To the Editor,
I read with great interest the editorial ‘Who Should Make Medical Decisions When a Patient Lacks an Advance Directive?’ by Dr Dygert and Dr Lewis. 1 This editorial raises important bioethical issues. Indeed, at times where a patient is not in state to declare his wishes regarding advance directives, physicians are called to make choices along with his surrogates that have to do with critical issues, like the end of life or sustaining life even when its quality will be severely compromised. Several articles have attempted to approach this issue by mentioning real-life scenarios.1,2 It is of note that decision-making in such cases is highly affected by the cultural and geographical background of individuals involved in such discussions. For example, in South European countries, religion and family ties play a very important role in surrogates’ reasoning and were found to be the common factors among different South European countries. 3 On the other hand, in some Asian cultures, talking openly about death is postponed, even when it is imminent, as it is often considered emotionally difficult to handle, thus, appropriate decisions regarding advance directives are not taken. 4 Reducing the gap between surrogates’ and physicians’ reasoning in the case of disagreement regarding management of patients without advance directives that face the end of life would require, in the long-term, appropriate cultural changes that would allow for end-of-life discussions to be more easily performed, without fear of disagreement. Such changes could also require other changes, such as legislation changes that could, for example, require all admitted patients to pre-fill a form with advance directives upon admission, regardless of the cause of admission. This, would reduce the number of patients where advance directives were unknown, and is already performed in some hospitals in North America.
Furthermore, involvement of a psychologist early in the course of a hospital admission where complications seem to multiply and end-of-life discussions arise could soften the feelings of hopelessness and allow for an easier acceptance of an inevitable event. Such interventions should aim for avoidance of the feeling of guilt that often develops in surrogates of patients where end-of-life seems to be approaching, which makes it difficult for them to concede in non-application of all life-sustaining treatments. 5
After all, it is anticipated that acceptance by surrogates of the possibility of a patient’s death will continue to be a difficult issue for physicians caring for patients that approach the end of life, especially in specific geographic regions and specific cultural groups. Active involvement of experienced personnel in the short-term and public discussion and legislation changes in the long-term could aid in reducing the stress of end-of-life discussions and help towards achieving decisions that are for the best of the patients’ interest.
Footnotes
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Petros Ioannou https://orcid.org/0000-0003-1082-5674
References
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