New Delhi: The journey of life comes to a different turn when aging occurs. We all are aware that death is inevitable in life and hence end of life wishes trace prominence in health care system in the western world. Death is an unpredictable event in human life but making a wish of how you want your end of life to be can be notified in a living will. Advance Directives is the living will one can have of how she/he wants to rest in peace. There is a clinical significance to the fact of advance directives.
Most physicians come across with patients with a living will which provides specific instructions of the treatment plans for the healthcare provider. For example, a living will can stop financially steep life sustaining treatment. Wishes can be against receiving food and fluids through tubes. More living wills can include patient’s desire for not using medicines, use of ventilators, and cardiopulmonary resuscitation.
Dr. Bharat Bhushan, an NRI physician associated with the Sound Physician Hospital (Covenant Medical Center) in Lubbock, Texas, of the United States, has been passionate in raising awareness regarding approaches of high quality end-of-life care treatment and care as a hospitalist.
Dr. Bhushan was recently interviewed by Sreerupa Patronobish and his prominent views on advance directives is noteworthy in the context of the current healthcare system of India.
SP: Welcome Dr. Bhushan
BB: Thank you.
SP: How relevant is advance directives in modern healthcare system?
BB: The end of life care may include the following like artificial ventilation, artificial nutrition and hydration. This care can result in greater suffering for patients and increased cost to society. A known fact is that aging creates complications in health due to chronic diseases, cardiovascular diseases and other illnesses.
Critically ill patients who are suffering from cancer or any other life-threatening diseases know regarding their guarded outcomes. Sometimes advance directives are different like the way the patients wants to get relieve from the sufferings without too much medications, blood, blood products, chemotherapy and other life saving methods being implemented. So this definitely has a great relevance in modern healthcare.
SP: What are the different types of advance directives?
BB: Types of advance directives are different documents that are created according to the wish of any person which will be executed in the end of life care to that individual. This includes Durable Power of Attorney, here people can appoint anyone who is capable of taking decisions at the point the person in unable to take any decisions of their own.
Living Will, the most important type of advance directives document where the instruction are clearly mentioned like common choices being cardiopulmonary resuscitation (CPR), endotracheal intubation or any form of ventilation, refusing the actions this may be documented as follows: Do Not Resuscitate (DNR). Allow Natural Death (AND) and DO not Intubate (DNI). Other AD includes Physician’s Orders for Life-Sustaining Treatment (POLST). This is an agreement between the doctor and the patient which regulates as medical orders to respect patients wishes.
SP: What are the interventions of advance directives in a critical care unit of a hospital?
BB: As a physician I have performed a study on advanced directives and living will among patients admitted to the critical care unit. Cardiovascular diseases (CVD) is one of the major cause of death in the United States and advance directives can play a vital role in management of terminal CVD. Patients with heart failure must have advance directives to ease the end of life of patients in terminal stage.
In case of cardiovascular diseases in intensive care/cardiac care, the use of advance directives can be fruitful both for patients and the families to make decisions in seamless fashion. Families can survive, not only from moral but also from physical and emotional turmoil of the suffering of the near and dear ones. These initiatives ease the end of life sufferings and of patients of terminal stages of illness.
SP: When do you think advance directives will be a part of the Indian healthcare system?
BB: As I did my medical studies in India and spend many years in India so I am aware of the health care system in India. Many patients are unable to convey their wishes before death came suddenly. Though advance directives are not legally approved in India but there are cases which shows a light that the day is not far away. Advanced directives decision can be taken by patients’ family if they are unable to take decisions in case of terminal stage. In recent times in India we can have seen multiple cases of organ transplant according to the wish of patient’s family has taken place. So the capacity building for organ transplant is being carried out through advance directives.
This aspect is making the society enriched, with mentality of people changing. In case of organ transplantation, we have seen that organs are transported between cities in India through Green Corridor within the span of a few hours. In the event of an advanced directives being acceptable, the procurement of organs from beating heart donors (BHD) being feasible (in contrast to DCD or donation after death organs), which obviously are of inferior quality. Medico legal intervention and appropriate legislation shall make advance directives likely a routine practice in the Indian health care scenario, impacting high quality of end of life care as well as a post death activity like organ transplantation.
SP: How can end of life care be benefited from advance directives?
BB: Individuals who are in a life-threatening illness and approaching end of life need to be treated with care. End of life care is the most important part of one’s life where comfort care must be given. At this time planning is needed to know their choices and make decisions for their loved ones. Advance directives (ADs) and the use of a health-care proxy is recommended to improve communication about the patient’s preferences for health-care decisions.
Discussion of these issues during palliative care should help patient express their wishes and their advance directives. Implementing these directives is an important part to respect their words. Palliative care can improve the lives of patients and families who are suffering from life-threatening disease; the care prevents the suffering from physical and psychological problems. Though palliative care has proven to show improvement in the patient, their treatment plans permit longer survival if they are taking care from early stage. Advance directives should be offered to these patients where the sufferings can be reduced and also the cost of these care.
Some studies of the impact of the serious diseases have demonstrated that 10-20% of the families of patients with heart diseases and cancer are driven to poverty due to out of pocket health expenses, as nearly two thirds of the medical expenditure is privately funded. It is highly imperative that with an aging world that it requires prudence to carefully balance the need to prolong the life of a patient against driving the family to penury. The legacy of Luis Kutner shall imperatively find relevance in the Indian health care system in due course.
SP: Any final comments Dr. Bhushan
BB: Forth coming discussions regarding the importance of advance directives shall make the society aware of these pressing issues, rendering changes in people mentally and their prescriptive.