In the first half of the 20th century, most people died of an accident or disease or a physical disorder that inevitably lead to death. Life-saving medical interventions such as sophisticated resuscitation, ventilators, feeding tubes and other life-support were rarely used or even available. Nowadays there is great emphasis on curing medical problems, sometimes without considering that death might be a more welcome outcome.

Oftentimes the families of loved ones, who are near the end-of-life, will go to great lengths to try interventions that may be ineffective in prolonging life. The Terri Schiavo case is a reflection of the attitude of many Americans who are unwilling to let loved ones pass on. Estimates are that about 30% of Medicare reimbursements are spent on people in the last year of their life, although much of this medical care did little to prevent death and prolong life.

According to the Dartmouth Atlas study on death, "The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine's focus is disproportionately on curing, or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers. "

Those who live in areas with a high per capita supply of hospital beds receive much more end of life medical treatment than those who don't.

"Which is better?" From the dying person's perspective, more is not necessarily a good thing - more visits to doctors for someone who is very sick can be stressful and exhausting. For many people a hospitalized death is something to be avoided if at all possible. From the perspective of the health care system, much of the care being given is futile, and accomplishes little.

Deciding How and When to Stop Curing and Start Caring
Some people are content to leave decisions regarding their death in the hands of others. By doing so, they may expose themselves to unnecessary and futile treatments. They may experience numerous visits to the emergency room in the last stages of their life. And their dependency on others often results in great stress to family members when loved ones at the end-of-life lose their capacity and didn't make their last wishes known. Families are often forced to make decisions about life-support and treatment without knowing whether their loved one would have wanted these interventions. There are two basic means to handle end of life decisions. One is a Living Will, and the other is a Do Not Resuscitate order.

One of the most important ways for a person to express his or her intent for the end-of-life is through an advance directive. An advance directive for medical treatment known as a Living Will, and/or a Designation of Health Care Representative, will provide families with guidance on what their loved one wants, and give clear directions on who should have ultimate responsibility.

People often ask me if they should have a Living Will or a Do Not Resuscitate (DNR) order. I tell them a DNR is only appropriate for those people, who, because of a combination of age and severe medical/physical/ quality of life problems, simply do not want anymore medical procedures. In that situation, if they have a heart attack, nurses, or doctors or EMT's will not start treatment. Normally a person with a DNR wears a specially coded bracelet.

A Living Will, on the other hand, means that the person will get all medical treatment that is warranted, even if the Living Will is taped to the forehead, until such time as it becomes apparent that there is no reasonable hope of recovery, which is when the health care representative, who is usually a spouse or child, can tell the doctors to stop the machines.

I still remember a daughter with a Living Will for her mother who called me from the Emergency Room, very upset, that the medical people said she should stop treatment because her mother was very old and had many serious medical issues. She wanted to know if she had to follow their direction. The answer was that the decision was hers, and not the medical personnel, which greatly relieved her. She went home, carefully thought about the insignificant chance for any kind of meaningful recovery, and the next day was ready to decide and had the doctors stop the ventilator.

More detailed information about this subject and about other issues dealing with long term care planning can be found at www.longtermcarelink.net.

Attorney Stephen O. Allaire is a partner in the law firm of Ruggiero, Ziogas, and Allaire, members of the National Academy of Elder Law Attorneys, Inc., with offices at 271 Farmington Avenue, Bristol, (860) 584-2384), or on the web at www.rzalawyers.com. If you have a question, send a written note to Attorney Allaire at Ruggiero, Ziogas, and Allaire, 271 Farmington Avenue, Bristol, CT 06010, and he may use your question in a future column.