In past posts on this blog we have written about resuscitation as a decision that must be made for other is cases of disability.  There are also a host of other choices about medical interventions that must be made. 

Medical Intervention is a broad category but the some of the most commonly used interventions are Intubation,Tracheotomy, Surgery, Dialysis, Chemotherapy, Radiation, Biopsy, MRI, and Colonoscopy. 


Intubation and tracheotomy are used primarily to create artificial air ways.  Failure to use them often leads to rapid death.  Both procedures involve a painful recovery.  Both may last either a short time or for an extended period depending on the reason for the airways blockage.

Surgery, dialysis, chemotherapy, and radiation are primarily treatment options but may also be used even where recovery is not possible to extend life and to relieve symptoms.  All involve some pain, discomfort and a recovery period.  With the exception of surgery all are ongoing and can be tried for a period and then ended.  For example, you might leave instructions to try medical interventions for a period of 30 days and then terminate if there is no sign of recovery unless intervention is also serving a pain relief function.  In the alternative you might request that where there is no meaningful hope of recovery your would choose comfort care only which might include such interventions if the primary purpose was to relieve pain or other symptoms.

Biopsy, MRI, and colonoscopy are all diagnostic tools that may be necessary to allow treatment. None is pleasant but pain and recovery, if any, is usually minor.  However, some people may feel that even the mild trauma and pain is something that they wish to avoid if they are in a condition such as advanced dementia where they would not choose to treat any condition such as cancer that might be discovered.

In making decisions about such interventions it may be helpful to talk to a doctor or to a friend or loved one who has gone through the experience.  This is also an area where it may make sense to have an ongoing directive that addresses broad categories or gives general instructions about how to make choices but to consider updating your instructions to be more specific if you get a diagnosis that is likely to bring your  directive into effect when you will have a better sense of what specific interventions might be needed in h. 

Almost any website dedicated to teaching CPR bemoans the horrible CPR techniques employed by TV doctors, cops, and other heroes and the bad messages it sends the public about how to do the procedure.  But CPR on TV may have some other negative side effects as well.  It is grossly misleading about survival rates and procedures impact on the body.

Various studies of CPR on television medical dramas have 67% to 77% of patients making a full recovery after CPR.  The true long term survival numbers in US hospitals is around 14%.  Perhaps more significantly patients in both medical dramas, and even more often other action shows, show little impact from the procedure other than being slightly dazed and coughing.  In reality CPR almost always involves cracked ribs, internal bleeding, and long recoveries and often involves serious neurological damage and often extended mechanical life support.   

It is easy to dismiss the success of TV CPR as just good drama but it has real life impacts, just like the bad technique that accompanies it.  In surveys the general public indicates that they believe CPR works 60% to 80% of the time and show little awareness of the impact on patients. 

"If CPR were a benign and risk-free procedure that offered the hope of long-term survival in the face of otherwise certain death, few people would ever choose to withhold resuscitation," said Dr. James Tulsky, co-director of the program in medical ethics at Duke and co-author of a study of CPR on TV. "Controversy surrounds the use of CPR precisely because it can lead to prolonged suffering, severe neurological damage, or an undignified death."  That isn't what people see on TV.

Families are often asked to make choices about resuscitation in the middle of a crisis and their choices may often be influenced by the false images of CPR they experience in pop culture.  Without the true facts or contrary guidance from a patient's advanced health care directive, they may believe CPR is the right choice in every case. 

"In hospitals across the country, patients and physicians struggle with end-of-life decisions that involve whether or not to attempt CPR and other life-sustaining measures," said Dr. Susan Diem, a researcher at the Durham VA Medical Center. "In subtle but powerful ways, the misrepresentation of CPR on television shows undermines trust in scientific data. Because they appear realistic in many respects, these shows blur the line between fact and fiction."

We believe it is important that clients and their families have good information to make wise choices about care both while planning and while make choices. To learn more about how to make sure good choices are made for your care, contact us for a free consultation at info@phinneyestatelaw.com or (206) 459-1908.

