1. Ufema, Joy RN, MS

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As nurses, we're constantly reminded to ask about the presence of living wills and other advance directives. I'm curious about your experiences with advance directives. Do they sometimes complicate family decision making?-C.C., R.I.


Yes. In fact, your question reminds me of the time I was asked to help an 86-year-old patient's adult children decide about artificial nutrition for their dad. Mr. King, already terminally ill with advanced cancer, had suffered a massive stroke 2 days before and couldn't communicate his wishes. His son and daughter were coming to terms with his impending death. Then his nurse asked if Mr. King had ever completed a living will.


"Why yes, in 1998, after our mom died," his daughter replied.


After retrieving and reviewing the document, the siblings found that their father had requested no intubation or mechanical ventilation and no CPR. But their dad had also clearly checked the box indicating he'd want "feeding via tube." Stunned, they showed the document to me.


"His nurse said that we're obligated to follow his wishes as indicated in this legal document," his daughter said. "What should we do?"


As longtime readers know, I'm adamant about honoring a patient's wishes and critical of clinicians who look for ways to circumvent them. Now I had a patient who'd taken the time to ponder and express his wishes in writing, but these directions seemed contrary to his best interests in the present circumstance. Was I, too, going to maneuver my way around his expressed wishes?


We sat together in the small conference room. Mr. King's daughter began to cry.


"We just want to do what's right. He's been a wonderful father."


I asked, "If your dad could speak to us, what do you think he'd want, given his condition?"


In unison they replied, "Oh, he wouldn't want to be kept alive!!"


Then Mr. King's son said, "But he did make this living will, and it says he wants to be fed."


"I think we have an underlying circumstance here," I said softly. "Your father's stroke is so severe that any intervention would be considered medically futile. In his condition, his body is actually shutting down. It's inappropriate to feed him."


They sat silently, holding hands.


I continued, "I'm going to propose giving him comfort care instead of medical treatments. We'll keep him clean and dry and safe. If he appears feverish or restless or in pain, we'll treat the symptoms to keep him comfortable. How do you feel about this plan?"


The daughter smiled and nodded. Her brother agreed. We returned to the bedside to keep watch.


Mr. King died early that evening during a stunningly beautiful sunset.