Being Prepared: Advance Directives.

Awhile ago I put together 72 hour kits to prepare for disaster. We're working slowly on building food and water storage. I saw Dooms Day Bunkers on TV during my lunch break recently, and I really want to build one in our backyard. Seriously. I'm trying to prepare myself here.

Also seriously, there are other disasters that people need to be prepared for. Like traumatic accidents, chronic or sudden disease and illness, choosing to prolong life or let our loved ones pass on. Surprisingly (or maybe not so surprisingly since it's not a pleasant subject) most people are not prepared for these things, or prepared to make life altering decisions if a loved one gets critically ill or injured. Sometimes people have 'conversations' and they'll say things like, "If that happens to me, just pull the plug!" Maybe they said that one day 10 years ago when they were healthy and life was good. And now they're in a persistent vegetative state with little to no chance of recovering. And it was sudden. And the family doesn't know what to do because they are holding onto a very small sliver of hope that their loved one will recover, and they hold onto that hope because they're human, and they love their husband, or brother, son, or mother very, very much. Do they know for certain what your loved one wanted? Did they have it in writing?

In my short time as a nurse I've seen people make some very, very hard decisions. I've also seen families torn apart, literally - parents getting divorced, siblings fighting in court, and even fighting over the loved ones almost lifeless body - over these decisions. People need to be informed and KNOW what their loved one would want. However, it's not always so cut and dry. Is there a chance for recovery? Maybe. Maybe not. Doctors are regular people, usually making educated guesses and relying on their knowledge and past experiences. They are certainly not psychic, and definitely can't predict the future. I have seen tragedies and I have seen absolute miracles. Sadly, the tragedies outweigh the miraculous by far.

So, please, have conversations with your family members. All of them. Make sure everyone is on the same page. Get it in writing. Because if tragedy strikes unexpectedly, as it usually does, even if you've had these conversations, and have a living will, and KNOW what your loved one wanted, the decision to prolong or end life is not going to be easy, because every situation is different. Every family is different.

Off the soapbox and onto the technical. Do you even know what prolonging life means? Do you know what it entails? Did you know it can mean withholding food or antibiotics until the person dies? However, it never means withholding other comfort measures like pain medications. It isn't always as simple as "pulling the plug" and within minutes the person passes on. It can takes days and sometimes even weeks for life to end.

Sometimes medical professionals forget that we do this and hear these terms every single day, but that most people are not familiar with these things. Plus, people may be in crisis mode and unable to think clearly. So when we say things like, "Do you want us to do everything possible to keep them alive?," most people have no idea what "everything possible" means. Here are a few things that "everything possible" might entail:

*Putting patient on oxygen. Oxygen is delivered in many forms. It can be given through the nose, by a mask over the face, via a c-pap or bi-pap machine (which both include a mask that goes over the nose, mouth, both nose and mouth, or over their whole face), being intubated, which means a tube is inserted through the mouth that goes down the throat and into their lungs and that tube is connected to a ventilator (a machine that is now breathing for the patient). Oxygen via face mask is drastically different from a tube being down their throat and having a machine breathing for them.

*Putting a "feeding tube" in. Usually this means the patient is not eating enough to sustain life, or they are unable to swallow, so we need to feed them some other way. The first step is usually what's called an NG tube. It's a tube that goes into their nose and down into their stomach, and then a liquid nutrition is hooked up to the tube and they are fed that way. Also, they can get what's called a PEG tube, which is a tube that is surgically inserted directly into their stomach and the liquid feeding is hooked up there at the stomach. Someone who is cognitive and with it mentally, say after a stroke, but they are no longer able to swallow, may have a PEG tube put in place and can lead a fairly normal life. Someone who is in a persistent vegetative state with no brain activity can also have a PEG tube put into place, but their quality of life is very different from someone who is able to walk and talk, but just not eat.

*Administering antibiotics. Part of prolonging life may be giving the patient antibiotics to fight infection. Obviously, you aren't going to put your loved one on hospice because they have bronchitis. But if they have end stage Alzheimer's, do not know their own name, fell down and hit their head and now have a brain injury and are hospitalized, and while they are at the hospital they get pneumonia ... this is where you may start to consider administering antibiotics or withholding them. Trust me - there is very rarely a clear cut answer, and patients usually have multiple issues going on at the same time.

*Doing chest compressions. This can be a very traumatic event physically for your loved one. Bones are broken and electrical shocks are administered. Have I seen patients hearts start beating again because of compressions? Yes. Have I seen patients actually recover physically and mentally with no lasting brain damage after their heart stops? Yes. Talk about miracles! Have I also seen the heart start beating again, only to now have the patient have what they call an anoxic brain injury (no oxygen to the brain) and are now either in a vegetative state or in a semi-coma unable to communicate, control their bladder or bowels, eat, or even move. Yes.

*Dialysis. If a patients kidneys start to die because of an illness, side effects of medications, or side effects of treatments, they can go on dialysis. Several times a week the patient can be hooked up to a machine that takes their blood out of their body, filters out the junk, and then returns it back to the body clean(er). This can take up to several hours per treatment. Patients are also usually very nauseated from the build up of toxins, as well as after the dialysis. However, people can live years and years getting dialysis done on a regular basis. Patients sometimes decided to go off dialysis, and depending on the severity of their kidney disease, may die within a few days. Also, sometimes patients only have to be on dialysis for a short time while their kidneys heal, and then after a time are able to pee like regular people.

Those are just a few things to consider. Like I said, no situation is ever the same. It gets complicated. Sometimes really, REALLY complicated. I hope I never have to make these decisions, but I also hope that I never have to use my 72 hour kits. That doesn't mean I shouldn't be prepared.

For those of you in Utah, here is the website you can go to, and you can even fill out the advance directive forms online and just print them out. Seriously, it is that easy. If you don't live in Utah, google your state's name and advance directives. You do need to have a witness sign the form, and according to my wise father, who is a lawyer, you shouldn't have that witness be the same someone you name as the person who will be making decisions for you, or anyone who might benefit or not benefit from your death. So, don't have your spouse or siblings witness. Maybe a good friend or neighbor who you've known for years who you trust and who your loved ones (or the courts) will be able to get a hold of in case of emergency.