Why You Need Advance Directives!

It's important for everyone to execute advance directives and
powers of attorney. An advance directive, otherwise known as a living will, documents
a person's desires related to end-of-life medical decisions. A medical power of
attorney, is where someone is appointed to make healthcare decisions if the
person is no longer able to do so, due to either a physical condition or
reduced mental capacity. Also, a financial power of attorney is similar to the
health care power of attorney but deals with financial issues banking,
property, taxes insurance etc.

It's especially important for people with Alzheimer's to have
these documents prepared if they don't already have them. This should be done
early in the course of the illness, when a person is still mentally competent
to make such decisions.

When people with Alzheimer's have not executed advance
directives and are unable to make end-of-life healthcare decisions on their
own, it becomes problematic for the caregiver. The onus is on the caregiver to
make decisions, such as the use of CPR, antibiotics, hospitalization, a
ventilator or feeding tube and, ultimately, engaging hospice care services.

As described in a Huffington Post article

CPR: Doing CPR on an
elderly, debilitated Alzheimer's patient may do more harm than good. Risks
include broken ribs, collapsed lungs, brain damage and permanent need for a
ventilator. "The chance that it would even work for such a patient is
extremely low. The chance that it would return the patient to his or her former
quality of life is practically nil," Doug Smucker, MD, a professor of
family medicine at the University of Cincinnati Health Sciences Center, told
me. If the caregiver decides against CPR, it's necessary to ask the patient's
physician to put a DNR (Do Not Resuscitate) order in the chart.

Antibiotics, Hospitalization, Ventilator: It's probably best to make decisions about these issues at
the time of need rather than in advance. The decisions should take into account
the patient's general condition at the time. Is the patient alert and
responsive? Is he or she in pain? What is the person's quality of life? Is the
patient likely to recover from whatever is causing the need for the antibiotic,
hospitalization or ventilator? For example, if a frail patient has pneumonia,
you can try antibiotics and a ventilator if needed, but if the person's
condition continues to worsen, you can then withdraw the medication and
ventilator and allow the person to die in peace.

Nasogastric Tube Feeding: "During
the natural process of dying, the body is shutting down and no longer wants
food," says Darby Morhardt, a social
worker at Northwestern University Alzheimer's Disease Center. The use of
nasogastric tube has potential negative side effects, including pain and

Percutaneous Endoscopic Gastronomy (PEG) Feeding: Using PEG feeding (feeding through a tube inserted into the
stomach or small intestine) "can result in back-up to the esophagus,
increasing the risk of aspiration pneumonia," states Dr. Steven Post, a
professor of bio-ethics at Case Western University School of Medicine. He adds
that it also prevents the patient from walking, and can result in weeks of
unnecessary suffering. On the other hand, he points out that "cessation of
food intake results in the release of endorphins, which reduce pain."

Hospice: Hospice care focuses
on providing comfort at the end of life rather than using heroic means to
prolong it. If caregivers start hospice services, then change their minds, they
can sign their loved one off (or back on) hospice care at any time. However,
the Alzheimer's Association Ethics
Advisory Committee
has concluded that "all efforts at life
extension in the advanced stage of Alzheimer's create avoidable suffering for
patients who could otherwise live out the remainder of their lives in greater
comfort and peace."

Symptoms that Qualify the Patient for Hospice Care: Gregg Warshaw, MD, Director of Geriatric Medicine at the
University of Cincinnati and former president of the American Geriatric
Society, told me it may be time to consider using a hospice service if the
patient is showing any of the following signs:

  1. Two
    or more episodes of pneumonia or other serious infections within a 6-month
    time frame.
  2. Difficulty
    eating and swallowing, even with feeding help, that results in weight loss
    of 10% or more over the preceding 6 months.
  3. One
    or more skin pressure ulcers that are not healing.

The Most Important Decision: All of the above decisions are very difficult and can be
agonizing to the person who has to make them on someone else's behalf. But the
most important decision is to stop focusing on the loved one's approaching
death and start figuring out everything that can be done to help the patient
have the highest possible quality of life in the time that's left. This dynamic
shift in thinking will benefit both the patient and the caregiver.

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