November 19, 2003
HEADS, YOU DIE--TAILS, YOU LIVE:
Living Wills: Not a Be-All and End-All: They may seem like a good idea, but fate refuses to be controlled. (Angela Fagerlin and Carl E. Schneider, November 12, 2003, LA Times)
First, people have to be able to accurately predict how they would feel about various treatments down the line. But even patients evaluating contemporaneous treatments are often daunted by the difficulty of making such decisions. They falter in gathering information, they misunderstand and ignore what they do gather, and they rush headlong into choices. How much harder, then, is it for people to conjure up decisions for an indescribable future and unknowable medical conditions with unpredictable treatments?Further, their preferences must be stable. Yet on average, studies find that almost one-third of people's preferences about life-sustaining medical treatment change even over a few years. Understandably. Would Christopher Reeve have predicted that he could live so fulfilling a life with quadriplegia?
People must also grapple with drafting complex instructions. Studies find that living wills regularly contain mutually inconsistent instructions. Nor do the standard forms sufficiently help. One version deploys vague terms like "artificial means" and "heroic measures." Another asks the writer to specify numerous treatments for numerous conditions, a labor of analysis few of us are equipped to undertake.
Living wills must also reach decision-makers in order to be effective, but many never do, for the road from the drafting table to the ICU bed can be long. For instance, one study of 182 patients with advance directives found only 29 patients with those directives in their charts.
Ultimately, it is incumbent upon the surrogate decision-maker (typically a family member acting as executor of the living will) to interpret the treatment preferences correctly. But according to a recent study using hypothetical scenarios, surrogates who saw a living will did no better interpreting their loved ones' preferences than did surrogates who didn't see a living will. Even surrogates who had discussed living wills with the wills' writers had trouble.
The empirical evidence indicates that not one of the requisites to making living wills successful social policy is met now, or can be.
As long as we're cheapening life, why not televise it and let the audience vote? Posted by Orrin Judd at November 19, 2003 7:25 PM
I think you've got the makings of a new ~reality television~ show there. (We could start out with 11 players and 10 bedpans, and go on to situations like four patients and only three hearts, and they get to decide among themselves who gets what.) Brings new meaning to the term "survivor", too.
Yes, but Raoul, you don't want to exclude the audience. Imagine them watching a tape of an ex-spouse tearfully talking about how "he" always was against prolonging life "unecessarily", followed by Regis saying: "If you think he wants you to pull the plug, press button number one...".
Seriously, is it possible to deal with this gut-wrenching issue without being absolutist. There has to be soom room to accommodate Jeff's concerns. Sometimes I think we should make an age-based distinction, but then I recoil from that too when I think of all the aged who will be expected and pressured to "do the right thing". Are our hands completely tied ethically? I'm told it either is or will soon be possible to keep just about anyone alive indefinitely.
Posted by: Peter B at November 20, 2003 8:27 AMI keep seeing ads for The Bachelor. This looks to be a graver threat to marriage than same-sex marriage.
Posted by: David Cohen at November 20, 2003 8:49 AMI'm a little late to this one. I hope someone is still reading here.
Last week I brought up a recent thread on this same subject, regarding Terri Schiavo, with my wife.
Her immediate reaction: "If you leave me like that, you better hope there is no afterlife, for I will make it hell for eternity."
Before anyone, OJ, I'm looking at you, dismisses her comment, remember this: she has been there.
Posted by: Jeff Guinn at November 21, 2003 9:21 PMShe was living a life not worth living and someone didn't unplug her?
Posted by: oj at November 21, 2003 10:04 PMNo.
You said that no one who hasn't been in that condition couldn't possibly make an informed judgment.
She has been.
Posted by: Jeff Guinn at November 23, 2003 9:33 AMIn a coma?
Posted by: oj at November 23, 2003 12:04 PMNo. You have previously said it is impossible for anyone to make a living will, because they can't know in advance how they would decide, because they have never had the experience.
She has.
And, having, if only briefly, been there, she has decided a prolonged vegetative state, a la Terry Schiavol, is most definitely not for her.
Who are we to argue?
Posted by: Jeff Guinn at November 23, 2003 1:25 PMShe died in a past life?
Posted by: oj at November 23, 2003 1:38 PMOJ:
I was talking about an argument you made. Why don't you?
Posted by: Jeff Guinn at November 23, 2003 1:58 PMJeff:
You said your wife had been through her own near-death experience and decided she shouldn't have been revived, didn't you?
Posted by: oj at November 23, 2003 2:31 PMNo--you said people can't possibly make informed living wills, because they can't properly conceive the situation beforehand.
She had always believed she shouldn't live in a persistent vegetative state. Having gotten within shouting distance of that possibility, she still reaches that same conclusion, only more forcefully.
We aren't talking about a DNR here, but rather under what circumstances she would choose to live if unable to voice her preference.
Posted by: Jeff Guinn at November 23, 2003 5:04 PMOh, I see. So she never did experience personally the situation we're talking about, right? So my point stands.
Posted by: oj at November 23, 2003 5:59 PMWell, lemme see.
She did experience being in a coma. She did experience losing several weeks of her life.
Have you?
So she knows more about being in a vegetative state than you do, I'd wager.
It seems that ought to count for something.
Besides, it doesn't take very much extension of your line of reasoning to prohibit to us any decision on a course of action we have yet to experience first hand.
In the Air Force we had a saying for that: Can't go until you been.
Posted by: Jeff Guinn at November 23, 2003 9:02 PMSo she regrets being alive--that seems tragic to me.
Posted by: oj at November 23, 2003 10:49 PMOJ:
Why must you so badly misread what I write?
She was insistent she not be left in a permanent vegetative state. Which, regardless of the impression you have formed of her intellectual capacity, is quite different from a full recovery.
Posted by: Jeff Guinn at November 24, 2003 5:29 PMLuckily she wasn't killed before it proved non-permanent, eh?
Posted by: oj at November 24, 2003 6:19 PMWell, after reading this, she has concluded she is lucky to be married to someone who will honor her wishes.
So long as she doiesn't go into what might be a temporary coma while you have an itchy finger on the trigger...
Posted by: oj at November 24, 2003 10:28 PM