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„The Basic Problem Remains“
Patient's wishes should be clearly
stated and up-to-date
© Rainer Sturm/Pixelio.de
Georg Mols is again and again being confronted with advance directives in his every day working life. MEDICA.de talked to the anesthesiologist working at the University Hospital about imprecise phrasing, omissions in the new law and how to unburden doctors in terms of delivering life and death decisions not just legally.
MEDICA.de: Mr Mols, advance directives are binding for doctors in Germany starting on 1st September. Does that mean that discussions revolving around self-determination of patients are going to be finished once and for all?
Georg Mols: No, because the basic problem still remains. An advance directive does not always reflect the current patient's wish. Circumstances or health status may change quickly which in turn may influence the will to live. If this has not been considered and changed in the advance directive doctors still need to find out what kind of treatment would be the one requested by the patient in the current situation. This kind os questions also concerns us when an advance directive has been vaguely formulated.
MEDICA.de: Why is it so hard for people to precisely and clearly formulates their wishes?
Mols: Patients often misjudge medical treatment or they formulate their perceptions in a too simple way.
MEDICA.de: Can you give me an example?
Mols: Well, an example would be a patient simply writing down „I do not want to receive artificial respiration“. This is very broad. I suppose he does not want to receive that treatment over a long period of time. However, if this kind of phrase remains as imprecise it may be of danger for the patient in case he has an accident and needs quick surgery - a case where artificial respiration needs to come into action for a few minutes, maybe a few hours. Considering this in the context that the treatment will most probably be successful, it truly is debatable whether this patient really does not want to receive artificial respiration.
MEDICA.de: What could be of help to a patient in order to avoid such vagueness?
Mols: A medical consultation before writing down an advance directive may help to get rid off misunderstandings and in turn lead to more precise formulations. The law does not plan such consultations, though. That is unfortunate. If patients nevertheless want to get information they should seek advice with doctors that are being confronted with such situations in every day life such as critical care specialists, surgeons or internal specialists.
MEDICA.de: Does it happen often that doctors hold an imprecisely formulated advance directive in their hands?
Mols: This does not happen often in acute situations. In the case of an emergency such as an accident, treatment will begin as quickly as possible. Saving the person's life has highest priority. If an advance directive will come up later, it may well be the case that one did not treat in terms of the patient's wishes. However, far more often we deal with advance directives outside emergency situations. If these are not clearly formulated we try to find out the wishes with the help of relatives.
MEDICA.de: But this needs to be done too when there is no advance directive. Does the law then make sense at all?
Mols: A precise and current advance directive certainly is of help since we want to respect patient's wishes. As long as we are informed about those wishes we are more able to act in their best interest.
MEDICA.de: Are you confronted with a dilemma when the patient wishes to die? You as a doctor are supposed to save those lives.
Mols: This dilemma is not always that great. We are supposed to save lives but not at all costs. We have to weigh up also from a medical point of view whether life-sustaining measures are reasonable or only extend the suffering. Artificial respiration and total parenteral nutrition do not make sense when there is no prospect of recovery. However, since we are often faced with probabilities, it is hard to decide for or against a measure, also from a doctor's point of view. There is no such thing as total certainty whether or not the condition of a very ill person will improve.
MEDICA.de: Does the new law make it easier for you to decide by following the advance directive when turning off life-sustaining machines? At least, you are not to be held legally responsible anymore.
Mols: The law does give us some relieve from a legal perspective since we do not have to fear legal disputes anymore. But there is more to it than that because we want to respect the patient's wishes. It is not possible to legally regulate whether we do meet this wish with our decision after all. This means that the law does not disburden us from a personal perspective. I hope for the future that people will think more about what they really wanr in the case of an emergency. The only way that the law could really give us some personal relieve would be if it triggered a public discussion resulting in more precisely phrased advance directive.
The interview was conducted by Simone Heimann.