"Mr. B is a 76-year-old Vietnam veteran presenting with profound left sided weakness."
No matter what information was about to follow this opening sentence, I knew this patient was definitely in harm's way.

Sure enough, as the presentation continued, our team learned that Mr. B had noticed decline in his physical function for a few weeks at home, on top of worsening memory and cognition over several years. Soon he noted a heaviness in his left arm and leg, as well as pain in his ribcage, and in a matter of days he was so incredibly weak that he was crawling up and down the stairs. In an urgent care clinic, a chest x-ray revealed a large mass in his right lung, and further imaging studies told a most terrible story: metastatic lung cancer.


We went to Mr. B's room later that day and, following several minutes of conversation, told him he very likely has lung cancer that has spread through his body. He absorbed the information, slowly and stoically, and said he might have guessed as much — and this is where Mr. B's story becomes one encountered by millions of patients each year.

A new diagnosis of a major illness releases a torrent of emotions and raises dozens of essential questions. Among them: What do you want to do next? What do you select as your "code status" in case your heart stops beating or you stop breathing? Who do you want to make your medical decisions should you no longer be able to speak for yourself?

Though individual treatment choices rely a great deal on the details of the medical conditions at hand, other questions center on the issue of "advance directives" — the legal documents that spell out a person's values and wishes with regard to his or her medical care. Advance directives can take the form of a living will or a medical power of attorney, and they are an invaluable resource for patients, their families and physicians, yet so few people complete these documents prior to encountering dire medical situations. In Maryland, where I practice, more than 60 percent of people aged 18 years or older feel it is very important for their end-of-life wishes to be followed, but only about one third of them have completed advance directives. Why is this so?

One reason is that people often believe creating an advanced directive is much more difficult and cumbersome than is the case in most states. A complete advance directive packet is readily available from the Maryland Office of the Attorney General, either online or by mail, and other states make these documents equally accessible, but most people are unaware of these resources. In fact, a majority don't even know that they should have an advance directive, nor are they aware of what happens in cases where no such document is available and a patient cannot speak for him- or herself. (In these situations, the law dictates a hierarchy of medical decision makers, beginning with spouses, who are then charged with guiding the care of their loved one.)

It would seem that discussions of end-of-life wishes with family members would occur at least once in a while, but this is rarely the case. Whether due to the stigma associated with such topics or perhaps because of the difficulty of envisioning life and death circumstances and the choices such situations would entail, a majority of Americans go their whole lives without broaching this subject. Given Mr. B's possible history of dementia, we called his wife of nearly 50 years to discuss his goals of care, but she said that she and her husband had never talked about any of his medical conditions or values with regard to medical treatments. Organizations such as The Conversation Project are seeking to change this trend, and books like Atul Gawande's "Being Mortal" are helping to bring end-of-life issues to the forefront, yet a great deal remains to be done.

Mr. B's circumstances are particularly complex — a terminal medical condition and possible underlying dementia in addition to confusion induced by medications and brain lesions — and his story continues to unfold. But one lesson is clear: It's never too early to plan for the future and think about your goals and values in medical care. After all, even the best laid plans of patients and doctors can sometimes go awry.

Dr. Jason Liebowitz is a second year internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. His email is jliebow3@jhmi.edu.