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Health Blog :: Planning for your future care in advance

December 15, 2015

One thing is for sure, we are all aging. Even if you are not sick now, making healthcare plans for the future is an important step toward making sure you will be treated the way you would want, even when doctors are making recommendations for your care. At any age, a medical crisis could leave someone too ill to make his or her own healthcare decisions. More than one out of four older Americans face questions about medical treatment near the end of life but are not capable of making those decisions. You can think about how you would want to be treated when you get really ill and share your wishes with others. Write them down or at least talk about them with your loved ones and those who would make the decisions for you. You might take some of the burden off family and friends if you let your wishes known.

Advance care planning is a series of steps you can take now to reduce future burdens. It entails considering medical decisions ahead of time, and then letting others know about the type of medical care you want, often by putting them into a legal document called Advance Directive. This document goes into effect only if you become incapacitated or unable to speak for yourself.  An advance directive allows you to communicate your values and wishes related to end-of-life care and can be adjusted as your situation changes because of new information or a change in your health.

When doing advance care planning questions might arise that relate to some artificial means and mechanical ways that physicians might use to keep you alive if your heart stops or your breathing stops. Decisions have to be made about use of Electric shocks and chest compressions or CPR (cardiopulmonary resuscitation), use of a breathing tube and a ventilator, artificial means of nutrition (tube feeding) or artificial hydration (intravenous fluids), and finally pain control and relieving suffering by means of comfort care.

Electric shocks or CPR (cardiopulmonary resuscitation) might restore your heartbeat if your heart stops or is in a life-threatening abnormal rhythm. People respond differently to CPR. A young healthy person and an otherwise healthy older person whose heart is beating erratically or not beating at all, might respond and be helped by CPR. However, CPR is less likely to work well in a very sick person or an older person who is ill and can’t be successfully treated. CPR involves repeatedly pressing on the chest with force. This force has to be quite strong, and sometimes ribs are broken or a lung collapses during the process.

Electric shocks known as defibrillation may also be used that potentially cause burns and may be painful.

If your breathing stops or you cannot breathe on your own then a tube is put through the throat into the windpipe and connected to the ventilator machine so the machine can force air into the lungs and do the job of breathing for you. Putting the tube down the throat is called intubation. Because the tube is uncomfortable, medicines are used to keep one sedated (unconscious) while on a ventilator. The questions becomes if your wishes are to be kept alive and attached to these artificial machines long term and possibly for life. The tubes above are not meant for long term use. If one cannot continue breathing on their own after a few days, a physician may recommend a tracheostomy which is another tube inserted directly into the trachea around Adams Apple through a hole in the neck. A trach is more comfortable for long term use, and sedation might not be needed. People using such a breathing tube aren’t able to speak without special help because exhaled air goes out of the trach rather than past their vocal cords.

After a stroke a person might not be able to eat or drink on their own. A feeding tube and/or intravenous (IV) liquids may become necessary. These measures can be helpful if you are recovering from an illness. However, if you are ill and near death, these could actually make you more uncomfortable. When you are very ill your body may not able to digest food properly, even when provided through a feeding tube. IV fluids, which are given through a plastic tube put into a vein, can increase the burden on a failing heart or kidneys. If started, the feeding tube is first passed through the nose down to the stomach. If long term feeding is needed, the tube is surgically inserted through the skin into the stomach in the abdomen. These tubes need long term care, can become infected or non- functional and may become a burden.

Comfort care is anything that can be done to relax you and make you comfortable and relieve pain and suffering while staying in line with your wishes. Comfort care includes offering spiritual and emotional counseling; limiting medical tests and giving medication for pain, anxiety, nausea, shortness of breath and constipation. Many times this is provided by a program called hospice, which may be offered in one’s home, in a skilled nursing facility, or in a hospital. With hospice, a team of healthcare providers works together to provide the best possible quality of life in a patient’s final days, weeks, or months. Even after death, the hospice team continues to offer support to the family.

Nobody can foresee the future. It is very much possible that you may never face a medical condition where you are unable to speak for yourself and make your own decisions. But having an advance directive with your wishes written down may give you and those close to you some peace of mind if the need arises.

In upcoming blogs we will discuss some other aspects of advance care planning.

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