Phinney Estate Law Attorney Jamie Clausen will be the featured presenter at this month's meeting of the NW LGBT Senior Care Providers Network.  She will be presenting a talk on what care providers need to know about Disability Planning documents for LGBT Seniors.  The meeting is free and open the public.  It will be held on September 23, 2011 at 9 am at Fred Lind Manor
1802 17th Ave., Seattle, WA 98122. (206)-324-1632

When a patient cannot give informed consent for their own health care treatment and those choices have to be made by others, one of the most common and difficult choices that must be made is whether to approve resuscitation.

WHAT IS RESUSCITATION
Resuscitation is a medical intervention performed on a person whose heart has stopped beating or whose breathing has stopped.  The process includes compression of the chest over the breastbone, the placement of a tube in the windpipe with artificial breathing, and electrical shocks to the body.

DOES RESUSCITATION WORK?
Resuscitation can be an effective life saving devise and is estimated to double a patient's chances of survival.  As a result, many people know someone whose life has been saved by resuscitation.  However, it is most effective on younger adult patients with certain types of heart problems and in response to complications from other medical interventions.  Studies vary but only about 10% to 15% of people who receive resuscitation actually recover to be discharged from the hospital.  And those rates drop to less than 5% for those who are elderly or who are already suffering from other major illnesses

WHY MIGHT A PERSON DECLINE RESUSCITATION?
Resuscitation is a major medical intervention.  In the best of cases, patients can expect cracked ribs, possible internal bleeding, and a significant recovery period.  For people who are older or already facing chronic or advanced medical problems these impacts can be much more severe.  And although resuscitation can restore a heartbeat in up to 25% of such patients, very few survive long enough to be discharged from the hospital.  Those that do typically suffer serious brain injury and may only recover enough to be discharged to a nursing home and remain on life support until death.  

For patients who are already suffering unmanageable pain or face diminished quality of life, the pain and recovery of resuscitation may not be worth the suffering.  Even elderly clients in good heath may choose to decline resuscitation out of concerns that, even if successful, the changes of their being on extended life support or living in a nursing home with major neurological damage is inconsistent with their choices about end of life.  In such cases resuscitation may also be hard on the patients families as well.  Declining resuscitation can be honestly thought of as letting the patient die a natural death without in anyway being the cause of it.  Once resuscitation is performed and the patient is on life support machines and there is not open of their living without them, the family must make the choice to affirmatively end treatment which often feels very different.

Because resuscitation is such a common and significant choice, we encourage clients to give serious thought the circumstances in which they would or would not want to be resuscitated and to share those with others in an advanced health care directive.  They should also appoint an agent they trust to carry out those choices.  If they are already in a heath state where they would not want resuscitation, we can help them learn about tools to create a standing order to prevent resuscitation even outside a medical setting.    To learn more about these choices and legal tools, contact us for a free consultation at info@phinneyestatelaw.com or (206) 459-1908.

Planning for disability or incapacity tends to be an abstract process for many people.  In our opinion the best disability plans are ones where the person has truly imagined the kind of scenarios that would lead to the plan being used.  Understanding that helps them to think through what kids of decisions would need to be made, what qualities would you need in a decision maker, what kind of guidance would they need, and what conflict could arise.

Temporary Incapacity Due to Illness or Accident
When people think of this kind of planning they often focus on the end of life but many of us will need someone to make choices for temporary incapacity due to illness or accident as well.  At Phinney Estate Law we got a reminder of just how real that possibility was when Mike came down with a horrible stomach virus.  By the time we got childcare for our daughter and got the ER we was so dehydrated that he couldn't give coherent answers to the doctors trying to give him an IV about his medical history or consent for care.  Luckily we had his medical power of attorney on file with Group Heath and Jamie was able to take over making care choices for the hour it took for him to get enough fluids in him to be lucid.  Similar situations can arise when some has an allergic reaction, is render or is knocked out in an accident.  People in these situations usually want full active treatment and are able to resume decision making as soon as their situation is stable.  But for that short period, a good disability plan can make treatment more streamlined and effective.

