Family dynamics is one of the greatest challenges of aging.  Even in loving, communicative families there are differences in opinions as to appropriate or acceptable options, financing of care, responsibility for oversight and other decisions.  There is the emotional turmoil that each family member must face dealing with the deteriorating condition of a parent or loved one.  Family members are emotion filled and the most prudent decisions are difficult to make in this state of mind.  Often parents have cognitive difficulty and are not able to participate in the decision making.

Ask someone to help you negotiate your family challenges.  Do not be ashamed or think that you are unique.  You are not!  Every family and every person in the family has its baggage.  If the family understands that the senior wishes and well being is the center of the discussion, a facilitator can often move a resistant family in a positive direction. 

The first lesson for every senior, in fact every adult, is plan early.  As a senior you are in charge of your destiny and your dignity is important.  By sharing your wishes early, documenting those wishes and sharing the documents that articulate your wishes, you can keep the family in harmony.

Our society does not cherish the aged as some other cultures do.  Because of that, aging is not seen as a part of the journey that is to be relished and shared with the people we love on our own terms.  You do not want your family making life saving and ending decisions when they are emotionally over wrought and in crisis.  You want these decisions to be made long before the crisis situation arises.  One sage senior said it best, no one leaves this work alive.

Items for discussion include the following:

 Do not resuscitate – DNR – This is a physician signed order initiated by the patient when they do not want cardiopulmonary resuscitation.  Each state has a separate process and document for this.  Speak to your healthcare provider or a social worker at your local hospital.  This document is enacted if both your heart and lungs stop functioning.  The DNR will be rescinded during the time you are in operating room at a hospital for a surgical procedure.  If you are seeking this type of medical intervention, it is assumed you would want to be resuscitated.

Do not intubate – If your heart continues to beat, but your lungs and respiratory system is not functioning properly, do you want to have a tube placed in your mouth or nose to assist you in breathing.  This may be temporary or permanent.

Do not use a ventilator – A ventilator breathes artificially for you when your lungs or respiratory system is not working properly.  This is an adjunct to the do not intubate.  You will require intubation for the ventilator to be attached to your respiratory system.  In this case, your heart is work, but your lungs are failing.

No feeding tube – A feeding tube is a means of providing enteral or oral nutrition other than through chewing and swallowing.  This means that you are not able to eat safely for any number of reasons.  It could be temporary after a surgical procedure or permanent such as after a stroke or accident.  A feeding tube is most often used in the senior setting when the patient is unable to swallow (dysphagia) and at risk for aspirating food, fluids or secretions into the lungs causing pneumonia.

There is another resource for articulating and documenting your wishes.  It is called the Five Wishes.  The document may be the starting point for your discussion and is written in easy to understand language.  It can be accessed at www.agingwithdignity.org.

There are a number of other acronyms for living will wishes that hospitals and healthcare providers use.  The basic issue is the lack of discussion about any of these interventions leads to undue confusion and stress. 

The senior will want to discuss their end of life wishes when they are still able to make their own decisions.  Who do they want to make decisions for them?  What decisions do they want made?  Will the agent selected to make the decision be able to make the decision?  It is an honor to be selected as the agent, or decision maker, for anyone.  It means that person respects you and trusts you to support their wishes regardless of the consequences.  Family members do not need to be the agent.  At times, a friend or confidant may be the preferred decision maker.  This is about your life and your dignity. 

The documents have differing titles depending on the state that they are produced.  In general terms, both of these documents should be produced.  The first is the Power of Attorney for Healthcare (POAHC).  The second is the Power of Attorney for Finance or Property (POAP).  The POA is your agent, the person who will act on your behalf, when you are not able to make decisions for yourself.  This can be temporary or permanent.  Decisions are not made by the agent if you are capable of managing your own affairs.  Sometimes there is a challenge when the senior has dementia or a cognitive issue.  In those cases, an attorney, a hospital risk manager, the language or documents and/or your healthcare provider will help the family through the process.  The document is written in legal ease and is generic enough for use by all.  Problems arise if you have not designated someone in writing prior to your incapacity.  Often families cannot agree.  The courts are often called on to make decisions and assign guardians who do not know you or your wishes.  In addition to being expensive, your autonomy and dignity are in the hands of a stranger.  Select someone who is able to make the decisions you want made.  Speak to several people about your wishes and select the person who has beliefs similar to yours.  It is difficult enough to act as an agent, but very stressful if your personal or spiritual beliefs are in conflict with the decisions you are making as an agent.  In most states the specificity of the living will wishes is not clearly articulated in the legal language of the POA document, e.g. DNR, no ventilator, no feeding tube.  In most states you can rescind or change your documents at will.  An attorney can assists you with your state laws.