MGordon_MD
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Nov 16, 2006, 8:05 AM
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By Dr. Michael Gordon
Harold, a 52-year-old physician, is the spokesperson in his family, and he was struggling with decisions about Moshe, his 88-year-old father who had a malignant blood disorder. Moshe’s physician believed that palliative care, with comfort measures only, was appropriate. Harold felt that further blood transfusions, beyond the six Moshe had already received in the past two months, were needed. Harold’s three siblings appeared to be going along with him, though perhaps reluctantly. Moshe’s wife Rivka said she only wanted “the best” for her husband, but, as might be expected, she deferred to her physician son.
As the case of Terry Schiavo unfolded last year in the United States, many believed that if she had written a living will (often called an advance directive), the conflict between her husband and her family over her treatment could have been avoided.
Moshe had a living will, one that contained a lot of detail, but the interpretation of what he intended when he wrote about “comfort measures” and “no heroic measures,” as well being “allowed to die peacefully,” was causing conflict.
Moshe’s physician believed that the living will focused on the management of pain and other symptoms. Harold believed that blood transfusions, although not curative, provide comfort, and he wanted them continued for as long as necessary, while recognizing they would not alter the course of his father’s terminal condition. He had said, “My father’s well-being is what matters most to me, and a blood transfusion is not ‘heroic’ and provides comfort to him when he gets short of breath because of his anemia.”
In this situation, a caring and loving family and a dedicated physician were in conflict over the meaning of a living will. Rather than helping the family agree to a course of action, the living will caused as much trouble as if nothing at all had been written.
Without the document, the same question about Moshe’s care might also have arisen, but no one would have tried to interpret his written words in order to determine treatment. It would have helped had explained his intentions to his family at the time he wrote his living will, as he had become very sick and suffered from accompanying dementia and could no longer indicate his treatment preferences.
The last thing any caring family wants in an end-of-life situation is conflict, especially if bad feelings after death are the result. For the treating physician, the true wishes of the patient are usually paramount. When the patient cannot indicate them, physicians must rely on surrogate decision-makers who are usually family members. When a living will exists, it’s hoped that it will ease the treatment decisions for families and physicians – but as this case indicates, it doesn’t always turn out that way.
The resolution is not always easy. A family meeting with the doctor, a social worker and maybe an ethicist might help everyone understand the goals of treatment – which, of course, was to make Moshe’s last days or weeks as comfortable as possible.
Respect for his wishes was an important value for the family, so even if he had not explained in detail to anyone why he wrote what he wrote, it appeared that he did not want to suffer. As he indicated in the document, he had a good life and wanted a peaceful end. With that in mind, it was possible for the family and physician to agree to the limits of future blood transfusions and focus instead on other comfort measures.
With that approach, Moshe’s last days were comfortable, and the family could agree to support each other, with the help of the physician, during the very important final days of what had been a remarkable life.
This article originally appeared in The Canadian Jewish News.
Dr. Michael Gordon, is vice-president of medical services at Baycrest in Toronto, Canada, and co-author with Bart Mindszenthy of Parenting Your Parents.
Parenting Your Parents is available in bookstores and online at: Indigo-Chapters, Amazon and Barnes & Noble.
For bulk orders email info@dundurn.com. Call: 416-214-5544 or Fax: 416-214-5556
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(This post was edited by MGordon_MD on Sep 24, 2007, 1:34 PM)
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