Living Wills Helpful, but Unlikely to Solve Most End-of-Life Dilemmas
Living Will Dilemmas
"None of this is real until it is real," says Smucker.
"When the rubber hits the road, life and death is more complicated than can
ever be captured in a single document or a single conversation. Our zeal to do
this with [living wills] is probably misplaced."
So should patients even bother to have a living will?
Undoubtedly, yes, Smucker says. But what they really need is a relationship
with a physician and the ability to discuss the issues of end-of-life care when
the prospect of death is real.
"What I am a proponent of is discussions with people and
family members at the time they have a progressive illness that they know will
eventually result in having to make a decision to use or refuse life-sustaining
treatment," Smucker says.
Puchalski, who reviewed the reports for WebMD, says the
findings come as no surprise.
"[Living wills] would only work if life were neatly
packaged and totally predictable," she tells WebMD. "But in the vast
majority of cases, people are dealing with death from cancer, congestive heart
failure, diabetes, and other complex
diseases. These all have very unpredictable courses." She is an assistant
professor of medicine at George Washington (GW) University School of Medicine
and director of the GW Institute for Spirituality and Health.
She says she has had patients who tell her they don't want to
be put on a respirator if they are clearly dying. "But what does 'clearly
dying' mean?" she asks. "It may not be that obvious and is sometimes
Although Puchalski agrees that living wills have a place, she
says they need to be much broader. She explains that "Five Wishes" is a
living will form developed by Aging With Dignity that helps patients express
how they want to be treated if they are seriously ill and unable to speak for
themselves. According to Aging With Dignity, the document is unique among
living wills in that it "looks to all of a person's needs: medical,
personal, emotional, and spiritual."
The document is legally recognized in all but 15 states,
according to the organization.
"Patients and doctors need to know that their lives and
deaths are not 100% within their control," Puchalski says. "Both need
to honor the mystery of death. There is a tremendous amount of mystery in
living and dying, which flies in the face of our need to have everything neatly
packaged in a form."