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Chapter Ten: Advance
Directives
Betty Youngerman collapsed in the aisle of Country Market Grocery
Store, clutching her chest and gasping for air. The Emergency Medical
System was activated and in less than four minutes the EMTs arrived
on the scene. No family was readily available, and as Betty did
not have a Medic Alert bracelet stating "No Code" or "Do
Not Resuscitate" they immediately began Cardio-Pulmonary Resuscitation
(CPR), and began the rapid transit into Garland Medical Center,
continuing resuscitative efforts en route.
At Garland, while continuing resuscitation, they rifled through
Betty's purse to find any mention of family or personal physician.
Six phone calls later they found Sylvia, Betty's daughter, supervising
the girls at the Second Avenue Brownie Troop meeting. When they
explained everything to Sylvia, she was shocked. Hadn't her mother
sent in those papers they had been discussing for two weeks? With
her early Alzheimer's disease and her leukemia they had decided
as a family that in the event of an acute cardiac failure no CPR
or Defibrillation was to be performed. Sylvia told the nurse to
stop the Code Blue.
By the time that Sylvia got to the Emergency Department, they had
straightened up the room and removed some of the unnecessary equipment.
But as Sylvia talked with Dr. Poulter she learned that the entire
Code had gone on for a total of thirty minutes, and that her mother
had received a series of eight defibrillations. Her ribs had been
cracked in the process. "What a pity," thought Sylvia.
"Her mother could have gone peacefully, but because they never
sent that paperwork back in to the hospital she had to go through
all of this."
Emilio Bandera had been estranged from his wife for six years,
though they continued to live in the same Ohio town. Since Cynthia
had left him and moved in with another man, Emilio had made some
major changes in his own life as well.
Engaged to Kathy Gomez, they were planning to marry as soon as he
could get the divorce processed. Now here he was in St. Elizabeth's
Surgical Intensive Care Unit after nearly killing himself when he
fell off his roof while cleaning his gutters.
Important decisions needed to be made about how aggressive the surgical
team should be, whether they should proceed with surgery, and if,
in the event of a failed surgery, Emilio wished his organs to be
donated to those in need. As the social worker gathered all the
information and discussed it with the intensivists, an awkward realization
dawned on them all.
Under the law, Cynthia had all the legal say about these important
decisions. If she chose to consult the grown children or Kathy she
could, but legally she was not compelled to consider their wishes.
As the divorce had not been finalized, and the will had never been
changed, Cynthia would be the sole heir to all of Emilio's property
if he died, but if he lived she would likely receive very little
in the divorce settlement. After all, she had deserted Emilio, and
there were no longer minor children to consider.
While everyone realized the obvious conflict of interest, legally
the precedent was clear. Dr. Jenkins sat down with Cynthia and began
reviewing treatment options.
Bobby Jo Montgomery's wishes were quite clear, or so they seemed.
In the event of a cardio-respiratory arrest he did not wish to be
resuscitated. He had witnessed his father linger in a coma for three
months and vowed that that would never happen to him. So he was
not intubated, CPR was not performed and he died.
So he got what he wanted? Not really. Bobby Jo had imagined a specific
scenario and locked himself into specific actions based on his suppositions.
The real story was that he had completed the Living Will within
two weeks of his father's death, and then had never thought about
the document again. In the meantime he finished school, landed a
great job, married, had three children, and on this fateful afternoon
was eating a hamburger that he had just grilled at his twins' eighth
birthday party. A large piece of burger lodged in Bobby Jo's airway.
Within less than a minute he was wheezing and gasping for air. His
neighbor threw him in his car and raced to the local hospital, calling
ahead on his cell phone. As they arrived, a nurse with a wheel chair
met them at the door and scurried him back into the treatment room.
A series of Heimlich maneuvers failed to dislodge the meat, and
Bobby Jo was turning dark blue. Dr. Jensen called for a crash cart,
a tracheotomy cut-down kit and an endo-tracheal tube. He was ripping
open the cut-down tracheotomy kit, and was just about to start the
tracheotomy to insert the tube when the nursing assistant came rushing
into the room.
Waving his chart frantically, she shouted: "Did you know that
he signed a Living Will? He specifically says: Do Not Resuscitate,
Do Not Intubate."
Dr. Jensen froze with his hand halfway to Bobby Jo. Now what? Should
he do his best to save Bobby Jo, and possibly be sued for assault
and battery, or should he respect his wishes and hope for the best?
