Advance directive eases end-of-life decisions

It's difficult to imagine yourself in a situation in which prolonged life is meaningless and possibly painful. Should extreme measures be taken to extend a fragile life, or should the course of dying be allowed to continue peacefully? If you are unable to make a decision on your own, who should be in charge of directing your care? Such concerns can be put to rest with the California Medical Association's Advance Health Care Directive.

An Advance Directive may act as a replacement for a living will, as it allows you to choose whether or not you wish to be given life-sustaining treatment if you are terminally ill or permanently unconscious. It even goes a step further by ensuring that your healthcare desires are respected in any situation, regardless of the severity of illness.

Often, efforts made to save a life may fail. Even if a patient is resuscitated, the quality of life thereafter could be dismal. Many see resuscitation as a lengthening of the dying process rather than a preservation of a life.

"The thing about healthcare is that we don't want people to suffer," said Lee Abramo, R.N., M.S.N., and Director of Education at Los Robles Hospital and Medical Center. "When someone is at a terminal stage of life, nobody is looking forward to death. But some people don't want to be in situations where their suffering is prolonged."

In such cases, the option "do not resuscitate," or DNR, is available.

At Los Robles, there are three DNR levels to choose from. The first is a complete DNR, in which no measures to resuscitate, such as medication, chest compressions, ventilation or CPR, are taken. The second is arrhythmia protocol only. In that case, medication may be given to get the heart back into rhythm if a cardiac beat exists, but halted if this fails. The third level allows resu scitation without a ventilator. If there is a heartbeat but no respiration, an ethical decision is made by the family together with the physician and nursing staff.

DNR is a patient right that allows for a comfortable, dignified passing. Usually, individuals who benefit from this order have end-stage cardiac disease, multiple organ failure or terminal cancer.

"If, for example, patients don't have a DNR, we could resuscitate them and bring them back, but if they survive that, eventually they're going to have to die again. That's what they want to avoid by instituting a DNR order. They don't want to die twice," Abramo said.

On the Advance Directive form, you may also select an adult, preferably a family member or close friend, to be your "healthcare agent." This individual will voice your requests if you are unable to do so yourself and must share your healthcare desires to avoid the emotional and ethical troubles that may arise from conflicting wishes.

Last year's Terri Schiavo controversy is an example of all that can go wrong if a form like the Advance Health Care Directive isn't signed. It is illegal, and against the moral code of physicians, not to save a life at all costs if there is no proof that a patient wishes to remain DNR.

But what happens in cases like Schiavo's if the result of resuscitation is an individual in a permanent vegetative state- machine-dependent and completely unaware?

Los Robles has a bioethics committee that consists of physicians, nurses, social workers and community members interested in bioethics. After discussing an ethical dilemma, they meet with the family to inform them of their loved one's chances of survival as a functioning person.

"The process is very professionally done, keeping in mind all the emotional stress of the family," Abramo said. "The committee is there to support the family and never forces them to do anything."

Making end-of-life decisions while you are still healthy is understandably a sensitive task that can be difficult to initiate. Yet taking the time to fill out an Advance Directive will help alleviate the doubt or guilt that you or a loved one may feel if a time for such decisions arises.

Any California resident who is at least 18 years old can complete an Advance Health Care Directive. You may pick up a copy at your doctor's office or local hospital or you can download a form from the Internet.

Chelsea Ma will be a senior this fall at Westlake High School. She's completing a sum- mer internship for the Acorn Newspapers.