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Do yourself a favor: Fill out a living will

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Saturday, March 24, 2012

At least once a month, critical care doctors at Allegheny General Hospital find themselves in a thorny predicament. They can't agree with families of patients about which direction to go in the care of a very sick relative.

It goes something like this: Patient gets sick, lands in the intensive care unit and is unable to tell anyone what he wants. Family members intervene, convinced Uncle Pete would've never wanted aggressive treatment. They beg doctors to stop treatment.

But the doctors don't stop. They keep the patients alive on ventilators and feeding tubes. There's a reason for that, according to Dr. Arvind Venkat, an emergency department physician who chairs AGH's ethics committee.

It all boils down to a piece of paper.

The patients lack an advance directive or living will outlining their wishes should they be unable to communicate. Without such a document, the physicians' hands are tied, Venkat said. As long as they feel the patient has a shot at recovery, doctors will continue treatment, he said.

Venkat's solution is simple and practical: Write your wishes down. Even if you have a spouse, there's always a chance that he or she will butt heads with the doctor and not agree on what to do.

"We can keep you alive for very, very long periods of time," Venkat said. "But just because we can do something doesn't mean we should do something, or that you would want the consequences of that treatment."

The lack of advance directives can lead to ethical dilemmas worthy of a soap opera.

Venkat describes some of them in a paper he co-authored with Julianna Becker, a law student at the University of Pittsburgh. One case involved a 59-year-old man with chronic severe liver disease and a staph infection traced to an hip prosthesis.

Doctors felt the patient had a shot at recovery with surgery and aggressive treatment, but the patient's son objected. The disagreement led to so many delays the patient became too sick to withstand surgery and eventually died.

I asked Venkat if doctors push treatment because they want to make money. Yes, that often happens, he said matter-of-factly. But physicians also don't want to be perceived as being the ones who take hope away.

"There's an inertia to the health care system,'" Venkat said. "Things get moved along, and no one says stop."

When doctors push and push, patients end up in a quandary because most of us tend to trust our doctors. If the doctor says 'You need a stent' or 'You need back surgery,' chances are we'll go along with it instead of saying 'No, I don't need this treatment.'

It's safe to say we're not conditioned to talk about preparing for death. Venkat's own father, also a physician, has not talked to his 87-year-old mother about her wishes. We don't talk about those things, Venkat said his father told him.

Do yourself a favor and fill out a living will. That piece of paper can make a difference between weeks in the ICU or a dignified death. As Venkat so well put it, as much as physicians are invested in your care, they go home at the end of the day.

"You and your family are the ones who live with the consequences of treatment decisions much more than anybody else," Venkat said.

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