Happy New Year, Get Yourself an Advance Directive

I celebrated New Year’s with an old friend from college who hosted a party in his studio apartment. He served homemade salsa and roasted mushrooms, and the most raucous moments of the night involved a banjo, a kazoo, and a Radiohead singalong. I’ve known him to spend his time studying philosophy, farming, making music, and romancing,  and he managed to continue all this while deciding to become a doctor, completing medical school, and beginning his residency. That is to say, like any admirable doctor, or person in general, my friend is smart, thoughtful, compassionate, and hard-working, and he appreciates the good things in life.

Despite this, in conversation with me (a nurse) and another young doctor, he said, “We were coding this lady for the 4th time, she probably didn’t have a single intact rib left. Her body was so fucking edematous from all the chemo, she was totally blown up with fluid, that while I’m doing chest compressions, some part of her skin just pops and she starts leaking interstitial fluid all over the place. It’s all over the bed, on me, on the floor, my shoes, it was so fucking disgusting…”

The response to this is to laugh and share another code story. The other doctor mentions coding a 93 year old for an hour, the nurse doing weak compressions and saying she was getting tired, telling her “step aside, sweetie,” (sweetie? that’s another story). I’ve done my share of laughing at the tragedies that are ludicrously magnified and extended beyond their natural proportions by the miracles of modern medicine. One memory that stands out is of a teenage boy whose drug experiments had resulted in an anoxic brain injury. He was brought to our unit in an unstable condition, but after only a few days he stabilized, and while he didn’t look like he’d be walking, talking, thinking, or waking in the near or remote future, he was no longer sick enough to be in the ICU. A nurse who had taken care of him in the beginning asked about him as we gathered before our shift, and another nurse said she’d transferred him out to the regular hospital floor the day before. “Really? He was okay to transfer?”

“I mean, his vital signs were stable.”

“Ah. So he’s got that going for him.” This brought snickers from around the table, including me. It’s hard not to become jaded.

But what’s worse than being jaded is feeling that working in a hospital means entering a madhouse where common sense does not rule, and feeling that since you are only one tiny piece of the massive, impressive, and flawed healthcare puzzle, there’s nothing to do but shrug, roll your eyes, laugh, and keep doing those compressions on your patient in her 90s or sending your vegetative patient off for another operation, or whatever it is that shocked you when you first entered the field and now just seems like the more depressing aspect of your job.

So on New Year’s Eve I said that we shouldn’t just be laughing about these gruesome situations; we shouldn’t be doing things to patients who are so far gone that it doesn’t even occur to us to wonder how they would feel about being handled this way; we shouldn’t be coding 90 year olds–it shouldn’t happen! And the doctor responded with a grin, “I hate hospitals.”

I write about this in part because I think the sarcastic, disillusioned culture among healthcare professionals is somewhat secretive or closed, and that people who have no connections in the medical community would be surprised to learn how often doctors–compassionate, thoughtful, smart doctors–provide treatment that they would never want for themselves or their loved ones.

Don’t leave it to the professionals to decide how to treat you when you are unable to express yourself. Make an Advance Directive, or complete a POLST form, and have a conversation with your family about it. Advance Directives are written documents that describe a person’s choices about the medical care they would receive if they were unable to communicate and can include the appointment of a healthcare proxy, and POLST forms (Physician Orders for Life Sustaining Treatment), which are more often used for people who are currently seriously ill and under medical care, are sets of standing medical orders used to direct care.

I don’t want to be all talk. I’m 29 and healthy. I’m not one for New Year’s Resolutions, but I’ve decided not to let 2014 close without completing my own Advance Directive. I hope you’ll consider doing the same.

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