Advanced Directives Should Focus on Quality of Life, Not Technology

A letter to the editors of the New York Times: 

 Re “A Better Way to Face Death,” by Dr. Daniela J. Lamas (Opinion guest essay, Jan. 6): Too often, advance directives are construed as immutable guides to how one dies. 

We have found advance directives to be more helpful if we focus on how one wants to live. If we ask about ventilators or dialysis or artificial nutrition, we are typically asking people to express opinions about topics that they do not know well, usually based on preconceived and often inaccurate notions about these medical technologies. 

It is little wonder, then, when actually faced with the technology, patients will change their mind. What was once unacceptable may now be tolerable because life still holds a desired quality. The opposite may occur; treatment that was once strongly desired in the abstract may not deliver the quality of life that was hoped for. A

dvance directives should accomplish two goals: identification of a surrogate — one who can “stand in the shoes” of the patient, and the identification of preferences — what is important in how you live. A focus on evolving ideas rather than document completion will be more likely to bring the patient’s voice to decision-making at crucial times. 

 Margaret M. Mahon Ann Berger Bethesda, Md. 

Dr. Berger is chief of the Pain and Palliative Care team at the National Institutes of Health Clinical Center, and Ms. Mahon is a nurse practitioner with the team. 

 The other letters in response are also worth reading. Excerpts: 

 The anxiety, indignities and angst of advanced age demand acceptance — and a sense of humor. Like most of my peers, I am not afraid of dying but of being kept alive. 

 [My father's] health care proxy came by every day and turned up the morphine, and my dad always turned it down. He said he didn’t have that much pain if he lay still, and he found that he got more relief from holding hands than from morphine.