The term "Advance Directive" may refer to several different
types of documents. The two most widely used are the Living Will
(LW) and the Durable Power of Attorney for Health Care (DPAHC).
A third scenario, where no specific wishes are delineated, and where
no person is denoted as the decision-maker, is accounted for in
many states by a surrogate law in some form. In Illinois this is
called the Health Care Surrogate Act (HCSA).
Through the Living Will, which is legal in most states, people may
decide and document in advance exactly what types of medical therapies
and interventions they will allow the medical team to do on their
behalf. An obvious advantage of this is that if they strongly do
not wish certain procedures, such as intubation or defibrillation,
to be performed, they can exclude these treatments in advance. One
of the largest disadvantages of LW is that it is impossible to predict
all the variables that may come to play in a complex decision at
some point in the future. The closer to one's death that the LW
is written, the closer it will approximate the patient's true wishes,
but even this is not always true. Another problem with LWs, moreover,
is that in most states the LW does not take effect until a determination
of terminal illness or persistent vegetative state is made. Because
of some of these problems, many find the DPAHC a more suitable document.
DPAHC documents specify in advance the person or persons who will
be authorized to make health care decisions for the patient in the
event of patient non-competence. Thus, the determination of imminent
death or Persistent Vegetative State is not necessary. Some persons
include the DPAHC as a separate part of the same document that specifies
the LW. Thus, a person could say in the event of imminent death
the LW is to take effect, but in the event that the patient is not
able to make decisions due to acute injury or non-competence the
DPAHC will be in effect. Many Christians find the DPAHC to be more
reasonable, but it requires that the patient speak clearly and at
length with the designated decision-maker regarding their wishes.
Where both the LW and DPAHC have not been written, surrogate laws
take effect. Depending on the state the exact priority list may
differ, but each statute states who has decisional authority. Usually
this is prioritized:
1) spouse
2) children who have reached majority
3) parents
4) other relatives, and finally
5) close friends.
The person who is deciding for the patient is called a proxy, agent
or surrogate. The proxy is supposed to make decisions for the patient
based first on "Substituted judgment", meaning "I
believe that this is what the patient would have chosen."
When this is not discernible, the decision should be based on "Best
interests", meaning "I believe that this is in the best
interest of this patient given these facts."
An underlying assumption in all of the above discussion is that
patient autonomy is very important, and should be given first place
in authority for deciding difficult questions.
What does the Bible say about principles that apply to Advance
Directives? Let's look and see.
Scripture and Discussion Questions
Ecclesiastes 4:10-12
Mark 12:28-31
Proverbs 13:16a, 20
Proverbs 15:22
Proverbs 19:21
Proverbs 22:3
Proverbs 3:5,6
1) Ecclesiastes 4:10-12 discusses the benefit of facing life as
part of a team. Does this concept have any application in a discussion
of Advanced Directives?
2) Mark 12:28-31 and Matthew 22:34-40 tell us that the greatest
commandment is to love God, and the second great commandment is
to love others. How does this fit in with a discussion of autonomy?
Can you think of other scriptures that emphasize autonomy? What
is communitarianism?
3) Proverbs 13:16a tells of the importance of making decisions from
a base of knowledge. Does this pose a challenge to you as you think
about Advanced Directives? Do you really know what your options
are in end-of-life decision making?
4) Proverbs 15:22 talks about "many advisers" helping
plans to succeed. In the case of Advanced Directives might this
suggest any particular phrases you should include if you decide
on a Durable Power of Attorney for Health Care?
5) Given Proverbs 19:21, do we really have any obligation to think
about Advance Directives, or should we leave it all up to God? (Who
decides if we do not?)
6) Proverbs 22:3 discusses the need to plan ahead. But if we know
that it is all in God's hands anyway, why should we bother planning
ahead? What is our responsibility?
7) Proverbs 3:5,6 remind us that God is to be the focus of our lives.
Realizing this, and remembering the Mark and Matthew references,
above, how would this affect our decision-making process?
8) Is it immoral to take one's viable kidneys, corneas and heart
to the grave when these might prevent pain and suffering for others?
Conversely, would it be immoral to not share your no longer needed
body parts with others when you die?
9) "Conflict of Interest" is an important consideration
in many ethical decisions. The Bible tells us that we are to "avoid
the very appearance of evil". Yet, our lives are filled with
relative conflicts of interest. How do we decide when a conflict
of interest is legitimate?
