Portal de Periódicos da CAPES

Living Wills are Overrated

1993; Elsevier BV; Volume: 104; Issue: 6 Linguagem: Inglês

10.1378/chest.104.6.1645

1931-3543

A. Jay Block,

In the mid-1980s, the state of Florida passed a law entitled, “The Life-Prolonging Act of Florida,” which was the most enlightened living will law that I can imagine. Definitions were clear, terminal conditions were defined, guardianship was provided if necessary, and the living will forms were simple. This law is still in effect. In late 1991, the federal government enacted the Patient Self-Determination Act, which ensured that every patient was made aware at the time of admission to the hospital of their option to file a living will. One would think that these legislative actions would make decisions about death and dying easier for patients, families, and physicians. I have been an attending physician for many years in a medical intensive care unit in a tertiary referral hospital. In this setting, I have been pleased with the effect of the Florida law since it clearly defines the responsibilities of the patient, the family or guardian, and the physician. On the other hand, I have seen little effect of the Patient Self-Determination Act since its implementation. There is literature on the subject that appears to validate my observation. In 1991, prior to the implementation of the act, of those outpatients who wanted to issue some form of advanced directive, only 15 to 18 percent had actually done so.1Emanuel LL Barry MJ Stoekle JD Ettelson LM Emaniml EJ Advance directives for medical care: a case for greater use.N Engl J Med. 1991; 324: 889-895Crossref PubMed Scopus (637) Google Scholar In 1993, each patient, on admission to a hospital, was asked about a living will, given a brochure, and offered the help of a social worker or chaplain. Only 4 percent of these patients actually executed a living will during studied hospitalizations.2Silverman HJ Tuma P Caracci L Armistead N Roahen S Patient Self-Determination Act: effects on patients' awareness, knowledge, and discussions concerning advance directives.Am Rev Respir Dis. 1993; 147: A108Google Scholar Thirty-two percent of the patients did not recall being counseled or receiving the brochure. Even if the living will has been executed, it is often not available when acute care is needed. Emergency medical technicians, emergency room physicians, and intensive care unit physicians know that the document is often (1) in the lawyers office, (2) in the safe-deposit box, (3) in the offsprings home, (4) in an unknown location, etc, when critical decisions about resuscitation must be made. Abiding by the wishes of the patient as written in the living will requires that the document be present and available at the time of emergency care. The lay public appears to be unaware of this fact. It is clear that decisions about death and dying for patients with chronic illnesses may be facilitated by the existence of a living will, but the literature would imply that such patients are unlikely to have executed such a document. At least, in the nonemergency situation, the physician does have the time to discuss the issue with the patient and family and acquire a living will, if so desired. In addition, the patient and the family may not be able to anticipate the nature of the terminal illness. They have not attended medical school, and they cannot be fully informed as to all the possibilities that could conceivably occur. I remember one woman with metastatic breast cancer who had signed a living will that specifically prohibited intubation and ventilation. She entered the hospital with bilateral malignant pleural effusions, and during a thoracentesis, developed a pneumothorax. A chest tube was inserted emergently, and because she appeared about to die from a complication of a procedure (and the living will was at home), she was intubated and ventilated. She did well, was alert, and the family brought in the living will several days later. Since it was not dated and not present at the time of emergency intubation, I was relieved that we had made the decision to resuscitate her. Luckily, she did well, and after repeated thoracenteses and diuresis, she could be extubated. I asked her what she would have wanted us to do had we had time to make such decisions during the emergency. She stated that she had no idea when she signed the living will that she might be alert, oriented, and awake and still be intubated and ventilated. If she had been aware of this possibility, she would have definitely wanted to be resuscitated. How could she anticipate this situation and her eventual extubation? This is not an isolated occurrence. The decision to sign a living will is more complex than the general public is led to believe, and I think this complexity accounts for the reluctance of patients to execute such documents. Are there any solutions to these problems? The situation would be helped if physicians talked about living wills in advance of terminal illness. One could encourage specific documents which might better anticipate the terminal problem. Doctors should be given a copy of all living wills. Finally, patients should be encouraged to designate a healthcare surrogate who can make decisions if the patient is not competent. All of these measures make sense, have been advocated by ethicists, but are avoided by patients, families, and physicians.3Cammer Paris BE Carrion VG Meditch Jr, JS Capello CF Mulvihill MN Roadblocks to do-not-resuscitate orders: a study in policy implementation.Arch Intern Med. 1993; 153: 1689-1695Crossref PubMed Scopus (32) Google Scholar Because of the distasteful nature of these types of discussions, I do not expect a radical improvement in the acquisition and use of living wills. I am in favor of living wills. In the care of patients with chronic illnesses, living wills are useful if present. When caring for patients who are acutely and emergently ill, living wills are overrated.