According to a report in the Archives of Internal Medicine, advanced cancer patients who had end-of-life conversations with doctors had 35 percent lower medical costs in their final week than other patients. Those with higher costs had what the authors of the study describe as "worse quality of death."
Death and money, always an explosive pairing, have been on prominent display in the vitriolic debate over health care reform. Congress has been looking for ways to cut Medicare, and legislators kept reminding each other that a third of those funds are spent on older patients with chronic ailments during the last two years of life. It made a lot of elders nervous.
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And that was how, against all reason, the physician-advice idea was dropped – even though, as that recent report suggests, it only makes sense to talk about how you want to die before it happens.
Advance directives recognize an unpleasant fact: If you end up in a coma or some kind of semiconscious living hell, you're probably not going to be able to make a reasoned life-or-death decision. That leaves it up to your family or friends, and unless you've talked it over previously they have no clue to your preferences.
When the doctors told my brother and me that our mother was beyond their help, we didn't hesitate to let her go because we knew it was her wish. She would say, with exasperation, "I never knew it took so long to die."
There are two basic kinds of advance directives.
A living will lets you dictate ahead of time how you want to be treated under various dire circumstances, such as becoming terminally ill.
A health care proxy lets you name a person to make those decisions for you.
For years, gerontologists, doctors, and legal authorities have tried to get us all to think about our mortality long enough to prepare advance directives. Less than a third of Americans have done so. Even in nursing homes, fewer than half have signed on.
In case you're wondering, you bet I've filled out the directives. When there's nothing left of my mind and body worth saving, I want to go gentle into that good night, Dylan Thomas notwithstanding. I've too often seen the alternative.
I'm thinking of a friend, a lively, feisty, full-of-life man in his 70s. I saw cancer and cancer treatments shrink him into a helpless, suffering infant. "You're a fighter," his nurse would say to him. "You keep fighting." The doomed struggle went on, endlessly, unnecessarily, for weeks.
Euthanasia is illegal in the United States; if you kill someone to end that person's pain, you face a murder charge. Physician-assisted suicide to end suffering is also illegal, except in Oregon and Washington; in Montana, a ruling on the issue by the state Supreme Court is expected momentarily.
The withdrawing of life support, when doctors turn off or remove equipment and treatments that are keeping the patient alive, is held to be legal because the final cause of death is natural – the deadly disease or injury itself. Two types of aggressive sedation – one that may speed up death and another that renders the patient unconscious and no longer taking in food or fluid – are also legal.
Some of these end-of-life measures are wildly controversial, the subject of passionate debate on ethical, religious, and practical grounds.
Suppose the patient is helped to commit suicide and the doctor's diagnosis turns out to be wrong. Suppose a do-not-resuscitate (DNR) decision is simply more convenient for the physician, or in the hospital's economic interest. In one study, the strongest predictor of a terminal patient being discharged to home hospice care was neither the patient's desires nor the patient's prognosis, but the number of beds available in the hospital.
My stake in the debate is to pray that the options needed to grant my end-of-life wishes will be available when required.
There are already more than enough potential roadblocks in the way of advanced directives.
You may have squirreled them away where they can't be found. The physicians may not know you made out a do-not-resuscitate order – or may see it and choose to ignore it. The doctors may be worried about being sued for withholding life supports or may not want an operating room death on their records.
They may also take your age into account: A 1995 study found that do-not-resuscitate orders were written more quickly for patients older than 75 than for younger patients – regardless of their prognosis. The same study found that more than 45 percent of patients who asked not to be resuscitated were in fact resuscitated.
I've done the only two things I can think of to better my odds: I've filled out the advance directives – the forms are available all over the Internet. I've made sure my health-care proxy is someone who will fight for my right to choose my way of death.
Whatever your age, I hope you'll do the same.
