Unexpected Evolutions // A change of mind can be momentous

An accomplished doctor told the world that she is rethinking her assumptions about advanced care directives.

That phrase refers to patients’ communications of their wishes, in the event of their future inability to make independent decisions, about medical interventions they favor and those they refuse.

A 1991 federal law, the Patient Self-Determination Act, ensures patients’ rights to decide on their medical care. Patients can also appoint a proxy to make decisions on their behalf.

The doctor, Daniela J. Lamas, a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston, voiced her change of heart in The New York Times earlier this month. The title of her opinion piece bluntly encapsulated the reason for her reconsideration: “When Faced With Death, People Often Change Their Minds.”

In her essay, Dr. Lamas described the case of a patient who had consistently told her loved ones that she would never want to have a breathing tube, an intervention she had experienced when she was younger. And she formalized that decision in an official advance directive document.

In her late 60s, though, she contracted severe pneumonia and struggled to breathe. When doctors called her husband to say that his wife would likely die without intubation, he overrode his wife’s earlier directive and consented to the breathing tube, which was put in place.

At the time, perturbed by that departure from the patient’s declared wishes, Dr. Lamas “murmured an apology” to the unconscious woman.

But when the patient was finally awake and the breathing tube removed, she was grateful for the intervention. She told the medical team that she would choose, if necessary, to be intubated again, and even to undergo a tracheotomy, if it meant more time with her family.

Which led Dr. Lamas to realize that, had the doctors dutifully honored the patient’s earlier declared wishes, they would have violated her current ones by allowing her to die. And they would never know.

Such changes of mind, which Dr. Lamas feels likely happen often, have implications not only in the realm of advance directives but with regard to “physician-assisted suicide,” something already legal in seven countries and, in our own—in ten states and the District of Columbia.

Many years ago, I heard Rav Noach Weinberg, zt”l, recount the story of a Jewish man who, as a result of a swimming accident, became a quadriplegic.

Having spent the first 20-odd years of his life cultivating an athletic physique, he was devastated by his new condition, barred as he was by an obstinate spinal cord and an army of rebellious neurons from playing ball or swimming laps, from eating or going to the bathroom, from so much as scratching an itch on his own.

He could not, he discovered, even kill himself without assistance, which he desperately tried to garner, but to no avail.

Frustrated by his inability to check out, so to speak, he was forced to check in— to turn inward, to serious introspection. Pushed decisively from a universe of action, he entered one of mind.

If life is indeed now worthless, he had to consider, then were running and jumping and swimming and scratching, literal and figurative, itches really what defined life’s meaning before?

To make a long and arduous journey of self-discovery inexcusably short, the young man was led by his thoughts to his forefathers’ faith.

And, astoundingly, if logically, he came to see his accident as a blessing in a most horrible disguise. Had he not suffered his paralysis, he said, he would never have thought to consider the true meaning of his life.

“Humans,” Dr. Lamas writes, “have an amazing capacity to adapt to illness or disease. From the vantage point of youth or good health, it is easy for people to say that they would rather die than live with significant limitations, pain or dependence on others.”

“But people,” she explains, “evolve in ways they cannot expect.”

And, unlike deciding what to have for dinner or what color to paint one’s house, some choices are irreversible.

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