Using advance directives as tools

Guest Post by Dan Morhaim

The tools are here. We just need to use them.

These tools offer something rare and important in our modern medical system: an opportunity to exert influence. I am talking about advance directives, the powerful instruments that allow each of us to manage the final chapter of life in a dignified manner and according to our own wishes and values.

As an emergency medicine physician, I’ve seen scenarios like this one all too often: An ambulance brings to the hospital a frail, elderly patient with shortness of breath, irregular heartbeat, and plunging blood pressure. The wasted limbs indicate years of incapacitation, and the medical record reveals a long history of dementia. As we work to restore stability, probing paper-thin skin for a vein, the patient suddenly goes into cardiac arrest.

The patient does not have an advance directive or a Do Not Resuscitate (DNR) order, so the ER team goes into full CPR mode, cracking brittle ribs with every chest compression. If the team’s efforts are “successful,” the patient will endure suffering that may last for the rest of his or her life.

We know that too much of this “care” is futile, hurtful, and wasteful. While some will opt to “do everything” no matter how painful the treatment or how unlikely the chance for recovery, most people do not want to die in this manner.

There comes a time when most of us would choose to allow a natural death rather than use medical technology to prolong life for what is usually only a few extra hours, days, or weeks. But when that moment comes, we are often not in a position to speak for ourselves. That’s why we need advance directives, which are free, straightforward, easily available forms that are legal in every state.

Americans cherish the right to make their own medical decisions. In light of our ardent individualism, it’s puzzling that so few of us exercise this right when it comes to something most of us will face: medical care at the end of our lives. (A study from the Johns Hopkins Bloomberg School of Public Health showed that only about one-third of us have completed advance directives.)

Care at the end of life involves making some deeply personal choices. Who should make them? Doctors? Government? Insurance companies? Hospitals? Ethics committees? Religious institutions? As both a physician and a state legislator, I believe that the operative values should be the patient’s. When patients haven’t expressed their wishes or designated someone who can act for them if they’re incapacitated, controversy and painful family upheaval can ensue.

While cost is not the primary reason to have an advance directive, saving money is one of its consequences. Medicare estimates that 25-30 percent of its spending goes for care during the last six months of life. The costs to Medicaid programs and private insurance are equally staggering.

As the baby boom generation reaches its senior years, new lifesaving medical treatments are devised, and our health care system confronts a crisis of affordability, we, all of us, need to take time to record our end-of-life decisions.

I hope that, one day, completing advance directives will become as routine as renewing your driver’s license. If advance directives were to become the norm—if, say, 80 percent of adult Americans had them—we could offer more personalized and humane care for far less money. Respecting individual rights is the right way to reduce health care costs.

Remember: only you can complete your advance directive. No one can do it for you. Get the forms, fill them out, share with family, friends, and physicians as appropriate and then encourage everyone you know to do the same. This is not a tool just for “old people,” either. It’s a tool for everyone, to specify the kind of care you want as you approach the end of life, whenever that occurs.

The tools are here. We just need to use them.

And what better way to get started than on April 16, National Health Care Decisions Day?

Dan Morhaim and Brent Pawlecki, M.D., Medical Director Goodyear Tire Company  have written a column  for Health Affairs on the role employers can play in promoting advance directives.

morhaimDan Morhaim, M.D., is an adjunct professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, Deputy Majority Leader of the Maryland House of Delegates, and the author of The Better End: Surviving (and Dying) on Your Own Terms in Today’s Modern Medical World. He is board certified in emergency medicine and internal medicine.