As of this writing, former South African President Nelson Mandela remains in critical, but stable condition as he enters his second month in hospital. Court documents say he is breathing with the help of a respirator, and receiving dialysis.
There are hopes that Mandela will recover, but based on the little public information available, there is not a doctor I know who I have spoken to that expects him to. The odds are heavily against it. Mandela’s recovery would be a miracle. I really hope I’m wrong, and that he does come through this, but reason and experience suggest otherwise.
There are good reasons for keeping people alive on machines beyond the point they are expected to recover, and most of these center around the family, so that family members living far away can come and see the person while still alive and say their last goodbyes. We can assume that in Mandela’s situation, that has already happened.
If I had to choose the way I could die, I would probably like to go peacefully in my sleep. It seems that Nelson Mandela no longer has that option. He may have had, and perhaps even been on that trajectory when he was rushed to hospital in the middle of the night more than two weeks ago. It would not have been a bad ending for any normal, but frail, 94-year-old.
Mandela may be old and frail, but in no sense of the word is he normal. A normal 94-year-old would not be exposed to the intense scrutiny of a world hoping to see its most famous statesman, and now its most famous patient, recover.
Yet, as he approaches his 95th birthday, Nelson Mandela is in a South African hospital, being kept alive through the “wonders of technology”.
Regardless of the outcome, or his prognosis, I have to wonder to myself: Is this what he would have wanted?
More than any subject, avoiding talking about death ranks at the top of the list. Death of a loved one is also the one thing that causes the most damage to the survivors, when it had not been discussed fully in preparation for the end.
How many of us have made clear to our family and friends – who understand all too well what we liked in living – how we wish to die?
Our families and friends know our favorite foods, vacation spots, the music and movies we love, even the cars and clothes we like best. But, nine times out of ten, those same people aren’t prepared to make decisions about what circumstances we should die under.
You see, we are all a car accident, a fire, or a heart attack away from being in a situation where someone else will determine how we will die. People need to openly discuss their end-of-life care beliefs and choices with their families and doctors.
One needs to consider what he or she personally values in life and communicate that to people you love through conversation and even better, also in writing.
People should hope for the best while planning for the worst.
It doesn’t mean that you are giving up; it just means you are considering all of your options so that you can make the best decision regardless of what you find. In general, it is much easier to make this decision when you feel relatively healthy and are able to openly express your wishes to a family member or friend.
There are three main types of advance directives:
• Do not resuscitate orders (DNRs)
• Living wills
• Durable power of attorney documents (DPAs)
Do not resuscitate orders (DNRs). DNRs typically request that no extraordinary measures be used to save your life. Extraordinary measures typically include measures such as cardiopulmonary resuscitation (CPR), the use of an electrical shock to stop a fatal abnormal heart rhythm (defibrillation), intubation (placement of a breathing tube down your throat), or the use of lifesaving medicines. People with DNR orders can be given drugs that make them more comfortable. You may request that you be identified as a DNR if you wish to avoid expensive medical care that probably will not improve your long-term prognosis.
Living wills. Living wills are written documents that contain specific instructions about the type of treatment you wish to receive at the end of your life. Unlike a DNR order, which applies to a specific moment when you require resuscitation, living wills apply to more general situations.
You must meet one of two broad conditions for your living will to be triggered:
• You have slipped into a permanent coma.
• You are not able to make decisions on the type of care you wish to receive.
Once two doctors agree that the condition has been met, your doctor will deliver care based on the directions in your living will. Usually, living wills instruct doctors not to prescribe any treatment that would unnecessarily lengthen the process of dying.
Durable power of attorney (DPA). A durable power of attorney for health care document appoints a specific person (surrogate) to make decisions about your care if you are not able to make those decisions. Unlike DNRs or living wills, DPAs allow an independent observer of your choice to assess your current health condition and to speak to your doctor before any decision about your care is made. DNRs and living wills do not allow for this type of dialogue, because your treatment is based on choices you made without knowing the exact nature of your condition.
Although family members may make good surrogates because they are most familiar with your wishes, they also may be under a lot of emotional pressure. And please, let the person you designate as your surrogate in your DPA know up front, and make sure that he or she is comfortable with this role. It is not good for someone to be surprised to learn that you named them your surrogate.
Being chosen to make decisions about the type and amount of treatment delivered to another person is an enormous responsibility. If you feel that you do not have the strength to undertake this task, you should tell the person who selected you to select another person
DNR orders, living wills, and DPA documents all are rather simple to change. You only need to verbally tell your wishes to a witness, your doctor, or any other health professional. To make sure that your wishes will be followed, make sure that a note is made in your medical file that you have changed your end-of-life care instructions.
Anyone can ask himself or herself, and answer the following question to increase their power over death, dying and the end of life:
“What is most important for me in my remaining time? (Be that 5 months or 5 years)
After answering this question, communicate with your family and healthcare providers that you want to choose medical care that will support you in accomplishing these goals.
Take good care of yourself and live the best life possible!