Cancer
Approximately 20% of all Americans will die of cancer and many more will have successful treatment of the disease.  Cancer deaths peak at age 65 and diagnosis is usually proceeded by relative good health.  Diagnosis is usually followed by intense medical treatment with either recovery or a short terminal phase.  Cancer treatment frequently requires surgery and it is not uncommon that doctors will discover additional tumors during an operation.  Because the patient is usually under and can't give consent, the frequently need to seek authority from others to address those issues rather than risk further surgery.  Chemotherapy and Radiation are also frequently used.  Both can cause unexpected side effects that can render the patient temporarily unable to make medical and other life choices.  If the cancer cannot be treated, the end of life is often accompanied by intense pain that can be managed by medication but not without making the patient too groggy too make their own choices.  This is a period when choices about care can be complicated and when patients often benefit from hospice.

Organ Failure
Deaths from organ failure, generally heart, lung, and kidney disease, peak among patients 75 years old.  These deaths account for about one in four deaths in America. Deaths from organ failure often runs a far bumpier course than cancer. These patients’ lives are punctuated by bouts of severe illness alternating with periods of relative stability. At some point rescue attempts fail, and then death is sudden. While the patients are often able to make all the decisions necessary for early interventions and chronic treatment, frequently others must make choices during crisis including how to manage the final emergency. 

Dementia & Frailty
For many people death following extended frailty and dementia is their worst nightmare. It can be an long and dignity robbing series of losses for the patient, and an exhausting and potentially bankrupting ordeal for the family. But approximately 40 percent of Americans follow this course, and the majority of those living beyond 85 years of age. 

These patients must depend on the care of loved ones, usually adult children, or the kindness of strangers, the aides who care for them at home or in nursing facilities.  Those suffering from physical frailty lose the ability to walk, to dress themselves or to move from bed to wheelchair without a lift. These patients require diapers, spoon-feeding and frequent repositioning in bed to avoid bedsores. Those with dementia, most often Alzheimer’s disease, lose short-term memory, fail to recognize loved ones, get lost without constant supervision and eventually forget how to speak and swallow. They typically need custodial care and someone else to make all of their medical choices and take over their financial management.  These decision makers face many tough choices about when to seek or decline medical care for patients, especially as their quality of life diminishes, and these choices are made more difficult when the decision making takes place over a long period of time with no meaningful input from the patient.

Each of these scenarios present their own challenges, stresses, and conflicts.  In our experience each is made more bearable for all involved if their advanced planning that assigns the right person to make choices and provides them with a guide as to what choices they should make.  If you are interested in setting up a free consultation to get started on such a plan, please contact us (206) 459-1908 or info@phinneyestatelaw.com.

Many people don't realize that fewer than 10% of us will die a sudden death from something like a car accident or unexpected heart attack. The chanced of such a death go down even further for people over 65 years of age.  The rest of us will die from a protracted life-threatening illness.

Almost all of us who die of a protracted illness and even many of us who do die a "sudden death" will face medical choices at a time when we lack the capacity to provide informed consent. 

Informed Consent is the necessary agreement to care or the withdrawal of care that a patient must give to a surgical or medical procedure or participation in a clinical study after achieving an understanding of the relevant medical facts and the risks involved.  Such consent requires that a patient have the mental capacity to truly understand the treatment involved and the ability to communicate their wishes.  When a patient has cognitive impairment, whether from a head injury, side effects of medication, dementia, or even dehydration they many have the understanding necessary.  If they are unconscious they cannot communicate. 

At those times, someone else must make those medical choices for them.  A disability plan designates who should make those choices and provides guidance about what those choices should be. The plan also says who should be managing their finances and care for their children and pets. 

Because of the importance of the jobs being delegated and the frequency of need, a good disability plan should be a key part of any estate planning practice.  It can also be done as a stand alone project.  If you are interested in scheduling an appointment to learn more, contact us at info@phinneyestatelaw.com or (206) 459-1908.

Informed Consent:
Consent by a patient to a surgical or medical procedure or participation in a clinical study after achieving an understanding of the relevant medical facts and the risks involved.  

Ideally informed consent would always come from the patient themselves.  In reality, more than 90% of us will go through a period where important medical choices must be made but where we lack the capacity to give it due to either an inability to understand the relevant facts or risks or an inability to communicate their wishes.   The best way to make sure that in such a circumstances the right choices would be made by the right person it is vital that adults make and regularly update their disability planning for heath care.  

At Phinney Estate Law, disability planning for health is included in all estate plans and offered as a stand alone service.  To learn more contact us for a free consultation at info@phinneyestatelaw.com or (206) 459-1908.