Advances in Advanced Directives

 

Gaster et al. have proposed a template structure to help shape Advanced Directive writing for the particular context of dementia. Standard templates for Advanced Directives don’t quite fit for a long-term, mostly slowly evolving illness like dementia, and among other key points, the authors suggest that patients (or patients to be) consider that their wishes may shift with deepening stages of cognitive impairment. For example, someone may want all therapeutic interventions pursued during a mild stage of dementia but none of the same at a severe stage.

This is your reminder: have you done your advanced directive planning? Have you reviewed any existing documentation to reflect changes in contact information or changes in your philosophy? While it may be unpleasant to anticipate your end, it can be very helpful to those who care about you to have your wishes clearly laid out!

Excerpted from their JAMA Dec 12, 2017 article:

Possible Example of Goal-Directed Options for a Dementia-Specific Advance Directive
If I had (mild, moderate, or severe) dementia, then I would want
the goal for my care to be:
• To live for as long as I could. I would want full efforts to prolong
my life including efforts to restart my heart if it stops beating.
• To receive treatments to prolong my life, but ifmy heart stops
beating or I can’t breathe on my own, then I would not want
my heart shocked and I would not want to be placed on a
breathing machine. Instead, allow me to die peacefully. I choose
this option, at this stage, because if I took such a sudden turn
for the worse, my dementia likely would be worse if I survived,
and I would not want the trauma of cardiopulmonary
resuscitation or a breathing machine.
• To receive care only in the place where I am living. I would not
want to go to the hospital even if I were very ill. If a treatment,
such as antibiotics, might keep me alive longer and could be
given in the place where I was living, then I would want such
care. But if I continued to get worse, I would not want to go
to a hospital. Instead, I would want to be allowed to die
peacefully. I choose this option, at this stage, because I would
not want the possible risks and trauma that can come from
being in the hospital.
• To receive comfort-oriented care only, focused only on relieving
my suffering such as pain, anxiety, or breathlessness. I would
not want any care that would keep me alive longer.