10) The Bobby Jo Montgomery vignette offers a springboard for discussion.
How specifically have the members of your class discussed their
wishes with their family members?
Comments
1) Some families who have poor or no insurance coverage may receive
very large bills for all the activities that occur within the last
hour of a loved one's life. Ambulance costs, Emergency Department
fees, medications, respiratory therapy, doctors' fees, and radiology
charges can add up quickly. If the patient has definitely decided
that they do not want this type of treatment they need to makes
this obvious to their family, and to any Emergency Medical System
personnel who might be involved. A Medic Alert ™ bracelet is
a simple way to do this.
2) Due to our infinite ability to deny our mortality, we may not
update our wills as frequently as we should. Remind your class to
consider this.
3) Sometimes the Living Will creates more problems than it solves
since it cannot accurately predict the questions that will arise.
The DPAHC is a superior document. If one then wishes to spell out
a few particular preferences this still allows the person designated
as Power of Attorney appropriate latitude.
4) In addition to "Substituted Judgment" and "Bests
interests of the patient", another guideline sometimes used
is "What would a reasonable person who had all the available
information want to do in this situation?" This is not quite
as specific as "Substituted Judgment" and provides an
additional parameter to the concept of "Best interest of the
patient".
5) Autonomy is the framework for this whole discussion, but the
constraints of the futility discussion apply as well. If the LW
or DPAHC requests futile measure be undertaken the medical team
has no obligation to perform these measures.
6) The Bio Basics booklet referenced for this lesson is really quite
brief. Reading this in advance of the lesson might prove very valuable.
7) In the second vignette, when the doctors realized that Cynthia
had an obvious conflict of interest, their hands were not really
tied. They could have consulted their hospital attorney, sought
a judicial ruling, or referred the case to their hospital Ethics
Committee. In most hospitals almost anyone, including nursing, family,
physicians or even janitorial staff can contact the Ethics Committee
and request a consultation.
PRAYER REQUESTS: As you close today's
lesson together, pray that God will help you begin to think about
your end-of-life decision making, and give you wisdom as you discuss
some of these issues with your parents, spouse, children or close
friends.
For Further Reading:
Gary P. Stewart, William R. Cutrer, Timothy J. Demy, Donal P. O'Mathuna,
Paige Cunningham, John Kilner and Linda Bevington, Basic Questions
on End of Life Decisions-How Do We Know What's Right? (Grand Rapid,
Michigan: Kregel Publications, 1998). This brief booklet is part
of the Bio Basics Series sold through The Center for Bioethics and
Human Dignity. It is authored by true Christian authorities, but
can be read by most people in less than two hours.
Franklin E. Payne, Jr., M. D., Biblical Healing for Modern Medicine
(Augusta, Georgia: Covenant Books, 1993), pages 101-102. Dr. Payne
offers some alternative views on living wills and durable powers
of attorney.
Note: Case Study #3 from Breathtaking Decisions, uses a case from
Bette-Jane Crigger, ed., Cases in Bioethics, 2d ed., (New York,
New York: St. Martin's Press, 1993) which in some ways is parallel
to the Bobby Jo Montgomery vignette. Breathtaking Decisions is a
weekend seminar sponsored by Center for Bioethics and Human Dignity,
of Bannockburn, Illinois. If your community is interested in sponsoring
or co-sponsoring such a weekend event, please contact Dr. John Kilner-see
lesson thirteen, for further information.
A. A. Howsepian, MD, 'Are Advance Directives an Advance?' in Ethics
and Medicine--An International Christian Perspective on Bioethics
14:2 (1998) p. 34-41. Dr. Howsepian is not sure that they are. Read
why in this well-researched, comprehensive look at Advance Directives.
William F. May, Testing the Medical Covenant, (Grand Rapids, Michigan:
William B. Eerdmans Publishing Company, 1996). Dr. May, on pages
31 and 32 raises concern that even when Advance Directives are appropriately
executed, they are often, unfortunately, not followed.
Charles Junkerman, M.D., and David Schiedermayer, M.D., Practical
Ethics for Students, Interns, and Residents-A Short Reference Manual,
2d ed., (Frederick, Maryland: University Publishing Group, 1998).
Offers a concise overview of living wills, durable powers of attorney
for health care, and non-statutory forms. The book compares and
contrasts these documents.
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