In trying to honor Vincent’s autonomy, we abandoned him in hell. A decade ago, as a doctor in the intensive care unit at the University of Medicine and Dentistry of New Jersey in Newark, I met Vincent — I’m using this name to protect his privacy — on his ninth stay of the year. He was a “frequent flier,” back and forth between the I.C.U. and his nursing home down the street. He would come in dying, we’d plug him into life support, treat his infection, pump up his blood pressure and send him back to the nursing home. But then he’d deflate like an old tire and be rolled back in by paramedics within anywhere from three days to three weeks.

By the time I met him, Vincent was no longer really with us. The only signs of life occurred during dressing changes and bed-turning, when, despite extra pain medication, pain fired up dormant neurons and his blue eyes flared. There was no family, no friend, no person from Vincent’s life to serve as a guide for our treatment goals. There was only his advance medical directive, which he had completed 10 years and a lifetime earlier at the age of 75. And a handwritten note stapled twice to the form.

An advance directive is a legally valid form that allows a person to choose the type of medical care he wishes to receive. It goes into effect when he is no longer able to speak for himself. Nursing homes typically highlight advance directive completion rates as a point of pride, a metric to prove that they are concerned about the patients’ preferences.

But the advance directives that we receive from nursing homes are cookie-cutter similar. Almost all indicate that a patient has stated that all attempts to prolong life should be pursued. No treatment is considered unacceptable, regardless of prognosis. There are neat signatures from two witnesses, usually the admissions clerk and the social worker. Almost never the physician.

And, sadly, that makes sense. Discussing values, preferences and personal goals in the event of debilitation is difficult, time-consuming and often harrowing. It is an ambitious load. And since nursing homes are paid to care for patients in perpetuity, are their employees really the right people to oversee the completion of these forms? (…) Read Full Article Here

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