Before the early 1960s, there was no particular need for a living will or advance directive. Back then, if a person’s heart stopped, that was it. Cardiac arrest rapidly led to death. But in 1960, a method of “closed-chest cardiac massage” was described in an article in the Journal of the American Medical Association.1 The article reported on 14 patients who survived cardiac arrest via application of the new technique. The innovative procedure was refined over the next few years and became known by the term with which we’re familiar, cardiopulmonary resuscitation (CPR). Guidelines for the use of CPR were developed and continue to be updated.2
CPR provided the possibility of a return from death under certain circumstances. The primary concern with CPR, of course, is the amount of time that the person’s brain has been deprived of oxygen. MedlinePlus, a service of the U.S. National Library of Medicine and the National Institutes of Health, states that permanent brain damage begins after 4 minutes without oxygen and death may occur as soon as 4 to 6 minutes later.3 Problematically, fewer than 50% of persons in cardiac arrest receive CPR from bystanders, and emergency responders have no accurate means of determining how long it has been since the victim’s heart stopped beating. As a result, many of those who survive CPR have some degree of brain damage, often serious or severe. Given a choice, at least some of these persons might have desired not to be resuscitated if the circumstances were not optimal.
Similarly, terminally ill patients or those suffering a catastrophic injury may require artificial hydration and artificial nutrition (ANH) to sustain life. But some persons, given a choice, might not choose such means of survival if they were able to state their preferences and desires. ANH might be viewed as unacceptably onerous. The quality of life obtained might be viewed as insufficient. These persons would prefer to permit natural processes to determine whether they live or die.
But if one has not enacted a formal living will, one’s medical treatment is determined by the medical standards of the community. Typically, any and all available life-saving measures will be utilized when needed, based on the presumption that saving a life is always better than the alternative. A living will is required in the event that one is not able to speak on one’s own behalf. With respect to medical treatment, a living will provides the opportunity for having one’s desires and preferences honored and implemented.
1Kouwenhoven WB, et al: Closed-chest cardiac massage. JAMA 173:1064-1067, 1960
2Field JM, et al: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation 122:S640-S656, 2010