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An elderly woman with chronic kidney disease told her daughters that if she ever ended up with dementia she wouldn't want to live like that. Years later she developed senile dementia and moved into a nursing home. Although she did not recognize family or friends, she enjoyed the company of others and the nursing home's cat. When her kidneys stopped functioning, staff at the nursing home expressed ambivalence about the value of kidney dialysis, yet asked her daughters whether their mother should be started on dialysis.
A patient who has coronary artery disease and congestive heart failure shows his physician his advance directive that states he wants to receive cardiopulmonary resuscitation and other forms of life-sustaining treatment.
What should the doctor say to the patient in response to this?
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"?
An elderly woman with chronic kidney disease told her daughters that if she ever ended up with dementia she wouldn't want to live like that. Years later she developed senile dementia and moved into a nursing home. Although she did not recognize family or friends, she enjoyed the company of others and the nursing home's cat. When her kidneys stopped functioning, staff at the nursing home expressed ambivalence about the value of kidney dialysis, yet asked her daughters whether their mother should be started on dialysis.
Should the daughters consider her previously stated wishes as an advance directive? What questions should health care providers and family members ask to clarify patient values and preferences so that they can be more easily applied in the future?
Advance Care Planning: Case 1 Discussion The daughters should consider her previously stated wishes as well as her current best interests. The daughters don't know how to proceed because they did not have the advance care planning conversation that clarified what their mother meant when she said that she wouldn't want to live with dementia. Was it the cognitive problems, the problems with self care, living in an institution, or the sense that living with dementia would not bring any joy? Without knowing this, the daughters are unprepared to step into her mother’s shoes. However, asking the daughters to describe their mother and what brought her enjoyment and meaning throughout her life might help clarify the meaning of her words. Without really knowing their mother's wishes or feeling comfortable about what she would want as a goal of care under the present circumstances, the decision about dialysis is difficult. The daughters may choose to approve dialysis with the proviso that future triggers could lead to its discontinuation. For example, if her current quality of life deteriorates to the point where she is no longer experiencing joy, or if her behavior on dialysis requires early termination of the dialysis sessions, it may be appropriate to discontinue dialysis at that time.
A patient who has coronary artery disease and congestive heart failure shows his physician his advance directive that states he wants to receive cardiopulmonary resuscitation and other forms of life-sustaining treatment.
What should the doctor say to the patient in response to this?
Advance Care Planning: Case 2 Discussion The patient's expression of a preference should be explored to understand its origins. It is possible that the patient believes, based on television shows, that CPR is usually effective. If this is the case, the doctor should educate the patient about the near futility of CPR under these circumstances. However, the physician may learn that the patient has deeply held beliefs that suggest that not trying to live is tantamount to committing suicide which he perceives as morally wrong. In this situation, the doctor might want to ask the patient to explore this further with him and perhaps the chaplain.
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"?
The use of this expression is as vague as saying, "I don't want any heroics or extraordinary treatments" or, "Pull the plug if I'm ever in ...." If these types of comments in advance care planning discussions are not clarified, they are not helpful. For some patients being a "vegetable" means being in a coma, for others it means not being able to read. Gently discuss the patient’s hopes, fears, and specific preferences in order to clarify the meaning of the term and the patient’s preferences for end-of-life care.