Let’s take a deeper dive into each of the decisions you need to consider when you’re writing your Advanced Directive. In this article, we’ll just focus on intubation and ventilation, two of the procedures we heard so much about during the recent pandemic. Many people lie in bed on ventilators for weeks, causing a national shortage of the breathing machines. What would it mean to be on a ventilator for that long?

Let’s say you arrive unconscious at a hospital and are having trouble breathing. At first, the doctor may put you on a ventilator using a simple oxygen mask to ensure that oxygen gets to your lungs. As you get worse, the doctor may put a breathing tube in place. This procedure is called intubation. An endotracheal tube (ETT) is passed in through the mouth or nose, then down past the voice box, then on down into the lungs. Intubation may also occur if you arrive in cardiac arrest. The tube can be left in the lungs for a few hours or a few days. If it is to be left in place longer than that, surgery may be performed to insert the tube more directly into the lungs so that you will still be able to talk, swallow, and drink.

According to the Cleveland Clinic website the risks of intubation include inhalation of vomit or blood, infections (especially sinus infections), and injury to the teeth, mouth, tongue, vocal cords, and airway. WedMD also notes that problems with intubating can cause the lungs to fill with fluid or even to collapse. Furthermore, the inserted tube can go down the wrong way, entering the esophagus instead of the windpipe. If this isn’t noticed immediately, the blockage of the airway can cause brain damage, even death.

Ventilation, on the other hand, begins when you are hooked up to a machine that pumps air into your lungs through that tube once it is in place. You could still talk and swallow when you had just a facemask on. If you are intubated, you cannot do these things. The risks of ventilation increase the longer you are on a ventilator. Aside from the risk of intubation, the American Thoracic Society warns that ventilation can cause lung injury if too much pressure is applied, or if the air from the machine leaks into the space between the lung and the wall of the chest. If the ventilator delivers too much oxygen, you can suffer oxygen toxicity.

Furthermore, it turns out that some people cannot be weaned off of ventilation. Ventilation may be prescribed despite the fact that a patient is dying of a disease that cannot be slowed by ventilation. In this case, it makes sense to decline ventilation since it often takes a long time to recover from days or weeks on a ventilator. Nerves and muscles grow weak when the treatment is prolonged. Generally, ventilation is considered a rather high risk procedure, although it was used in as many as 75% of patients arriving at the hospital with Covid-19, according to the National Thoracic Society.

The National Thoracic Society also reports that, on average, Covid-19 patients stayed on ventilation more than a week and only 50% of those on ventilation recovered long enough to leave the hospital. Only 20% of people over the age of 80 recovered. SARS and MERS may also require intubation in an ER. When people stay on a ventilator for weeks, lying on their backs, it impairs nerves and muscles. Blood clots can also form when a person lies on their back for long periods.

At one point during the pandemic, it was reported that a patient who stayed on a ventilator for more than three weeks was unlikely to recover. This may be a reasonable amount of time to specify in your Advanced Directives if you want to be intubated when EMTs arrive or when you go to the ER and are having trouble breathing. If you are 80 and you are dying, you may want to consider a directive that prohibits intubation and ventilation when you are unable to make decisions for yourself. If you don’t do so, you are likely to be given CPR in an emergency at home, in the ambulance, or once you arrive at the ER.

On a personal note: my father died at the age of 75 in an ambulance on the way to the hospital. They revived him, but he never regained consciousness. My mother always thought this was because the healthcare providers wanted him to be able to say good-bye to her. More likely, they did so because they were required to. She was not happy about this, as the bill for it was substantial. My father wouldn’t have wanted it either. He was dying of atherosclerosis and had already lost one leg to the disease and was about to lose the other leg. Neither one of them would have approved the procedure, and certainly not at the cost of thousands of dollars they didn’t really have.

These are some of the reasons why it makes sense to carefully consider what you do or do not want done for you under a variety of medical circumstances. It also makes sense to review all of this once in a while, to make sure that you still feel the same way about all the life-saving (and life-ending) decisions that will need to be made for you should you not be able to make them yourself.