Date: Fri 05-Apr-1996

Publication: Bee

Author: KAAREN

Quick Words:

eithics-seminar-Ashlar

Full Text:

w/photo: Ethics And The End Of Life

B Y K AAREN V ALENTA

Despite all of the discussions in recent years about living wills and

end-of-life decisions by the elderly and terminally ill, a surprising number

of doctors don't know what their patients really want.

The need for health care givers to find out whether patients want to be

resuscitated or placed on life support, and to see that these directives are

followed, was the focus of a seminar on health care ethics last Friday at

Ashlar of Newtown.

"Mind, Body, Spirit: the Professional's Role in End of Life Decisions," was

held to explore the medical, legal, spiritual and personal rights and

responsibilities in caring for the elderly and the terminally ill. The

panelists included Dr Jeffrey Friedman, medical director of Ashlar; the Rev

Ray Cooley, director of spiritual services for the Masonic Geriatric

Healthcare Center in Wallingford; Cheryl Koeber, a social worker for the

Regional Hospice of Western Connecticut, and Michele Murphy, a registered

nurse and attorney who specializes in elder law.

Atty Murphy said that studies have revealed some surprising information. A

study of 10,000 patients in five US medical centers, published in the Journal

of the American Medical Association, showed that only 47 percent of physicians

knew when their patients preferred not to have CPR (cardio-pulmonary

resuscitation).

Another survey done in nursing homes showed that 60 percent of the patients

surveyed wanted CPR if their heart stops beating and 89 percent wanted

hospital treatment, she said.

"Nursing home residents seem to be saying don't give up on me," Ms Murphy

said. "Obviously we don't know what people want, and we can't assume that what

they want is no treatment. We have to make sure their wishes are stated in

legal form and followed."

The state's Attorney General's Office has prepared a summary of the

Connecticut law and a series of forms that include an advance directive, a

durable power of attorney, appointment of a health care agent and

attorney-in-fact for health care decisions and a designation of a conservator.

By federal law, everyone entering a hospital or nursing home must be given the

opportunity to use these advance directives. Once completed, these forms are

there for when you are unable to tell care givers what you want, Ms Murphy

said, but they must be given to the health care givers, the clergy and others

who are providing care, not hidden away in a drawer or safety deposit box.

Someone who has been given a durable power of attorney cannot make decisions

about withdrawing life support or feeding tubes, she noted, and living wills

are only followed when a patient is judged to be in a terminal condition or

permanently unconsious.

"Living wills can be changed or revoked. Power of attorney can be revoked,"

she said. "Unfortunately this topic is right up there with `What funeral home

do you want?' when you are talking about the least pleasant question to ask a

client."

Making Big Decisions

Ms Koebler said the average amount of time spent in hospice care seems to be

dwindling and, as such, the time available to make decisions has been

shortened.

"People often don't understand what possible treatment involves and whether

they want it," she said. "They need to know, for example, what additional

treatment will mean - will it extend my life? What will be the quality of my

life? Where will I live and who will take care of me?"

Often, she said, the entire family gets so bogged down in the progress of an

illness that they are not able to communicate about larger decisions. Care

givers should try to facilitate communication, end alienation in families "at

least for the short-term" and not interject their own opinions or be

judgmental.

Dr Friedman said physicians need to be investigators, determining in advance

the wishes of the patient and the wishes of the family. They should provide an

understanding of terms such as CPR and ICU (intensive care unit).

"Most people - especially the elderly - have no concept of CPR. They often

think DNR (do not resuscitate) means no treatment," he said. "CPR is very

different for people of various ages. The outcome of CPR for people in their

90s is dismal. The chances of recovering to their former status is extremely

small. But CPR and advanced life support are good for people who have a chance

to recover with therapy."

Doctors need to explain clearly to the patient's family the current status,

prognosis, the ramifications of CPR, possible life support measures and the

meaning of DNR, he said.

Dr Friedman said care givers should have a team approach involving medical

personnel, social services and religious services. "Our health care system has

until recently never addressed this," he said. "Patients see their doctors for

10 or 15-minute appointments. The real decisions get made by interns on duty

in the middle of the night when people come in to the hospital in critical

condition."

Rev Cooley, chairman of the Ethics Committee at the health care center in

Wallingford, said he serves on an ethics "swat team" which responds to

situations involving terminal patients. But every case is different, he said.

"In one case a woman, who was terminal, had signed a living will," Rev Cooley

said. "She appointed her husband as her health care agent. He directed that

she be provided with treatment that was prolonging her life. Some staff felt

her wishes were not being carried out."

But Rev Cooley explained that the woman's daughter was not ready to let her

go, and the husband felt his wife would want to live longer if it would help

her daughter get ready to let go."

Most elderly people don't want to die, Rev Cooley said. Letting go is a major

part of death, and sometimes a spiritual advisor can help people become ready

to let go.