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Week of 10.9.09

The Hidden Dangers in Living Wills
By Ferdinando L. Mirarchi

Excerpted from Dr. Mirarchi's Book: "Understanding Your Living Will"

Book Cover: Understanding Your Living Will Even though living wills are developed to alleviate pain and suffering for patients and families, they have inherent dangers. The greatest of these dangers is the possible misinterpretation of the patient's true wishes by medical personnel. Living wills often contain such terms as "terminal condition," "incurable illness," or "seriously incapacitating," leaving the interpretation of such terms to physicians. One physician
may view a patient as needing aggressive treatment while another physician might say that treatment should be withdrawn.

Understanding the potential problems in your living will and the damage they could cause can mean the difference between your wishes being followed and long, destructive conflicts among family members about how you intended for your medical care to be carried out. Simply put, avoiding these problems can mean the difference between life and death.

Potential problems in living wills include:
  • Living wills may be misinterpreted as "Do Not Resuscitate" (DNR) orders or "Do Not Treat" orders. Further, living wills lack code status designations that medical personnel would readily understand.
  • Living wills are often not individualized for the patient and his/her medical condition.
  • Living wills often lack informed consent—a patient may not fully understand the document he/she has signed.
It's crucial that you understand these matters before you begin preparing or revising your living will. These problems can make living wills useless or, worse, cause them to be misunderstood by health care workers so that patients are subject to treatments they do not want or are not treated when they wish to be.

...

Why "DNR" Should Not Be in Your Living Will

You've already read that the Do Not Resuscitate (DNR) code status can result in confusion for health care professionals as well as for family and friends. In the
worst-case scenario, a patient can be allowed to die when with proper treatment the patient would have recovered. To be safe, make sure that your living will does not contain the code status DNR. As explained, the Full Code Except Cardiac Arrest will serve you better.

Also note that some hospitals have policies stating that DNR patients are not to be admitted to their intensive care units. More than likely, you would not be told
of this policy, and the patient is sent to a floor with a lower level of care. In order to be treated, you would need to be moved to a hospital that has no such policy. Ask your physician about the policies at your local hospitals, and avoid having provisions in your living will that designate a code status of DNR.

Other Codes Status Designations to Avoid in Your Living Will

No Code

Although a No Code is basically the same as a DNR order, the term No Code is too vague to be useful and can be confusing to health care workers. The same problems that arise from using DNR as a code status will arise with the designation No Code, and so that this status designation is best avoided as well.

Do Not Intubate (DNI)

Patients who ask not to be intubated, which refers to having a breathing tube placed in their throats, are asking not to be placed on a ventilator for the long term. Unfortunately, health care workers may believe the Do Not Intubate (DNI) designation means you have made an informed choice not to be intubated for any reason.

If you are drafting a living will, you should be aware of the confusion that may arise from instructions about being intubated or placed on a ventilator. In fact, many misconceptions exist about being placed on a ventilator. You may think that once you are placed on a ventilator, you will remain attached to it for the rest of your life. This conjures thoughts of lying in a hospital bed for years, being kept alive by artificial means. However, the truth is that if you are placed on the ventilator, you are not likely to be connected to it for a lengthy period of time. You may need the ventilator for only a matter of days, and the breathing tube will be removed when you are able to breathe without assistance. Often, the patient's fear of depending on a ventilator forever, or the doctor's wish to avoid having to take the patient off a ventilator will lead to use of the DNI option.

You should bear in mind that the time you need to be on a ventilator may be brief. If you have chronic lung disease, such as emphysema, long-standing asthma, or congestive heart failure, it may be more difficult for you to be removed from the ventilator; but, it's possible that you may not require it at some point. Should a ventilator become a long-term medical intervention, it may be withdrawn if you so designate this in your living will.

Chemical Code

A Chemical Code means that a patient wants to be treated with medications only. In some hospitals, this means that no other procedures—CPR, insertion of tubes, invasive procedures, or other therapies—are to be used. The problem with this approach is that most medications cannot be given to the patient effectively without using these procedures. For example, a number of medications cannot be circulated through the body without CPR. Many more medications can be given to a patient only intravenously, and the insertion of an intravenous line is considered an invasive procedure since it involves entering a vein with a needle. The Chemical Code seriously limits the usefulness of medications, and it creates a conflict if you request the use of medications but refuse
all the procedures needed to give them to you.

Slow Code

The term Slow Code is used among some health care workers to describe situations when it is easier to delay treatment than to determine what level of treatment the patient wants. The Slow Code is often applied to patients who do not appear to benefit from medical care, such as patients of very advanced age, patients with several serious medical problems, and patients with chronic terminal illness. For patients with a Slow Code designation, health care workers will provide the most superficial levels of care, predicting that the patient will die before questions about their health care wishes arise.

Using very specific terms in your living will and making sure that your wishes are well known can prevent you from becoming a victim of the Slow Code.
 
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