Tuesday, January 20, 2009

Why Do Doctors Ignore Living Wills?

In the reading for today, the author cites a survey which concluded that 65% of physicians "would not follow a living will if the instructions conflicted with the doctor's own view of the prognosis or expected quality of life." (Colby p. 142) My first reaction to this statement is: Who do those doctors think they are, substituting their judgement for my wishes!!!

But then I begin to wonder how this situation arises. The living will seemingly can only "respond" to specific scenarios. Who is defining that scenario that the living will is responding to? Who beyond the physician is outlining the prognosis or expected quality of life? Who is the doctor disagreeing with? Is this statistic saying that physicians substitute their judgement if they think the patient didn't really mean what they said in their living will or that they would feel differently about their life (say as a quadraplegic) if only they had a chance to live that life?

Other thoughts about what this statistic is really indicating?


  1. This is a great question to raise. (You will see it again in less than 24 hours!) Without revealing all of my thoughts before tomorrow's lecture, I would encourage you to think more in the direction of, as you write, "The living will seemingly can only "respond" to specific scenarios. Who is defining that scenario that the living will is responding to?"

  2. This hit from left field for me as well. I guess the question I have is what are they considering a living will?

    I believe Cosby is referring to a self-written document that outline situation and outcomes - any other ideas?

    In WA we have a living will site (http://www.doh.wa.gov/livingwill/) that includes the Advance directive, DPOA, POLST & Mental health directive.

    With the 'living will' alone without the above documents I can see why their is such a high percent not used. Most of the time outcomes are not known as firmly as they are written in the Living will. As much as we might see it as medical staff not following our guidelines, percentages of chance are not usually written in, it seems to be more of a blanket statement.

    Also as a interesting side note, there is a huge movement within the disabled community to fit such decisions, stating that there should be a "waiting period" for adjustment. I am not sure to what effect, if any, it has on this percentage.

  3. Living wills often use the phrase "if two or more physicians determine that I am suffering from a terminal illness" then care should be withdrawn. If I did not think that a patient had a terminal illness (even if the patient might think so) then wouldn't I be obligated to ignore the directive. Or look at it in regard to an actual case: a young relatively healthy 54 year old man, who's parents had died a prolonged death via use of supportive care in the ICU, had a living will that directed providers to remove him from a ventilator (if he required it) if he was not better after 7 days. We were given this information shortly after he was admitted with a severe pneumonia that progressed to ARDS. Initially he got worse, then on day 3 or 4 started to get better. On day 7 he had still shown significant improvement but was not ready to come off the ventilator. We (I) ignored the directive because the living will did not specifically comment on the level of improvement and seemed counter to wishes he had expressed to family. So I ignored a living will that was trying to respond to a clinical scenario, but did not seem to completely grasp the situation at hand.

  4. I think a physician has the obligation to use their judgment in all decisions. That's why we are there.
    If it was simply a matter of following orders, then Army Medics could run the world (which might be better :))... But it isn't.

    That said.. I have a POLST filled out for myself, and I expect it to be followed. But it is VERY specific, and rather limited... so I imagine it would be. But a lay-person my not have the same specific medical language that we have, and may be unable to express their wishes in a way that providers can actually understand.
    I man.. maybe the average "living will" is too grey for 65% of doctors to actually follow?