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

Living Will Dilemmas

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"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."

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."

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