**8. The living will in the end-of-life**

The controversies about the end-of-life ethical dilemmas can be traced to ancient Greece and Rome. In that distant past, it was mainly focused in the treatment stubbornness. However, it is with the development of knowledge and research in lifesaving drugs and technologies, that the debates medialize on various fields, the main point of convergence being euthanasia and dysthanasia.

In a nearby future, with an increase in average life expectancy and innovations in medical technoscience it seems little probable that there will be a decrease in these disputes. Anyhow, a realistic hope in the reduction of the controversies should have its mainstay based in prevention. Hence, an objective of all those who have a leading position in the society should be to curtail the disposition towards this confrontation.

How to downsize this problem?

The struggle to curtail has evolved through the years and there has been no consensus for an acceptable agreement. Starting with the denomination of the dilemmas, passing to the definition itself and ending with the parties involved, an acceptable accordance is far from being a reality.

For example, so far as the denomination of futility is concerned there have been various suggestions to shift for a different terminology like non-beneficial treatment, medically inappropriate, medically inadvisable or not medically indicated, among others, but each one with some drawbacks.

In any dispute of end-of-life dilemmas, there is an involvement of three parties, the patient, the family, and the team of physicians and the institution that provides the health care.

In my opinion, the solution to ease this challenging problem will be met, at least partially, by the unveiling of the living will. Henceforth, in this demanding issue, every effort should be directed to engage all the involved parties in supporting and diffusing the living will.

In the western societies there have been a progressive acceptance and legislation of the living will. The main reason for its broad recognition and approval is the affirmation of the principle of autonomy, through the informed consent, in the Anglo-Saxon countries.

Other arguments for its recommendations are religious creeds (no acceptance of blood transfusions by Adventists cult) and those who reject resuscitation maneuvers fearing a bed quality of life that could result from this procedure.

On the other side, in the eastern countries, or societies where there is a predominance of principle of beneficence and family-oriented decision-making, the living will have hardly made any inroad in this matter.

#### **8.1 The living will**

The living will or advanced directive specifies what types of medical treatment are desired by a person in circumstances in which he is no longer able to express informed consent.

A living will can be very explicit and precise or very general. The most frequent statement in a living will, appeals that if the patient suffers an incurable, irreversible illness or condition, and the attending physician decides that the condition is terminal, life-sustaining measures, that would serve only to prolong dying, be withheld or discontinued. More explicit living wills may include details regarding an individual's desire for measures such as pain relief, antibiotics, hydration, feeding, and the use of ventilators, blood products, or cardiopulmonary resuscitation.

The intrinsic objective of living will has two main intents: give the concerned person a control regarding his health in an end-of-life setting and take a burden and distress off the shoulders of his family and thus avoid the self-condemnation complex that sometimes curtails a painful decision. Moreover, the living will elude the discords which may arise among family members about the prescription or withholding of specific treatments.

In this circumstance, it is expected that the author of the will is mature enough to interiorize his illness, the natural process of the disease and his own death.

The decision to draft a living will is not a sprint against time; it must be a follow-up of various steps that entails the acceptance of the illness by the patient, the treatment limitation and the evolution of the disease till the death. For all these discernments required, the living will should not, a priori, be addressed in acute settings.

It should be retained that the living will can be revoked or changed as often as the person wishes. However, he should notify all parties who were informed of the living will.

It is desirable, but not indispensable, for the patient to discuss with his physician his apprehensions, fears, and values. No one, better than his physician, to explain him the natural history of his illness, the prognoses, the technical means, and their limits.

Not under any condition, can the physician use his knowledge to shape or imprint the decision in a negative way.

In brief, the living will have, typically, two parts:

On the one hand is named the person who will be answerable to fulfill with treatment orientations and care in the end-of-life. The attorney should be someone in proximity and trustworthy to the person and with awareness of his line of rationale. The attorney, one or more, can be a family member or a close friend. In case of more than one attorney it should be overtly established if the resolution should be collective or individual and how to decide in a case of a stalemate.

On the other hand, there should be clearly stated what diagnostic methods and treatments should be authorized and those that are to be refused.

The living will is not an alchemy for all the dilemmas related to end-of-life ethics, but it is, beyond any doubt, a good means to obviate many scenarios of anguishing treatment decision making and provide the patient a dignified death.

#### **8.2 The physician role in the living will**

What can be the role of the physician in the patient's living will?

The living will that is considered in this text is the one dealing with chronic diseases in their advanced stages. In this setting the physician should consider the

**43**

the result.

*End-of-Life Ethical Dilemmas*

and prognosis.

*DOI: http://dx.doi.org/10.5772/intechopen.93616*

require in the acute exacerbations.

**8.3 The family part in the living will**

ness of the vulnerable patient.

environments of the societies.

**8.4 The hospital involvement**

**9. Concluding remarks**

those presumptions.

and uncertainties?

consider, not enforce, the living will.

patient at home.

timing of the discussion, nature of the illness, quality of life, the end-of-life care,

The dialog should take place not in a specific visit of the patient but through the various follow-up assignments. The physician should explain in a clear and accessible conversation the natural history of the illness with its effect on his quality of life, the end-of-life care that he may eventually need and the treatments options that he may

This conversation can be handled by the primary care physician or the specialist consultant who has been following the patient. In my opinion, the consultant physician, with all his experience, will be in a better position to clear the doubts and eager-

The feelings and attitudes towards the end-of-life depend on the sociocultural

In some settings, the family can refuse home nursing the household or allow the treatment limitation and bring back home the family member. This posture can take place for various reasons: spiritual and psychological unpreparedness for the death of their beloved, not knowing how many days would ensue till the patient's death or the physical, familiar and financial concerns that would imply to take care of the

The role of the hospital should be focused mainly in preventive measures that should be aimed to remind the physicians, through codes of conduct, to clarify the patient and the family of the evolution of the illness, and, at the proper moment to

In case of disagreement between the family and the physician, the back-office team involving a representative of ethics committee, a psychologist, and an eventual patient religious representative, can have good chances of solving the struggle.

