Friday, March 2, 2012

Avoiding Tithonus’ Mistake

Over 150 years ago the renowned Alfred, Lord Tennyson first published his poem about Greek mythology’s Tithonus, a mortal who was the lover of Eos, the goddess of dawn. Eos loved the handsome Tithonus and the couple wanted their love to go on forever. But they knew that they would be separated when the mortal Tithonus died while immortal Eos would live on.

Tithonus came up a plan that involved what we might today view as an advance health care directive. He would seek to become immortal himself. 

On her lover's behalf Eos petitioned her father Zeus, who ruled the gods of Mount Olympus, to grant Tithonus eternal life.  Zeus had the power to approve the request and was sly and jealous of the handsome Tithonus. He understood that there was tragic flaw in Tithonus petition. Zeus granted the request for eternal life but with no provision for Tithonus’ continued youth or health.    

As time passed, the aging Tithonus’ became increasingly decrepit and demented. (In some versions of the myth, though unable to allow his death, Eos was able to ease Tithonus suffering by turning him into a cricket). 

Tithonus mistake was that had made an irrevocable decision about the continuation of his life without fully understanding what conditions might be like in his future.  He neglected to build any flexibility into his eternal life directive – so he couldn’t take it back or change it, and though he eventually longed for death, he could not die.

Of course immortal earthly life is not currently an option for any of us. But, medical advances have increased our ability to extend life in circumstances where patients would formerly have died. The extension of life can be a great blessing if it allows for a meaningful continuation of existence. But there may come a time in our life where prolonging it would be poisoned gift and we, like Tithonus, would rather be dead.

When we prepare end of life instructions in an advance directive (like a living will or health care power of attorney) we should remember Tithonus' story and recognize that we cannot now fully anticipate the health care situations we may encounter in the future. In addition, our view of how we want to deal with medical conditions and treatment may change with the life experiences and aging that we experience after we sign a directive. This means that when we give instructions for our future treatment we should be careful to provide enough flexibility so that the decisions that are made for us will be appropriate under unforeseen and changing circumstances.

Tithonus failed to consider that his circumstances and desires might change as he aged. And he failed to build flexibility into his advance directive.  Don’t make Tithonus mistake – don’t lock yourself too narrowly into decisions for tomorrow based upon today’s limited vision.   

How to Build Flexibility Into An Advance Directive

One way we can build flexibility into our advance directives is to appoint a trusted surrogate (agent) to make decisions for us and to give that surrogate the authority to determine the right course of treatment under whatever circumstances may arise. Here is an example of the type of provision some people include in their directives:

The instructions contained in this document are intended to provide guidance to my Agent. I recognize that it is impossible for me at this time to anticipate all of the contingencies that could develop.  It is my desire that my Agent apply my general philosophy to the total circumstances that may arise in determining whether any specific treatment should or should not be instituted or continued.

But appointing a fully empowered agent is not enough. Our advance directive can still result in our receiving unwanted care if our agent in uninformed and makes poor decisions.

There is a natural tendency for people who care about us to provide us with too much care. An agent, under stress, and acting on inadequate information, can too readily authorize life-prolonging treatment that we would prefer to refuse. And our doctors, who may not know us at all and for whom a patient’s death may represent a kind of failure, may encourage families towards more treatment. As a result, when a decision needs to be made, there is often an understandable but undesirable bias toward over-treatment.

We can use frank and open conversations to fight the tendency toward over-treatment and give our caregivers the information they will need to make the right decisions for us. 

A future medical crisis situation may not give you the chance to discuss critical issues with your family. Don’t delude yourself that your family members will know what to do. They probably won’t unless you have prepared them. 

Talking now can spare your family members from the agony of having to make painful decisions without any meaningful guidance about what you really want. Important issues can be considered while there is time for reflection and discussion.

Planning should be a Process not a Document
Don’t make the mistake of thinking that your planning is complete when you sign an advance health care directive. Effective planning is a process not a document. The key aspect of planning is ongoing discussion which begins now and continues as we age and our health and viewpoints change.  

To plan effectively, consider following these steps:
  • Think about the care you want to receive at the end of your life,
  • Discuss your preferences with the person you choose as your surrogate decision maker and your family and others close to you,
  • Complete documents that record your decisions and which are flexible enough to allow your surrogate to make appropriate decisions for you under whatever circumstances arise,
  • Continue having regular discussions with your surrogate and potential caregivers as time goes on and your life, health, and attitudes change.

Although it may be uncomfortable at first, now is the best time for you to think about your preferences for end of life medical care and talk with your family and physician. If you start the process now, and continue it as you encounter life’s transitions, your family won’t have to make uniformed decisions at the time they are most stressed and emotional. Your family and doctors won’t have to guess at what you would want.

A wonderful tool has been developed to provide families with a relatively easy means of opening the conversation about future health care.  This tool, the Health Care IQ Test, is available for free downloading from the Marshall, Parker and Associates website at:  

Thinking ahead and talking in advance about some of the dilemmas that may arise toward the end of your life can be a great blessing to both you and your family. The more your family and caregivers know about your preferences, they less they will have to guess and disagree and argue. The conversations will enrich everyone’s perspective and equip those who care for you to best benefit your life at its end.  

Further Reading

Advance Directive Planning Tools, Marshall, Parker & Associates 

Taking Care: Ethical Caregiving in our Aging Society, The President's Council on Bioethics

Weighing the Chances at Life's End, New Old Age Blog

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