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