Nutritional Support

When a patient is hospitalized with a life-threatening illness or injury, very quickly he will need nutritional support to avoid the complications of a starvation state. If that patient cannot eat, nutrition can be given directly into the gastrointestinal (GI) tract via a tube, or through a special IV. Either way is labor intensive and expensive, each with its own advantages and complications. Nutritional support is usually discontinued when a patient is able to eat. If the patient is getting ventilator support, nutritional support is indicated early, the intent being to minimalize muscle wasting and the time spent on the ventilator. Eating is one of life's sublime pleasures. If I have no prospect of being able to eat again, I do not want a tube placed into my gut to keep me alive. If I'm coherent, I will state this. If unable to speak for myself, I want someone to refuse nutritional support for me.


Arrhythmia implies abnormal heart rhythm. It usually refers to ventricular fibrillation or tachycardia, both of which result in ineffective pumping action and cessation of blood flow. It is usually fatal unless normal rhythm is restored.

Ventilator / Respirator / Mechanical Ventilation / Breathing Machine

A ventilator is a bellows that breathes for the patient who cannot breathe for himself. Mechanical ventilation requires a breathing tube in a patient's airway and care in an ICU. Usually such a patient is paralyzed with drugs to maximize the benefits of the machine. A breathing tube is a soft, plastic tube about a foot long. Such a tube can damage a patient's vocal cords if left in place longer than 3 or 4 weeks. After that, the patient needs a tracheostomy, a tube surgically placed into the airway below the vocal cords through the lower neck. With either of these breathing tubes in place, a patient is unable to speak. Most patients with respiratory failure eventually breathe on their own and are disconnected from the ventilator. In worst circumstances, patients need a ventilator the remainder of their lives (Steven Hawking, Christopher Reeves). If I am on a ventilator for longer than 4 weeks with little chance of getting off, I want the paralyzing drugs stopped so that I have the opportunity to awaken, have the breathing tube removed, and say goodbye to my loved ones.


Without kidneys one builds up toxins in the blood that in a week or so will lead to coma and painless death. Dialysis involves an artificial kidney machine that “cleans” the blood of toxins. Acute kidney failure can be transient, requiring only short-term dialysis. Unremitting, chronic renal failure requires lifelong dialysis. A dialysis session usually takes several hours to complete, after which the average patient is “wasted” the rest of that day. The typical patient has to repeat dialysis three times a week. Chronic dialysis patients are often some of the sickest and most fragile of patients, requiring their own specialist (nephrologist) for care.


CPR is performed when a victim has no heartbeat and/or stops breathing. This involves blowing a large breath of air into the victim's lungs, followed by heavy pressure applied to the breastbone with the heel of one's hand (hard enough to compress the underlying heart and force blood out of the heart chambers, mimicking the pumping action of the heart). CPR extends thousands of lives annually and has become the standard procedure in hospitals and nursing homes when patients have cardiac or respiratory arrest (unless there are orders stating otherwise). CPR can also involve electrically shocking (defibrillation) the heart to convert an ineffective heart rhythm into one that works. The better the overall health of the patient, the more likely CPR is to be successful. However, CPR has a dismal track record when used in chronically ill or terminal patients. The number of these patients who eventually leave the hospital is infinitesimally small. If I have an unexpected cardiac and/or respiratory arrest as an isolated event (I have no prior pathology in either of these organ systems), then I want CPR. However, if I am critically ill or terminal when I arrest, I do not want CPR. Death due to either circumstance would be a natural and good way to die.

Terminal Condition

If a person has only 6 months or less to live in the eyes of two physicians, his condition is called “terminal.”

Brain Injury/Pathology

The brain pathologies to which I refer leave you severely compromised cognitively, unable to live independently. Stroke, brain hemorrhage, and head trauma are examples (e.g., Terri Schiavo). I consider a vegetative state a condition far worse than death.


Hemiplegia refers to the paralysis of one entire side of the body.

Progressive Dementia

For example, Alzheimer's.


Aphasia is the inability to speak.

High Spinal Injury

Severe spinal injuries of the neck cause quadriplegia (paralysis of all four limbs) and occasionally respiratory failure. These injuries are permanent and leave the victim severely disabled. Evacuation of bladder and bowel no longer occur naturally. These patients are at high risk for infection (pneumonia, urinary tract) and for skin breakdown (bedsores). Life span for them is usually significantly shortened (e.g., Christopher Reeves). At my age, I do not want to live with this degree of incapacity.

Severe Burns

For purposes of discussion I chose 50% or greater of the total body surface area burned full-thickness (third degree). Burns of this severity are associated with very high mortality rates and even greater complication rates. Recovery requires emergency resuscitation, months spent in a Burn Unit, many operations to restore skin coverage and preserve limb function, and often requires lifelong physical therapy. Pain control issues are huge. Survivors often say they would never have wanted resuscitation had they known what they were in for at the beginning. If I am the unfortunate victim of a burn this bad, I would prefer to die, which would occur anyway without heroic support. If I am able to speak for myself, I will refuse resuscitation, asking only for pain relief while waiting to die. Bad things happen to good people—meaning you and me. Any of us could have a life-threatening problem tomorrow. Does it then not make good sense to have a document that clearly states what we want done if we are in a medical crisis? Does it then not make good sense to talk with our loved ones about what we would want, what they would want, if any of our lives were threatened by some pathologic condition? Does it then not seem prudent to name someone who knows us well to speak for us if we are unable to speak for ourselves? In the introduction above, the reader will find ample information for writing one's own AD. The time is right. Do it!

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