I had just arrived to a mid-afternoon shift in the ER when I was called emergently into the room of an unresponsive 94 year old fellow. The paramedics told me that they thought he had either a bleeding stroke or an infection in his blood stream because he was so comatose.
Eyeballing my new patient as the paramedics gave report, he appeared as many of my patients do who are near to death- he was reclined on the bed with shallow breathing, mouth relaxed and wide open, with eyes gently closed. His medical documents from the assisted living facility, where he resided, read like a medical text book for most of the extremely aged: dementia, diabetes, chronic urinary tract infections, prostate cancer. But, what was NOT listed in his paperwork was ANY kind of advanced directive...NADA, nothing, no mention of end-of-life wishes documented anywhere although he was clearly at or near the end of his life.
I moved forward to rest my hand on his chest and bent down near his ear to speak to him. I didn't expect any response when I said rather loudly, "Mr Green?" yet, his eyes fluttered open, much to the shock of the paramedics who said that during transport he didn't rouse at all. He even turned his head to look at me...I was relieved.
Why was i relieved? Because, in the absence of any advance directives or surrogate decision makers, in an emergent situation (such as a completely unresponsive and comatose patient), my job is to put them on artificial life support first and then ask questions later. So, in the case of Mr Green I was relieved that he was beginning to respond, this meant I had time to call around and find a surrogate, or his doctor, or do some research in his medical record to determine if anyone had ever discussed or written any wishes.
But, it is CRAZY that I ever even have to do this. Certainly any person who is in any type of assisted living facility or nursing home (i.e. frail, or near the end of life) should have official advance directives documented, which are also sent with them ANYTIME they must be transported to the hospital or a doctor's office.
After examining Mr. Green and writing orders, I left his room and headed back to my computer to look up old records in attempts to find any possible advance directives or documented discussions, but was instead called into his neighbor's room. I entered the adjacent room to find an 82 year old female having chest pain concerning for a heart attack ( also from an assisted living facility). I walked in just in time to hear the staff ask, " Do you have an advanced directive or a living will?" She answered, "No," as she looked toward her 90 year old husband who sat beside her (looking as though he should have been a patient himself). He was also shaking his head "No" to the question of advance directives.
I wanted to scream!
So listen people! We have not invented the "eternity pill", and you are not going to live forever. So you had better make some decisions for yourself while you still can and get these written down on an OFFICIAL document that travels with you. If you do not have these discussions or get your paperwork in order and you come into my ER unresponsive at age 94, you just might end up like this...
Now, i don't know about you, but when I am 94, this is not the way I want to leave this world.
How do you avoid this for yourself? (Assuming that you do not want to die in the ICU, on a ventilator, with your arms tied down, at age 94)
1- Write down all of your wishes for yourself in advance. Make them official in a living will or state approved advance directive.
2- Share these with your doctor, who will write official medical orders reflecting your wishes, if appropriate (example: Do Not Resuscitate, or Allow Natural Death orders, or a POLST form)
3- Share these wishes with your family members and your selected surrogate medical decision maker (your health care proxy or power of attorney). Make them promise to follow your wishes if you do not want them to change your plans.
4- If you or a loved one is a resident of an assisted living facility or skilled nursing facility (like a rehabilitation center or nursing home), PLEASE make sure that advance directives are on file, are well known by the staff, and are included in the medical records that accompany you or your loved one when going to the hospital or to a doctors visit.
Next week, I will tell you why I love the POLST and think it should be legalized in every state as "the" standard advance directive. See POLST.org for a sneak preview.
Monica Williams-Murphy, MD
(picture citation: 02varvara.wordpress.com, google images)
(As always patient stories are altered to protect privacy and publication date has no relevance to the actual date of the patient encounter)