View Full Version : Advance directives ease end-of-life care

03-27-2005, 06:59 PM
An advance directive would have eliminated the Schiavo battle.

Date published: 3/27/2005

STORIES ABOUT the Terri Schiavo case are flooding the newspapers, television news programs, and the Internet. Proponents on both sides of this issue have poured gasoline on the fires of emotion, creating a wildfire that threatens to make end-of-life care issues even more painful for families across the land.

The core issue of this fight is the question: "Who has the right to make decisions for Terri Schiavo?"

All citizens have the right to make an advance directive. An advance directive is a document that declares one's wishes for end-of-life care. Advance directives are created by state law and vary slightly from state to state. A typ-ical advance directive states, "If at any time I am diagnosed with a terminal illness, or I am determined to be in a persistent vegetative state, I wish to forego all life-sustaining treatments that will artificially prolong my life. I wish to receive comfort care that will manage my pain and other uncomfortable symptoms."

Terri Schiavo, like most Americans, did not make an advance directive.

When someone becomes incapacitated without an advance directive, the laws in most states provide a hierarchy of people who are authorized to make medical decisions for the incapacitated person.

In most cases, the list is: the surviving spouses (as long as there is not a legal separation or a restraining order), the adult children of the incapacitated person, the siblings, the parents, and finally a majority of concerned family members present.

In this case, Michael Schiavo, Terri's husband, has the clear legal obligation to make decisions for his wife. He is obligated to make decisions that reflect her beliefs and wishes--in essence, he is charged with the duty of making decisions just as Terri would do if she were able.

Terri's parents, friends, and other relatives have no legal standing to participate in or influence care decisions for Terri.

Terri Schiavo has been kept alive for many years by the placement of a feeding tube. Feeding tubes are placed in patients who lose the ability to swallow and safely take in nutrition by normal means.

People who do not swallow well often have bits of food or liquid slip into their lungs while eating. This is called aspiration, and it leads to a form of pneumonia. Feeding tubes are placed in patients who would quite literally die as a result of trying to eat or drink.

In some patients, especially those who have had a stroke or other traumatic event, a feeding tube is medically appropriate because the patient will regain the ability to swallow, and thus eat normally, in a few weeks.

In cases like Terri's, the feeding tube becomes a problem when the patient does not regain the ability to swallow after a few weeks. The patient is then dependent on the feeding tube for nutrition and hydration.

Removing the feeding tube is simply stopping a medical treatment. However, we tend to complicate the issue by attaching all sorts of emotion to the issue. We frame the issue as, "We are starving her," or, "We are going to make her die of thirst."

While we may have these feelings, the feelings do not match the facts of the case. Terri's body has lost the ability to take in food and water naturally. This is a common way that human bodies begin the dying process. Our bodies stop taking in food and water, body systems begin to shut down, the body slips into a comfortable coma, and the person dies very peacefully.

When we force Terri, or anyone else, to take in artificial nutrition and hydration, we force them to live. When we refuse to come to terms with our own feelings of grief and loss and we use our medical technology beyond its scope and design, then we force our loved ones, like Terri, to become hostages to our emotional process.

Terri Schiavo will die, if not from withdrawal of a medical treatment--artificial nutrition and hydration--then from aspiration pneumonia (caused by regurgitation of nutrition supplied by the feeding tube), or an infection or bed sores that will not heal, or some other complication of her medical treatment.

Some aspect of her medical care will contribute to her death. Persons on feeding tubes do not live to die of old age.

This is a terrible and painful time for Terri's parents, the Schindlers. This is a terrible time for Terri's husband, Michael. None of our medical technology will reverse Terri's brain damage. As much as we wish that she would improve, it is not medically possible for Terri to regain her ability to interact with others or to even sense pleasure again. This family's grief and pain is only magnified by playing it out in the courts, the legislature, and the national press.

If you would like to help in the midst of this tragedy, there is something that you can do. Talk to your family today about your choices for end-of-life care.

Be very clear about what types of treatments you want and about the treatments that you don't want.

Then, go one step further: Make an advance directive. Put your wishes about end-of-life care in writing. Appoint a medical power of attorney to make medical decisions for you in the event that you are not able to make them for yourself.

Give a copy of your advance directive to your physician and to your family. It may be difficult to verbalize your end-of-life care preferences, but it is far less painful to create an advance directive than it is to have a family fight about end-of-life-care for a loved one.

The real tragedy is not that a woman in Florida is caught at the end of life in a family feud that has captured the national stage. The tragedy is that this drama about end-of-life care is played out in emergency rooms, intensive-care units, and hospices every day of the week.

The solution calls not for legal action but for personal action. You have the power to end this problem today. Will you do it?

CARRINGTON L. BAILEY of Fredericksburg is a health-care chaplain who has worked in end-of-life care since 1988.

link (http://www.fredericksburg.com/News/FLS/2005/032005/03272005/1712838)