Decisions for Advanced Care Planning

“Undeniably, we all must say goodbye someday—how would you wish to say goodbye?”

The end of life approaches quietly, whether through aging or illness. That’s why becoming familiar with the concept of advanced care planning is always a good idea regardless of age, health status, or diagnosis. It offers a meaningful opportunity to explore one’s options, resources, and personal wishes, ensuring that your informed choices and expressed preferences are as clearly defined as possible. This guarantees that those responsible for your care and its effects will act on your behalf in the event of a debilitating illness or death.

Failing to plan causes additional suffering for both the patient and their family. In vulnerable moments, we will be asked to make decisions when we may not be able to, or even speak for ourselves, even with the best intentions, others will be forced to make decisions for us. The stress and struggle to fill the planning void can trigger family conflicts, disrupting the deepest bonds that can be shared during this precious time. Therefore, prior planning can make a significant difference in the end-of-life experience.

- Planning empowers: It preserves a sense of self-sufficiency through personal decisions when we often depend on others.

- Planning provides direction: It allows us to reflect on our lifestyle and quality of life in the future, our medical treatment (with strict limits for accepting or refusing life-prolonging measures) while we have full mental capacity.

Planning allows for creativity and meaning: The biggest concerns of people nearing death are: the well-being of their survivors, the memory they will leave behind, and having completed their unfinished business. How would you use your time at the end of your life? Perhaps you would create a video with loving and inspiring messages for your family, or perhaps you would have a gathering to celebrate your love for family and friends.

Concerns of the terminally ill: the memory they will leave behind, the well-being of their survivors, the frustration of unfulfilled goals, and having completed their unfinished business.

It is relevant to discuss the inclusion of end-of-life decisions within the medical context, such as:

• Advance Directive

A legal document in which conscious and competent individuals establish and describe in advance the care decisions that the patient would or would not want regarding their treatment in the event of incommunicability or incapacity to make decisions..

• Medically Justified Refusal of Treatment

It is the right of any patient to refuse treatment, in the exercise of their freedom of conscience and in accordance with the principle of autonomy, after an informed process of weighing the benefits and risks of the available options, to deny consent to receive any type of treatment. It will always be important to define precisely the type of refusal being made and to have it documented in writing.

• Suspension of treatment

Refusal may also apply to treatments already in progress. A patient may choose to discontinue interventions with the understanding that death may result from the underlying condition.

• Limitation of therapeutic effort

This involves withholding or withdrawing life-sustaining measures (e.g., ventilators, transfusions, resuscitation, artificial nutrition / hydration) when prognosis is poor and the intervention is deemed futile and only contributes to prolonging a biological situation that lacks reasonable expectations of improvement, thus avoiding therapeutic obstinacy.

• Deep and continuous sedation

Reducing the level of consciousness (Central Nervous System) as an anesthetic procedure in order to treat pain or suffering when no further improvement is possible, even if resources and knowledge are available, but, it is only indicated with the consent of the patient (oriented, attentive, knowledgeable about the disease, with a balanced risk-benefit assessment, and not under coercion) or family member.

Ethically, the intentionality is considered in light of the principle of double effect, where the beneficial effect justifies (desire of relief but undesired unconsciousness)

Types of sedation:

- Primary: during invasive procedures.

- Secondary: a side effect of medication (drowsiness).

- Intermittent: maintains periods of alertness.

- Continuous: Sustained unconsciousness

- Light: verbal or non-verbal communication.

- Deep: Complete unconsciousness.

- Palliative: relieves symptoms.

- Terminal (Agonal): Irreversible decline in consciousness during active dying phase.

Care of the sedated patient: continue with sponge baths, skin hydration, postural changes, exercises and massages, hydration, cleaning the mouth with an electric toothbrush, leg bandages or compression stockings, and maintain oxygenation.