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On The Other Hand...

the type of medical care they wish to receive if they become terminally ill (or permanently unconscious, in New Hampshire and some other states), and a durable power of attorney for health care, which designates someone to make medical decisions on a patient's behalf if the patient is unable to do so. Only about 20% of U.S. adults have signed advance directives.

Longtime DHMC Ethics Committee member Marie Bakitas, D.N.Sc., a nurse practitioner in palliative care, is leading an initiative to get all DHMC and DMS employees, as well as their families and friends, to complete advance directives and to be sure they are on file in their hospital records. National statistics show that fewer than 30% of health-care workers have indicated their wishes in writing—a little, but not a lot, better than the rate among the general population. Bakitas reasons that if more medical staff have signed advance directives, they will be more likely to encourage their patients to have them, too. (Any readers within DHMC's service area who would like assistance in filling out an advance directive are welcome to call the Office of Care Management at 603-650-5789.)

"A lot of the cases that we deal with in the Ethics Committee that involve end of life could be eliminated—we wouldn't have to have an ethics consult—if the patient had an advance directive," explains Elizabeth Stanton, a lawyer in DHMC's Risk Management Department and another longtime member of the institution's Ethics Committee. "I think the plan, with Ethics Committee support, is to elevate advance directives to the status of flu shots, smoking cessation, and similar health-care initiatives."

Hilary Ryder: Communication often occurs on "completely different levels"

The Dartmouth-Hitchcock Medical Center Ethics Committee, which was established in 1983, was one of the first such groups in the nation. By 1987, 60% of U.S. hospitals had an institutional ethics committee.

Often, admits medical student Emily Rubin, caregivers neglect to explain what it means for elderly patients who are very ill to have their heart shocked back into rhythm. "When you really sit down and talk to families in detail, [they] often will rethink their initial decisions."

But some of the cases that come before the ethics team involve patients who do have an advance directive indicating that in the event of a terminal illness they don't want to be kept alive by artificial means. Yet doctors may be torn between honoring the directive and continuing to deliver aggressive treatment. Or family members may not have accepted the situation's finality. An ethics consult can help everyone reach agreement on what the patient would have wanted.

Advances in medical technology, and thus the ability to keep people alive longer than used to be considered natural, are a good part of the increasingly complicated nature of medical decisionmaking. And changes in technology are moving so fast that the law can't keep up, says Stanton.

"Technical advances are coming in floods now instead of just waves," explains Kate Clay. Along with new technology has come a flood of new technical terms that patients and their families often don't understand. It's difficult enough to make treatment decisions when the facts are clear, but today's plethora of arcane terms adds to the confusion. Without thinking, medical professionals toss around terms like "CPR," "DNR," "DNI," and "intubate" or "extubate."

"The word 'intubation' has absolutely no meaning outside the medical community," admits Sarah Stableford, R.N., a critical-care nurse who recently joined the Ethics Committee. "Intubation" refers to the insertion of a tube down the patient's trachea; the other end of the tube is connected to a ventilator that breathes for the patient. "Extubation" means the removal of the tube when a patient is taken off a ventilator.

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