Advance directives amidst COVID: a critical look – GWC Mag

Are advance directives any better than they were four years ago when COVID was surging? Are patients still comfortable with being placed on ventilators? Do physicians better understand how to treat COVID as a serious illness? 

Physicians provide emergency measures unless there’s an advance directive to the contrary. Only one-third of Americans have advance directives when “down for the count” with serious illness.

Most people prefer to die at home, but many COVID patients died in ICUs and were discarded in cooling trucks behind hospitals. An advance directive expresses the need to beat the proverbial “dead horse” in futile situations.

Advance directives often encourage individuals to consider The Five Wishes. As an emergency physician, I need patients to expressly decline medical treatment when death is certain. This decision, like organ donation, can be as simple as yes or no and is acknowledged publicly by a symbol on the driver’s license.

There’s no uncertainty about an individual who consents to organ donation. Current advance directives are left to interpretation and confused with advance care planning which is subject to change. For an advance directive to be consequential, an individual needs to acknowledge and sign this declaration:

In the event of certain and imminent death, disfiguration, or permanent incapacitation, WITHHOLD medical treatment and provide comfort measures. AND if within three days of certain and imminent death, disfiguration, or permanent incapacitation, WITHDRAW medical treatment and provide comfort measures.

The unsuspecting person may never believe death is certain or imminent at any age. This is an opinion. A trained physician who gathers evidence knows when death is certain and imminent. This is intelligence. The battle between “what is” (intelligence) and “what’s believed” (opinion) was rampant during the COVID-19 pandemic.

Certainty, like dignity, is a matter of intelligence.

Emergency physicians know best how to manage mass casualties through intelligence, not opinion. Who lives or dies is a split-second decision. Similarly, an advance directive functions best as a split-second, yes-or-no consent for medical treatment when death, disfiguration, or permanent incapacitation is certain or imminent.

All too often, resuscitative measures are initiated due to the disbelief or lack of intelligence about death, disfiguration, or permanent incapacitation. When cooler heads prevail, health care proxies remain reluctant to pull the plug on loved ones. This is why the second provision to the consequential advance directive is necessary and makes it foolproof.

The dying wish of most patients is to have all their physicians and family members in the same room in support of patient autonomy. Most people will never make a life-or-death decision on their own and risk alienation. This explains the resistance to completing current advance directives. 

The U.S. Constitution endows Americans with the inalienable right to life, liberty, and the pursuit of happiness. A consequential advance directive ensures individuals the inalienable right to death, certainty, and the withholding/withdrawing of medical treatment in the event of death, disfiguration, or permanent incapacitation. 

Military personnel risk being wounded or killed during service and are required to complete advance directives. Many wounded warriors might opt for consequential advance directives in retrospect. Might we support consequential advance directives for those willing to make the ultimate sacrifice?

In matters of life and death, decision-makers often say, “We’re not there yet.” Given this, advance directives have not evolved beyond wishful thinking to become a sacred document. Even with the advent of National Healthcare Decisions Day, which occurs each April 16, death is still not as certain as the tax deadline, April 15. 

We, the people, owe a debt to society and are expected to pay taxes. We might acknowledge a debt of gratitude for our life experience by signing a consequential advance directive that prioritizes quality of life and health span over lifespan.

How many suffer the consequences of extending their lifespans through medical treatment? How many might endorse healthspan over lifespan by signing a consequential advance directive on National Healthcare Decisions Day 2025?

Many advocate for current advance directives yet are likely resistant to changing the status quo. With the recent article about the billion-dollar future of advance directives, who might elevate the concept of the “consequential advance directive” to ensure Americans have the right to withhold/withdraw medical treatment when death is certain?

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.