End-of-life care presents challenges on every level – individually and culturally.  There are steps we can take as individuals and as a society to assist in planning for and managing our own definitions of a good death.  

People who have learned to live with dying have found out how to do something most of us find profoundly difficult -- talking openly about it.  Such honesty is critical if we're to make choices about the manner of our dying and insure those choices are honored.
Unfortunately, these are conversations few families have.  It's up to each of use to start our own conversation – with our families and with our physicians.  It's best to do it before we become ill and not when everyone is emotionally distraught and in crisis.  And it's best to write it as well as say it.

If you become unable to make decisions for yourself and don't have advance directives in place, major decisions about your care may be made without your input.  Your wishes are best translated into written form with advance directives such as the following: 

Living Will.  This is a written, legal document that describes the kind of medical treatments or life-sustaining treatments you would want if you were seriously or terminally ill.  It isn't just for people who want to avoid being sustained indefinitely on mechanical life support. It's a way to spell out personal wishes.  A Living Will doesn't let you select someone to make decisions for you.

Durable Power of Attorney.  This advance directive allows you to designate a surrogate – a person who will make treatment decisions for you if you are unconscious or unable to make medical decisions.

Health Care Proxy.  This is another name for a Durable Power of Attorney.

Do-Not-Resuscitate Order.  This is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing.

You may change or cancel advance directives at any time, as long as you are considered of sound mind to do so.

A recent advance in advance directive record-keeping is the Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life Sustaining Treatment (MOLST) form.  This form provides a mechanism to communicate patient preferences for end-of-life treatment across treatment settings.  They increase the likelihood that an individual's wishes will be honored by allowing physicians to record a patient's preferences regarding cardiopulmonary resuscitation (CPR), mechanical intervention, and other life sustaining treatments a single form as a physician order.  It is not intended to replace advance directives. 

Advance directives are not perfect.  Sometimes they are too unspecific and general to provide clear instruction.  A surrogate may not be present at a critical moment.  And, they simply can't cover every eventuality.  A combination of ongoing conversation with your family and doctor as well as written advance directives is your best opportunity to make sure your end of life wishes will be realized.   

When you look across the spectrum of American society, there are enormous cultural and individual differences in what quality of life and quality in dying means.  Our individual role is to use the tools we've been provided to create the best possible death for ourselves.  But what is society's role?  First and foremost, society must continue it's traditional role of protecting the vulnerable.  More has to be done, though, to change attitudes about dying through education and encouraging public dialog.  As a culture, we need to provide an environment that supports effective pain management and motivate individuals to ponder end-of-life decisions and discuss them with their family, clergy, and physicians.  We have to keep talking – and listening.