Whose wishes are we honoring?
Sometimes uncertainty can be met with a time-limited trial: Use intensive treatment for an agreed period, define what improvement would look like, then reassess together.
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Sometimes uncertainty can be met with a time-limited trial: Use intensive treatment for an agreed period, define what improvement would look like, then reassess together.
EMERGENCY procedures — including chest compressions, electrical shocks (defibrillation) and emergency medications — used to restart the heart and restore circulation if cardiac arrest occurs.
My father was 91 when he died. Ninety-one is an age that now carries both gratitude and grief for me: gratitude for the long life we shared, and grief because no number of years makes a father easier to lose.
Recently, a patient of mine also turned 91. She is lovely, strong-willed and living with several medical problems. Until recently, she had been doing well. The suddenly she was in the intensive care unit. I will keep the details private, but seeing her age on the chart brought my father suddenly into the room. For a moment, I was both physician and daughter, aware of how different those two positions can feel.
In the ICU, families may be asked whether to intubate, continue dialysis, give medications to support blood pressure, or perform cardiopulmonary resuscitation (CPR) if the heart stops. The questions sound technical, but their center is deeply personal: What outcome would this person consider worth fighting for? What burdens would she accept for a chance to return to a life she values? What would be too much?
This is where advance care planning helps. It should not begin with, “Do you want us to do everything?” That phrase can make any limit sound like abandonment. A better conversation begins with the person: “What matters most if your health worsens?” “What are essential to your quality of life, such as the ability to breathe on your own?” “Who should speak for you if you cannot?” The physician must then explain, in plain language, what each treatment can realistically achieve and what it may cost in pain, loss of function, or of independence.
A do-not-resuscitate order is often misunderstood. It does not mean “do not treat,” and certainly not “do not care.” It applies to chest compression if the heart stops or intubation if the patient is unable to breathe on his own. Other treatments — antibiotics, oxygen, dialysis, nutrition, blood-pressure support, or careful relief of pain and breathlessness — are separate decisions and should be matched to the patient’s goals.
An advance directive is also not carved in stone. A patient who still has decision-making capacity can change or cancel it. Present wishes take precedence over an older document. Code status and treatment limits should be reviewed when the illness, prognosis, or the patient’s priorities change. Sometimes uncertainty can be met with a time-limited trial: use intensive treatment for an agreed period, define what improvement would look like, then reassess together. If the goals are not reached, stopping an intervention is not the same as abandoning the patient. Care continues; its purpose changes.
But reversibility must not become a way for families to erase a patient’s voice once she can no longer speak. A surrogate’s task is not to answer, “What do I want?” It is to ask, “What would the patient choose?” We listen for the answer in what she said before, how she lived, what she feared, what she valued, and what she considered an acceptable life. If her wishes were never known, the family and medical team must consider her best interests, including the likely benefits and burdens of treatment.
In the Philippines, where end-of-life directives still lack one comprehensive national legal framework and hospital procedures may differ, clear conversations and documentation become even more important. A written directive should be shared with the chosen decision-maker, family, and physicians, then revisited after a major diagnosis or change in health.
When my father was ill, I learned that loving someone can make us want one more day, one more treatment, one more chance. That longing is human. But love must also listen. The most faithful decision may not be the one that prolongs life at any cost, nor the one that ends treatment quickly. It is the one that comes closest to the life and wishes of the person before us.
My patient is 91 and strong-willed. If illness has temporarily taken away her voice, our responsibility is not to replace it with our own. It is to help her voice carry over so that we may hear what she has to say.