In Medicine**,** bioethics is a field of study concerned with the ethics and philosophical implications of certain medical procedures, technologies, and treatments; in this case, the end-of-life ethical dilemmas, are directly or indirectly related to

The main interrogation is to know why these procedures raise so many doubts

As previously outlined, in the words of French sociologist Edgar Morin, the great bestowal of knowledge left by the twentieth century was the awareness of the limits of knowledge. And he endowed that the major conviction is that uncertainties

For this scholar, the knowledge is imbued by three principles of uncertainties:

In the pursuit of medicine, despite of countless progress in the fields of physiopathology and technical advances that evaluates and modifies the natural history of numerous clinical ailments, the skepticism and the unpredictability can overshadow

are unable to be dismissed not only in action but in knowledge.

The brain, the psychic, and the epistemological uncertainties.

#### *End-of-Life Ethical Dilemmas DOI: http://dx.doi.org/10.5772/intechopen.93616*

*Bioethics in Medicine and Society*

withholding of specific treatments.

imprint the decision in a negative way.

**8.2 The physician role in the living will**

In brief, the living will have, typically, two parts:

collective or individual and how to decide in a case of a stalemate.

treatments should be authorized and those that are to be refused.

What can be the role of the physician in the patient's living will?

The living will or advanced directive specifies what types of medical treatment are desired by a person in circumstances in which he is no longer able to express

A living will can be very explicit and precise or very general. The most frequent statement in a living will, appeals that if the patient suffers an incurable, irreversible illness or condition, and the attending physician decides that the condition is terminal, life-sustaining measures, that would serve only to prolong dying, be withheld or discontinued. More explicit living wills may include details regarding an individual's desire for measures such as pain relief, antibiotics, hydration, feeding, and the use of ventilators, blood products, or cardiopulmonary resuscitation. The intrinsic objective of living will has two main intents: give the concerned person a control regarding his health in an end-of-life setting and take a burden and distress off the shoulders of his family and thus avoid the self-condemnation complex that sometimes curtails a painful decision. Moreover, the living will elude the discords which may arise among family members about the prescription or

In this circumstance, it is expected that the author of the will is mature enough

It should be retained that the living will can be revoked or changed as often as the person wishes. However, he should notify all parties who were informed of the

It is desirable, but not indispensable, for the patient to discuss with his physician his apprehensions, fears, and values. No one, better than his physician, to explain him the natural history of his illness, the prognoses, the technical means, and

Not under any condition, can the physician use his knowledge to shape or

On the one hand is named the person who will be answerable to fulfill with treatment orientations and care in the end-of-life. The attorney should be someone in proximity and trustworthy to the person and with awareness of his line of rationale. The attorney, one or more, can be a family member or a close friend. In case of more than one attorney it should be overtly established if the resolution should be

On the other hand, there should be clearly stated what diagnostic methods and

The living will is not an alchemy for all the dilemmas related to end-of-life ethics, but it is, beyond any doubt, a good means to obviate many scenarios of anguishing treatment decision making and provide the patient a dignified death.

The living will that is considered in this text is the one dealing with chronic diseases in their advanced stages. In this setting the physician should consider the

to interiorize his illness, the natural process of the disease and his own death. The decision to draft a living will is not a sprint against time; it must be a follow-up of various steps that entails the acceptance of the illness by the patient, the treatment limitation and the evolution of the disease till the death. For all these discernments required, the living will should not, a priori, be addressed in acute

**8.1 The living will**

informed consent.

settings.

living will.

their limits.

**42**

timing of the discussion, nature of the illness, quality of life, the end-of-life care, and prognosis.

The dialog should take place not in a specific visit of the patient but through the various follow-up assignments. The physician should explain in a clear and accessible conversation the natural history of the illness with its effect on his quality of life, the end-of-life care that he may eventually need and the treatments options that he may require in the acute exacerbations.

This conversation can be handled by the primary care physician or the specialist consultant who has been following the patient. In my opinion, the consultant physician, with all his experience, will be in a better position to clear the doubts and eagerness of the vulnerable patient.

#### **8.3 The family part in the living will**

The feelings and attitudes towards the end-of-life depend on the sociocultural environments of the societies.

In some settings, the family can refuse home nursing the household or allow the treatment limitation and bring back home the family member. This posture can take place for various reasons: spiritual and psychological unpreparedness for the death of their beloved, not knowing how many days would ensue till the patient's death or the physical, familiar and financial concerns that would imply to take care of the patient at home.

#### **8.4 The hospital involvement**

The role of the hospital should be focused mainly in preventive measures that should be aimed to remind the physicians, through codes of conduct, to clarify the patient and the family of the evolution of the illness, and, at the proper moment to consider, not enforce, the living will.

In case of disagreement between the family and the physician, the back-office team involving a representative of ethics committee, a psychologist, and an eventual patient religious representative, can have good chances of solving the struggle.
