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Living Wills Helpful, but Unlikely to Solve Most End-of-Life Dilemmas

Living Will Dilemmas

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A second report found similar results when 24 physicians tried to predict patients' wishes for end-of-life care with and without a living will. In that study, the ability of primary care physicians to predict the wishes of more than 80 elderly participants was not improved either with a scenario-based living will -- in which patients could choose from treatment options for a range of medical conditions -- or with a value-based living will, according to the results.

Smucker and others say the complexities of modern medical care and the very fluid nature of the process of dying -- in which patients can be skirting death one minute and relatively safe the next -- makes it nearly impossible for a technical document to capture all the possibilities.

"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 very nebulous."

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