Prairie Doc Perspective: An advance directive can simplify end-of-life choices for loved ones | TSLN.com
Richard P. Holm, MD

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Prairie Doc Perspective: An advance directive can simplify end-of-life choices for loved ones

An elderly late-80s gentleman came into the emergency room unconscious with the diagnosis of a new stroke. The CT of the head indicated there was no bleeding into or around the brain, indicating he had a blood clot, not a bleed that caused the acute brain injury.

Symptoms had begun six hours earlier, but the patient and his family just didn't get to the emergency room in time to try a clot-busting medication that can sometimes save the brain. The family and I had a long talk. I discovered that the patient had been living alone in his home of 50 years, still visiting a nursing home every day to see his wife who had severe Alzheimer's Disease.

He had an advance directive about which his family was aware. He had enjoyed a good life, his financial affairs were in order, and he did not want resuscitation if it was required. I remember a previous encounter with him where he told me, "that would be an easy way to go, so do not resuscitate. And what ever happens, no feeding tubes unless I have a reasonable chance of returning to a normal life, where I would know what's going on."

After the stroke, the patient had significant brain injury with no capacity to swallow or speak and minimal awareness. With his family's agreement, we did not start intravenous fluids, in consideration for brain edema that can occur in new strokes, and gave it a little time to allow for the edema to reduce and improve the situation. This also bought some time to see if we were going to get any recovery or not. After the third day, the writing was on the wall. His outlook, if he survived, would require him to have a feeding tube.

The family told me to follow his advance directive and allow a natural death. Over the next nine days he gently slipped away, no feeding tube, no respirator, no suffering.

Take home message:

1. Make an advance directive, and use it as a communication tool to talk about end-of-life choices with your family.

2. Realize that the patient's choice is primary. If the patient is not capable, the family chooses for the patient, and their obligation is to respect the patient's prior expressed wishes, or do their best in how he/she would have chosen. Sometimes this may mean pushing against what the care-providers are wanting to do.

3. Because often there is no advance directive, and because families don't realize their responsibility to respect the dying patient's wishes, too often feeding tubes are placed, and what might have been death with dignity becomes one with suffering.