Our story begins with the attending physician calling a family meeting to discuss the approach to future treatments as he felt that future blood transfusions were not warranted. The family included an aging husband and two daughters and a son, the latter a physician.

Interpreting wishes

The patient had written a living will, a copy of which was on the health record. Based on what was written, the treating physician suggested that the patient, who at this point was significantly cognitively impaired, had indicated that treatments of the nature of the blood transfusion would not have been wanted if she were able to communicate.

The wording included, “no heroic treatments, … no hope of recovery … comfort measures only.” The treating physician interpreted the living will as meaning that further treatments, including blood transfusions, should be stopped and the patient provided with end-of-life care in a palliative mode. He indicated to the family that blood should be looked at as a very special resource of limited supply and that it should not be used in a terminally ill patient for symptom control when there was not hope for any significant long-term benefit.

The son, who was a doctor, disagreed, stating that he believed that the blood transfusions were part of palliative care in that they provided his mother with relief from the shortness of breath that occurred when her blood count level fell below a critical level. The patient’s cognitive status was such that she could really add to the discussion nor indicate what she really meant in her living will’s directions. What did “no hope for recovery” mean? Was it from the anemia that could be treated with blood transfusions from time to time or the malignant blood disorder which clearly was beyond any therapeutic benefit from previously tried chemotherapy?

What is “heroic” in contemporary medicine? A blood transfusion is technically very simple these days, but it does require someone to donate the blood for the purposes of helping an ill person. Is such a use for short-term benefit really justified and is this what the patient might have meant when she wrote about “heroic measures”?

Is there a right answer?

The case became quite complex with disagreement among the various parties, including within the family. One of the daughters believed that her mother would not have wanted to have her life prolonged under such circumstances.

An ethics consultation was requested. Ultimately the patient was transferred to a palliative care unit where the idea of blood transfusions would be considered one option in the care but not the main approach to providing comfort measures.So, did the living will really add anything to the terrible decision-making process when this very devoted family struggled to find the “right” approach to care?

During and after the Terri Schiavo case there was intense media attention and legal wrangling at the highest levels until the decision was made that she be allowed to die. The final decision was based on her husband’s assessment of what her wishes would have been had she been able to communicate.

The questions are whether a living will would have avoided the controversy and acrimony in the Schiavo case and whether having one for most people would really help their families make difficult end-of-life decisions.

Be clear ahead of time

Many in the field of aging would suggest that although the living will can be a useful document, the most important part of the process is not the written document itself. It’s the discussion and the expression of values, beliefs and wishes that the family should be able to use more than a sometimes ambivalent written document when figuring out what decision reflects the expectations of your loved one. My advice is to make sure that the discussion takes place now, whether it is written or not, and clarify issues that may be unclear so that everyone in the family feels comfortable making heart-wrenching but very important end-of-life decisions. n

Dr. Michael Gordon is Vice President, Medical Services; and Head of Geriatrics and Internal Medicine at Baycrest Centre for Geriatric Care. He is the co-author of Parenting your Parents, now in its second edition.