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