End of Life Directives

An uncle has categorically told us in writing that if he becomes unconscious, he is not to be resuscitated. This “do not resuscitate (DNR)” guidance is an example of an end-of-life (EOL) directive.

If my uncle were to really become comatose, I would still make sure he gets to an ICU and until the exact problem is known and has been diagnosed, I would find it impossible not to intervene. I have told him this in so many words, which has led to serious arguments…the one thing we do know is that when he is unconscious, he will not be able to question the decisions we make. If he recovers and is in good shape after the incident, then all arguments become moot, and if he doesn’t recover, then there is no argument anyway.

There are certain situations where an EOL directive may perhaps work. A person with end-stage cancer that has spread everywhere and has stopped responding to any form of medication, with all possible options including alternative ones exhausted, and is in pain, may elect to stop any further medical support, except for pain-killers and decide to spend the remainder of his/her life at home or in a hospice. This would be a decision that perhaps would be respected by all. But in more acute situations, when there may be a chance that the person might recover, these decisions become extremely difficult to make. In reality, even those who have decided to end their lives, find it difficult to go ahead when the time comes.

Recently a person I knew suffered a cardiac event, then started bleeding and eventually arrested a couple of times. He had given his family a DNR directive, but when the time came, no one had the guts to “not try” one last time. This extended his life by a few days and it was only in the end when it was obvious to everyone that nothing would bring him back that the decision was taken to let things take their natural course. The son was upset that he couldn’t abide by his father’s wishes, but it is difficult at that point in time to “do nothing”.

The issue is also of who takes the decision. If the sick person himself/herself decides to stop medication or perhaps stops eating and drinking, that is one thing. But if the decision has to be taken by the relatives and immediately family, when the patient is not in a position to talk or in a state of mind to be part of the decision making, then it becomes just that much more difficult.

I was discussing this with a friend of mine, who along with is brother, both doctors, had decided never to resuscitate their father who was ailing for a long time. In the end when an acute event occurred, neither had the guts to hold back and the father went on a ventilator to live for a few more months.

It is not easy! If family members elect not to follow DNR orders of their parent / relative, it does not mean that they are breaking a promise. Religious issues, family ties and personal courage all play an important role and to my mind, there is perhaps no right or wrong here! Judging these decisions from outside may actually be the only wrong!

In the end, it is all very well to have DNR and EOL directives…they sound great in theory, but are extremely difficult to implement in practice! And if you as a close relative can’t abide by them, so be it!

12 Comments

  • Bhavin: A great point, well-said. We have gone through a somewhat similar situation. There was no EOL or DNR directive though. One very senior relative was terminal. For two months, we did all that we could do. Our relative came through to a point where his age was a blocking point, 92. And after two months of continuous heavy medication, the blood count went very low, even pushing blood was not an alternative. So we had to decide to let him go. Last two days were a bit difficult but DEATH IS A NECESSITY at such points. Stay active on your key-board. Regards: Sugata

  • Lakshmi Menon wrote:

    I have prepared a “Living Will” with DNR instructions and also that any useable organ be offered for transplant and that my body should be donated for research purposes. There should be no funeral, instead the family and friends could hold a Memorial session as a closure to my existence.
    My family is naturally aware of my request and hopefully will respect my wishes. Beyond that I have no control. Lakshmi Menon

  • H.L. Chulani wrote:

    There are many ‘If’s’ in your blog. There is no ‘if’ in your uncles desire not to be resuscitated should he becomes unconscious. His wish should be respected. A sect, Jehovah’s Witness do not take blood from another and their wish is respected even in a dire emergency. As an analog, if I desire to donate my organ before dying (as permitted by law) or after death my relatives should respect that and not bring their beliefs or prejudice into a decision which go against mine. Sorry, but your emotion is misplaced.

  • khushboo wrote:

    I totally agree with you. All sounds good in the start, just while saying..but its the time to implement, emotions come in between. My aunt to has told us that if she has to go through some medications for some illness, she would take anshan(willingly not eating or drinking till death). But i know, we would not let her take that decision ever.

  • jamna varadhachary wrote:

    A friend’s husband was ill and going. she wanted no ventilator as per the decision after discussions with the spouse. She came out for a bit from the icu In that interim the ventilator was put in. This prolonged his life by half a day and his sons were able to come “in time”.It was taken out of her hands. Call it destiny.

  • I think, that the last word is with the person concerned,no matter what.It is a very difficult decision as several close ones are involved,mindset. and everyone has his or her

  • V.Subramanian wrote:

    A DNR or EOL directive or Euthanaisa are not legally enforcable as they tend to be equated with suicide attempts which are illegal.They also raise moral and ethical issues as well. However it is the inability to ascertain the longeivity of the patient,given his medical state, that causes confusion.It is difficult to discern for anyone unconnected with medical profession,that even reknowned doctors,at times cannot make clear judgement calls. Relatives of most patients with serious ailments at an advanced age, grapple with the question as to when to pull the plug of (life) the VENTILATOR.Trust deficit with the intent of the hospital authorities,balooning medical costs, and attitude of Insurance companies complete the tragic sequence of the hapless relatives.Can’t ever forget the incident when the Body of an young erudite close relative who had died of Blood Cancer, had arrived and the Driver of the “Hearse” started pestering me for an enhanced Bakshish.

  • I would agree with your views that it isn’t possible to just “let go” of someone without even a semblance of a fight back. Yes there are cases when you can take a call mid way that the treatment doesn’t work / is causing more agony than relief and so at such times justifiable. But not doing anything about it just doesn’t make sense. I have people in my own family who have said this but when push comes to shove, I would not give up without resistance.

  • C.J.Patel wrote:

    Messy subject..of no real value..millions are born and millions die..how and why is irrelevant..correct point of view only ends one life a few days earlier or later!! later determination just a matter of ego

    C.J.P.

  • This End of Life Directive is called a ‘Living Will’. Just as a person making a will bequeaths his/her assets after (s)he has passes away, is respected and observed, so too a Living Will is a heartfelt wish of the person who absolves his/her family from taking decision other than what (s)he has expressly stated.
    I think, that wish should be honored. When we think of bypassing that wish, to do our bit to save our near and dear ones, is a premise based on the fact when we think we can save a life by interfering with divine providence.

  • Jayesh Desai wrote:

    In all such situation the purpose behind taking any decision is important, prolonging for couple of day till near and dear relative can come and see one last time is OK. But if motive is our selfish emotion that we do not want to let go of near dear one even though medical science has clearly reached it’s limit, and person concerned has no quality of life whatsoever is cruel and inhuman, or not to take decision because who will bell the cat kind of attitude and competitive show of emotion is unjustified. then again to respect the wishes of person concerned is very important but a doctor is not supposed to give up easily, his/her duty is to try as much as possible. Now that is why in case of doctor’s own relative this decisions become very difficult and we should sympathize with them and give support in any way we can by just standing with them.

  • […] pro­long­ing a life with­out dig­nity is not right…in prin­ci­ple. But I wrote the arti­cle last week because of the angst felt by a cou­ple of friends in the recent past, when they had to decide how […]

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