Diane Melancon, Oncologist

The Importance of Advance Directives

In part because her family never expected her to pursue a career, Diane Melancon took what she describes as a “curvy path” to her medical degree and her current practice in oncology (the treatment of cancer). After high school, she worked her way through a number of educational programs, earning a certificate in medical assistance from Diman Regional Vocational Technical High School, an A.S. in X-ray technology from Northeastern University, a B.A. from Wellesley College, and an M.D. from Dartmouth Medical School. In her medical practice today, she writes patient assessments and treatment plans. In the following piece, she argues for the importance of advance directives, in which patients spell out how they wish their medical treatment to be handled in life-threatening situations.

Consider these difficult situations: (1) A car accident seriously damages a young man’s brain, leaving his family to decide whether or not he should be kept on life support. (2) A patient’s cancer is not responding well to chemotherapy. She must decide whether to continue with the therapy, despite its physical and emotional strains, or to receive only care that reduces pain and provides comfort. Nothing will make such decisions any easier for these patients or their families. However, people who are able to provide guidance for their treatment in advance of a medical crisis can help ensure that their wishes are followed, even under the most difficult circumstances. Therefore, everyone should seriously consider preparing advance directives for medical care.

One major reason for preparing advance directives is that they make it clear to care providers, family, and other loved ones which medical measures patients do or do not want to be taken during a health crisis. Directives specify these wishes even after patients are no longer able to do so themselves — because, for example, they have lost consciousness. Advance directives include living wills, legal documents that indicate which life-sustaining measures are acceptable to patients and under what circumstances. These measures include the use of breathing aids, such as ventilators, and of feeding aids, such as tube-delivered nutrition. Living wills may also indicate a point at which a patient wishes to receive only comfort care, as opposed to aggressive treatment. Furthermore, living wills may specify whether patients wish to receive cardiopulmonary resuscitation if their heart and breathing stop. Finally, through a legal document known as a medical power of attorney, patients may select another person to make medical decisions on their behalf if they become incapable of doing so themselves. All of these parts of advance directives help reduce the risk that patients’ wishes will be overlooked or contradicted during any point of the treatment process.

Another important reason for preparing advanced directives is that they can reduce stress and confusion in the delivery of care. Ideally, patients should complete these directives while they are still relatively healthy in mind and body and capable of giving thoughtful and informed instructions for their own medical care. In contrast, waiting until a health problem is far advanced can increase the difficulty and stress of making medical decisions; at this point, patients and their loved ones may be feeling too overwhelmed to think carefully through the various options. In the worst-case scenario, patients may have moved beyond the ability to contribute to medical decisions at all. In such cases, family members and others close to patients may be forced to make their own judgments about which treatments should or should not be given, possibly resulting in disagreements and confusion. However, when patients have made their preferences clear in advance, care delivery moves more smoothly for them and everyone else.

Some people may believe that advance directives are too depressing to think about or that they are even unnecessary. They may take the attitude “Let’s cross that bridge when we come to it.” However, as has been noted, by the time the bridge is in sight it might already be too late. Although making advance plans for life-threatening medical situations can be difficult and emotional, avoiding such planning can create more stress for patients and their loved ones. Worse, it may mean that the patients’ true wishes are never known or acted upon.