Living Will seems essential for a dignified death 

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Dr Bharat Bhushan
Dr Bharat Bhushan
Living Will seems essential for a dignified death 

Faruque Ahamed

With the regular news of organ transplantation surgeries in different government and private hospitals in Kolkata experts in critical care treatment feel that an awareness 
should be taken into consideration to sensitise people about the advanced directives, living will so that terminally ill patients have ‘dignified deaths.’ 

This type of advance directives as well living will of dying patients have already been implemented in some foreign countries to save huge amount of money in lakhs and crores spent for them who lying in hospital beds with expensive life-support system for days and even months virtually wait for their last breaths. . 

“This is a very relevant issue particularly when many relatives cough up huge amount of money in lakhs and crores for the treatment of their dearest patients lying in hospital beds with critical care support like ventilators and other equipment though the chances of their survival are zero. It’s true that people always try their best spending money for their patients till the end comes,” said an expert in critical care at the state-run SSKM hospital. 

 
“Sometimes, with the advice of concerned doctors relatives give us consents to withdraw life support devices fixed with their dying relatives lying hospital beds when there are no chances of patients survival. These consents give patients dignified deaths and save money of relatives also. At the same time, patients who are also waiting desperately for critical care treatment get berths in the ICU of a hospital,” he said adding that in some parts of US and other foreign countries legal power of attorney are given to close kins of terminal patients who can give doctors about the advance directives or living will to withdraw life support devices and painful injections and medicines on such patients. 
 
Another critical care expert of a private hospital in the Alipore area said that this sort of advance directives or living will of patients would also give momentum to cadaveric organ transplantation programme in the city. 
“Death is an unpredictable event in human life but making a wish of how you want your end of life to be can be notified in a living will. Advance directives are the living will one can have of how she/he wants to rest in peace,” felt Dr. Bharat Bhushan, an NRI physician associated with the Sound Physician Hospital (Covenant Medical Center) in Lubbock, Texas in US. 
Dr Bhusan who has been passionate in raising awareness regarding approaches of high quality end-of-life care treatment while sharing his views with the ibgnews said that there is a clinical significance to the fact of advance directives.

Some excerpts of his views shared with Faruque Ahamed (FA) of the ibgnews are given below. 
Faruque Ahamed (FA): What are clinical significances of advance directives (AD)?
Dr Bharat Bhushan (BB): Most physicians come across with patients with a living will, which provides specific instructions of the treatment plans for the healthcare provider. For example, a living will can stop financially steep life sustaining treatment. Wishes can be against receiving food and fluids through tubes. 
 
More living wills can include patient’s desire for not using medicines, use of ventilators, and cardiopulmonary resuscitation.
FA : Could you just brief about the relevance of AD in modern health care?
BB: The end of life care may include the following like artificial ventilation, artificial nutrition and hydration. This care can result in greater suffering for patients and increased cost of medical treatment.
 
A known fact is that aging creates complications in health due to chronic diseases, cardiovascular diseases and other illnesses. 
 
Terminally ill patients who are suffering from fatal cancer or any other life-threatening diseases know regarding their guarded outcomes. Sometimes, ADs are different like the way the patients wants to get relieve from the sufferings without too much medications, blood, blood products, chemotherapy and other life saving methods being implemented. 

FA: What are the different types of ADs?

BB: Types of ADs are different documents that are created according to the wish of any person which will be executed in the end of life care to that individual. 
This includes Durable Power of Attorney, here people can appoint anyone who is capable of taking decisions at the point the person in unable to take any decisions of their own. 
Living Will, the most important type of advance directives document where the instruction are clearly mentioned like common choices being cardiopulmonary resuscitation (CPR), endotracheal intubation or any form of ventilation, refusing the actions this may be documented as follows: Do Not Resuscitate (DNR). Allow Natural Death (AND) and DO not Intubate (DNI). 
Other AD includes Physician’s Orders for Life-Sustaining Treatment (POLST). This is an agreement between the doctor and the patient which regulates as medical orders to respect patients’ wishes.

FA: What are the interventions of ADs in a critical care unit of a hospital?

BB: As a physician I have performed a study on ADs and living will among patients admitted to the critical care unit. Cardiovascular diseases (CVD) is one of the major cause of death in the United States and advance directives can play a vital role in management of terminal CVD. Patients with heart failure must have advance directives to ease the end of life of patients in terminal stage. In case of cardiovascular diseases in intensive care/cardiac care, the use of advance directives can be fruitful both for patients and the families to make decisions in seamless fashion. 

FA: Usefulness of ADs in Indian context?
BB: As I did my medical studies in India and spend many years in India so I am aware of the health care system in India. Many patients are unable to convey their wishes before death came suddenly. Though ADs are not legally approved in India but there are cases, which throw a light that the day is not far away. Advanced directives decision can be taken by patients’ family if they are unable to take decisions in case of terminal stage. In recent times in India we can have seen multiple cases of organ transplant according to the wish of patient’s family have taken place.
 
In case of organ transplantation, we have seen that organs are transported between cities in India through traffic jam free Green Corridor within the span of a few hours. In the event of an AD being acceptable, the procurement of organs from beating heart donors (BHD) 
being feasible (in contrast to DCD or donation after death organs), which obviously are of inferior quality. Medico legal intervention and appropriate legislation shall make 
ADs likely a routine practice in the Indian health care scenario., impacting high quality of end of life care as well as a post death activity like organ transplantation.
FA: Please give final conclusion on the issue Dr. Bhushan.
BB: The end of life care may include the following like artificial ventilation, artificial nutrition and many other costly investigation and interventions which does not 
improve quality of life but imposes burden on patients care without any fruitful effects. 
Forth coming discussions regarding the importance of advance directives shall make the society aware of these pressing issues, rendering changes in people mentally and their prescriptive.