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Wednesday, October 5th 2011

End of Life Care

A new study in JAMA looks at regional variations in how ‘living wills’ effect care. It appears that where care is aggressive to begin with making your desires known in a living will can limit that aggressiveness but where patients are already traditionally led towards comfort and less aggressive care the living wills have less effect on practice.

Nicholas and colleagues suggested that one interpretation “is that advance directives are most effective when one prefers treatment that is different from the local norms.”

It may be that putting limits on treatment “requires an explicit statement” from patients in areas where the default is to treat aggressively, the researchers wrote, but less so when the local culture already prefers palliative care.

Some data in the study indicated that advance care directives limit treatment in ways not envisioned when these were first introduced. Initially, their purpose was to prevent mechanical ventilation or tube feeding in patients who indicated beforehand that they did not want such artificial life-prolonging measures.

Nicholas and colleagues found that even when directives reduced the quantity of care given, they did little to discourage specific interventions such as intubation and ventilation.

What appears to be happening, the researchers argued, is that these interventions may be withdrawn faster when patients have left directives.

I feel like I have a lot of exposure to end of life issues. I would say the above is some of what I see. Rarely does a living will prevent emergency intubation and ventilation. This is largely because sometimes the issue of potential wishes is unable to be addressed during an emergency. Another is that even when the issue is breached families, even in the presence of a living will, choose initially, in an often pressed decision, to err on the side of intervention. Then they can always make a decision in the coming days or weeks about what their loved one would really want and move towards comfort care at a later date.

And so I agree in my experience a ‘living will’ is something that can be a comfort and encouraging to family making decisions for a loved one; reminding them exactly what the patient would have wanted. It leads much more to withdrawal of care and comfort measures more than it prevents aggressive initial care.