My friend Anne taught me some important things about dying.<\/p>\n
Anne had congestive heart failure. In January 2012 her cardiologist told her regretfully that she probably wouldn\u2019t live past the end of the month, so she went home to set her affairs in order and to say her goodbyes. She made up her mind to refuse any medical procedures aimed at keeping her alive; she\u2019d let nature take its course.<\/p>\n
The end of January passed. Anne was still alive, but she was weak, easily exhausted and tethered to a machine called an oxygen concentrator that helped her breathe.<\/p>\n
In April, a nosebleed that just wouldn\u2019t stop landed Anne in the emergency room. After getting the bleed under control, a doctor did a blood test. The result: she was so anemic that if she didn\u2019t have a transfusion, her internal organs would begin to shut down. The transfusion would be a life-saving procedure, something she\u2019d sworn she would avoid. She started to refuse it\u2014until she saw her husband\u2019s face. She agreed to be transfused.<\/p>\n
A few days later, she was amazed to find that she could breathe comfortably without the oxygen machine. Gradually, she regained some of her strength. In late April, she wrote to friends about how much she was enjoying \u201cthis sweet little coda to a life that almost ended this past January.\u201d She was still dying of heart failure but apparently not anytime soon. In fact, she lived for another 15 months, cramming her life with all the things she cared about most.<\/p>\n
I remember thinking that, if Anne had had a living will like mine and had arrived at the ER unconscious and extremely anemic, she wouldn\u2019t have been given a transfusion. My living will\u2014a fairly standard document that spells out what medical treatments I want (or don\u2019t want) if I\u2019m unable to speak for myself\u2014lists transfusions among the things I don\u2019t want done to me if I\u2019m terminally ill. She would have missed that sweet coda to her life. I almost tore up my document. <\/p>\n
But then I read an opinion piece at Next Avenue, in which Kathryn B. Kirkland, MD, a professor at Dartmouth\u2019s Geisel School of Medicine, argued that, in some circumstances, doctors can and should reject the instructions in a patient\u2019s advance directive<\/a>. (A living will is an advance directive.) Living wills work best, she wrote, when it\u2019s clear that a patient is dying. But often that\u2019s not <\/em>clear. The person might have some good months or even years ahead\u2014as Anne did when she had the transfusion. And legally, doctors can<\/em> refuse to comply with your directive if they consider its instructions wrong in your situation.<\/p>\n Kirkland described an 88-year-old woman who arrived in the ER struggling to breathe because her heart was failing. Her living will rejected all forms of life support when her time came, including intubation with a ventilator. But was she actually dying?<\/p>\n The doctor in charge consulted the patient\u2019s daughter, who was also her health care representative, legally entitled to speak for her if she couldn\u2019t speak for herself. The doctor and the daughter agreed that the woman should be intubated\u2014despite her living will\u2014because there was a reasonable chance she\u2019d recover if she was put on the ventilator temporarily and given heart medications. And she did recover.<\/p>\n I\u2019m sure some people were appalled when they read Kirkland\u2019s piece. Most of us who sign a living will assume medical professionals have to do what it says\u2014after all, it\u2019s a legal document. That\u2019s always been my assumption, and I\u2019ve sat at the bedsides of relatives whose doctors did <\/em>honor their wills, no questions asked.<\/p>\n