The first time I heard about Advance directives and living wills was when I was trying to cram my mind with sophisticated terms related to Bioethics, which I could flaunt in my med school interview. As the member of a yet to develop “third world” country, the very idea of directing the physician to stop efforts and letting go, was strange if not repulsive to me. I am a part of a community that strives to stay as far away from the medical community as possible. We endeavour to make sure that we maintain good relations with atleast one physician, so that in our time of need, he/she might go the extra mile and drag our soul down from the journey towards the heavens. Not once, had I thought of the idea of “dying with dignity”.
One argument that was put forth was that often at the very end of life, one is deemed to live as a vegetable due to the artificial ventilators which pump air unnecessarily in the system and keep the dead from dying. Wasn’t dying better than living as a vegetable? One with no ability to decide, no control over life and a mere financial burden to the economy was better off gone.
This argument had deeper implications, I could immediately think of three situations:-
a. A brain dead Mr.X- with no prospect of recovery, he could stay in the vegetative state for decades thanks to artificial means of prolonging life, but medically all treatment was futile. It was just a matter of switching off the plug and pronouncing the time of death.
b. An old lady around 80, who has an advance directive, which asks her physician to stop efforts of bringing her back as she would not like to live a life hooked to the “infernal” machines.
c. A young girl, comatose after an automobile accident, the decision makers in her case, her parents, aren’t able to reach a decision. The father feels that the girl is better off gone and the mother would like to wait for a miracle and believes that her daughter is going to wake up in another moment.
The first case here is that of “MEDICAL FUTILITY”. The healthcare team believes that no effort in the case of Mr.X is going to be successful and they have the power of switching off the plug and rationing the resources which would be better off used on someone else. A simple case as long as Mr.X isn’t your father, brother or husband. What would you do if your doctor suddenly tells you that your relative will no longer be treated as all resources used upon him are not bringing the success, they had hoped for. How come they get to decide, when your family becomes a lost cause. In case you fret and feel that the doctors aren’t acting in your best interest, they are most likely going to give you a day or so to calm your senses and then broach the question of withdrawing support. Ultimately, the power to let go must be mustered by the patient’s family.
The third case, would be an example of surrogate decision making, well the doctors ask the parents, what they would like to do with their daughter, she has minimal brain activity and is being fed by a nasogastric tube, how does the parent decide to let go? how do they decide if her quality of life now is better off or worse than what it would be if she were dead. The father has concerns, financial, social and physical. How much longer can he wait by her bedside waiting for her to stir? These concerns do actually figure in the mind of the person who is actually paying for the medical procedures. The mother feels that the treatment ain’t futile, she has shown minimal brain activity after all, it is only a matter of time before she becomes her cheery self again…..
What I wonder is how the doctor would maintain a neutral demeanour, he has just switched the plug off for Mr.X and here he is again asking about another vegetative patient, hasn’t this become routine for him? the job of rationing resources for better off cases and relieving the hospital of patients who are on the path of becoming futile cases. wouldn’t it indicate that medicine is actually only those who have potential for recovery, after a long day in the clinic, would a surgeon with the option of pulling the plug and going home spend another minute on the complex patient in front of him?
The second case, concerns advance directives. On the one hand, the old lady could be saved by charging the paddles and doing heroic medical procedures and here she is demanding to be “let go” on the basis of her hatred for the machines which have the potential of saving her life.
As a physician, wouldn’t this seem ironical that on the one hand there are patients who would like to be saved but are not responding to heroic measures and on the other hand they cannot save one who could be saved?
Indeed, she is doing a favour to the society by freeing resources which would be used upon her and her bed in the ICU can now be given to the emergency case waiting in the hallway but what this shows is the undermining of the principles of medicine, as a science and highlighting the role of philosophy in clinical practice….
Well bioethics, is indeed a complex area of knowledge, the more science develops the more the extent of conflicting situations but what I am pretty sure of is that my advance directive is only going to say
“Save me No matter what”………