Life & Death Decisions by Senior Citizens

During periods of personal crisis, you, family members, or significant others often come into contact with the healthcare system--where life or death decisions are made. In the past, physicians once made these decisions, whether to withhold life-sustaining technologies, behind closed doors believing they were protecting their patients and family members from what might be upsetting for them.

However, recent legal developments--living wills and the Durable Power of Attorney for Healthcare--support the rights of decisionally capable adults or a surrogate to be informed about a person's medical condition and to participate in decisions about their medical care. A living will is a document where you put in writing what your preferences are about terminal illness and the use of life-sustaining technologies. If you are named as an agent using the Durable Power of Attorney for Healthcare document you may be asked to make life or death decisions for a loved one when they no longer can. Although these authorizations allow the decisions to be made legally, it helps to have knowledge of life-sustaining technologies to cope with the ethical and moral obligations.

At anyone time, many thousands of elderly persons are receiving life-sustaining interventions. The vast majority of cases go unnoticed except by the patients, family members, and others directly involved in making and living with difficult treatment decisions. However, a few of these cases gain notoriety and public attention as it becomes apparent either that treatment was unwanted or futile or, conversely, that some new medical breakthrough or personal triumph over adversity has occurred.

Technologies that support or replace the functioning of a vital organ are capable of saving and sustaining life and, sometimes, capable of restoring health and independence. However, an individual's response to treatment can seldom be predicted with certainty; thus, it is never clear that a "life-sustaining" technology will sustain the life of a particular patient or, if it does, for how long. The quality of the life that is sustained may be even harder to predict.

An important factor that further complicates matters is that many patients with life-threatening conditions are not able to understand their treatment options or to express preferences regarding them. In addition, patients and other interested parties may evaluate differently the benefits and burdens associated with treatment versus nontreatment and with one treatment versus another.

The dramatic advances in life-sustaining medical technologies during the past three decades have been accompanied by rapid expansion in their availability and use. As equipment and procedures have been refined and experience accumulated, the necessary personnel, facilities, and reimbursement have expanded, and the clinical criteria guiding use have been broadened. The types of patients who become candidates for life-sustaining treatments have changed and their numbers have increased sharply. Many of these patients are elderly. As the population ages, as once "extraordinary" measures become commonplace, and as ever-more powerful technologies emerge, it becomes increasingly important to understand the problems associated with the use of these technologies.

At such times, patients or their representatives may request "no heroics" be provided or, conversely, that "everything possible" be done. These broad directives are open to a variety of interpretations by healthcare providers, and patients and families sometimes fail to consider to understand the implications of their request.

For example, resuscitation can be the starting point for prolonged dependence on other technologies such as mechanical ventilation. The patient or family members who request "no heroics" may feel quite differently about a fairly simple procedure like external cardiac massage than they feel about a more invasive techniques like open-chest massage, defibrillation, and pacing. Yet there is no way to distinguish among life-sustaining technologies when wishes are expressed in global terms.

Advances in medical technologies are providing considerable ability to alter the timing and circumstances of death. However, questions of this life-sustaining medical care now frequently revolve about judgements about what constitutes acceptable "quality of life" (and, implicitly at least, "quality of death"). Judgements of "quality" are subjective and personal; what is acceptable quality of life to one person may be a fate "worse than death" to another. Similarly, life-sustaining treatment that some would gladly endure, others would reject as "too burdensome" or "undignified." The problem becomes extremely more complicated when you consider the legal, moral, ethical, and financial issues.

In the past, a decision to use or withhold a life-sustaining treatment for an individual was based on consideration of the person's physical condition, legal and ethical constraints, and, in some cases, the wishes of the patient and family. The cost of medical care has always been a consideration for persons who are uninsured, but most elderly people are insured either through Medicare, Medigap, or Medicaid and most are covered for life-sustaining treatments (although sometimes only when the treatments are provided in a hospital). Thus, elderly persons, their families, and physicians have generally been insulated from cost considerations with regard to life-sustaining treatments.

For those who sign living wills--stating your wishes regarding life-sustaining treatment--and for those who may carry the burden of deciding for another, we are providing explanation of these technologies on the following pages. We are also providing information on a patient classification system that influence the decisions made by others on a person's behalf--but is not necessarily used in practice.

Life-sustaining Technologies
Life-sustaining technologies are drugs, medical devices, or procedures that can keep an individual alive who would otherwise die within a foreseeable, but usually uncertain, time period. While these technologies share some common ethical, legal, and healthcare delivery problems, each has unique characteristics that either raise special questions or suggest possible solutions. Although there are a number of technologies used to treat or manage life-threatening conditions, five important ones are:

Mechanical ventilation

Resuscitation

Renal dialysis

Nutritional Support and Hydration

Antibiotics