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Nixon's Last Hurrah

Notes from an emergency room doctor: This week as Nixon is laid to rest, pundits are busy judging his life like a court at the gates of heaven. I too shall weigh in by lauding the important lesson he gave us in his dying days.

Nixon had had atrial fibrillation for many years. This condition increases the risk of blood clot formation and a stroke occurred when a clot travelled to his brain. After a stroke, the brain commonly swells. Sometimes this swelling subsides and the patient can recover. At other times, the swelling increases, the patient becomes comatose, and eventually death occurs. To reduce the brain's swelling, doctors use diuretics like Mannitol to remove fluid from the body. Putting the patient on a respirator and increasing the rate of breathing alters the brain's chemistry and can also result in a reduction of swelling. However, once on a respirator it can be difficult to wean a patient off one. A stroke victim could survive in a vegetative state, on a respirator, for days, weeks, even years.

Nixon left a "living will" with instructions that "no extraordinary measures, or heroic life-support systems, were to be used to prolong his life."

"Living Wills" or "Advanced Directives" (ADs) are meant to legally entitle patients to participate in the medical decision making that might affect their end-of-life care. But unfortunately, these ADs are not being completed by very many people, and they are often ineffective in providing physicians with clear guidelines as to their patient's preferences. And when no clear guidelines exist, it is far easier for most physicians to choose some form of therapy, regardless of how futile, than none.

In a recent UCLA study, nearly 500 physicians were asked what specific therapies were meant to be withheld when different forms of AD's were used. When presented solely with a patient's "general statement," only 55% of physicians withheld a standard formula of therapies. When the patient indicated which "specific therapies" they wanted withheld, 71% of physicians complied. When physicians were presented with the fact that they had a "general statement" of the patient's wishes, that the patient had designated a proxy such as a family member to act on their behalf, and had a prior patient-physician discussion, 83% withheld therapy.

Given the medical, legal, and ethical complexities in end-of-life decision making, it is not hard to understand the results of the UCLA survey. Given no more than a patient's brief and vague legal statement requesting "no heroics," many physicians have trouble abandoning the armamentarium of life support systems at their disposal. Providing explicit instructions, indicating which specific therapies you wish withheld such as CPR, mechanically assisted ventilation, or intravenous fluids, adding a legal proxy to represent your intent, and having a prior relationship with your doctor obviously goes furthest in resolving any physician's dilemma.

Nixon had done all of these things. He had a long term relationship with his family physician who knew his wishes; he had designated his daughters as his legal proxy in case of his incapacity; and he had a legal living will.

The important lesson to be learned from Nixon's life is that despite adversity he never gave up, and in his last days he showed us that he knew that living life does not mean simply to survive at all costs.