When COVID killed thousands of seniors three years ago, few of them showed up in emergency rooms with advance directives. Even fewer thought about the end of life or how to die. Sadly, many lives were discarded in makeshift morgues/cooling trucks behind hospitals. It’s never too early to plan for the next pandemic, retirement, and the end of life.

On April 16, 2023, National Healthcare Decisions Day, take a moment and choose to end life with greed, gratitude, or glory by wanting, withholding, or withdrawing health care In medical facilities or your own home. Then select an advance directive with the end in mind.

The path to resting in peace begins with withholding medical intervention in life-threatening situations. A stressful end to life exists in regulated medical facilities. Those who wish to “fight the good fight” remain in the limbo of an incurable illnesses until they’ve had enough. The advance directive might draw the redline that stops health care heroes from sealing a fate worse than death.

7 out of 10 seniors wish to die at home, yet 7 out of 10 people end life in medical facilities. Only 3 of 10 people have advance directives. It’s easy for people to decide against their final wishes if they’re given false hope and don’t think the end is near despite the number of people who die of serious illnesses daily. How often are seniors informed that false hope easily sways their consent for medical treatment and that patients with COVID on ventilators rarely survive?

Seniors with life-threatening conditions are brought to emergency rooms for medical providers to save lives or honor final wishes. Since most seniors do not have advance directives that specify final wishes, heroic measures are undertaken through implied consent.

Dismal fact: 1 out of 12 seniors over age 80 will die within one month of an emergency visit, as reported in JAMA Network. Is the best way to end life inside or outside of the emergency room? Most seniors wait until it’s too late and anticipate the emergency physician will decide what’s in their best interest. Emergency physicians decide how seniors die unless they have clearly informed and formulated advance directives.

If few seniors get out of the ER alive, the advance directive is the do-it-yourself guide on how not to survive a life-threatening illness.

The “non-survivors rule of threes” includes:

• 3 minutes of withholding a ventilator
• 3 hours of withholding antibiotics
• 3 days of withholding IV hydration
• 3 weeks of withholding feeding tubes
• 3 months of withholding hope

The legacy of my 30-year practice of emergency medicine was withholding hope and offering hospice to those with serious illnesses like metastatic cancer or heart failure. Most seniors never consider this option because they choose not to complete advance directives. The solution is to have seniors select from one of three advance directives with Medicare enrollment.

Medicare advance directives might provide informed consent for aggressive medical treatment (Medicare advance directive A), benevolent end-of-life care (Medicare advance directive B), or considerate transitional services (Medicare advance directive C) when a life-threatening illness occurs.

If seniors are told, “You can die from this illness.” And asked, “How do you wish to die?” Their particular Medicare advance directive – embedded in the registration number as A, B, or C – provides the ready answer. This serious illness conversation goes without saying and averts obliging them to comply with medical protocols to save lives. Ideally, the serious illness conversation takes place at the time of Medicare enrollment, not in emergencies.

The Patient Self-Determination Act of 1990 requires health care providers to inform patients of their rights to make healthcare decisions and to periodically inquire as to whether a patient executed an advance directive. How’s this working for seniors when the U.S. ranks 43rd in quality end-of-life care, just behind Romania?

Since seniors cannot be given the realistic choice not to die, they need to decide how to die through impartial healthcare insurers like Medicare, not medical providers who have a conflict of interest. The Medicare Advance Directives Act would build upon the Patient Self-Determination Act and give context to National Healthcare Decisions Day. Medical decisions are less random and more certain with an advance directive in place. Certainty is the path to dying with dignity.

The curious case of Damar Hamlin, who suddenly collapsed on the football field in January, provides the impetus for everyone to complete an advance directive on April 16. When does “wanting hope” end and “withdrawing hope” begin if you were him and remained in a coma? How soon would you wish to withdraw treatment in the ICU, the hospital, or a skilled nursing facility …. within three days, three weeks, or three months? At what point do you deem “fighting the good fight” to be inglorious and insufferable?

Begin National Healthcare Decision Day on April 16 with the end in mind by wanting, withholding, or withdrawing medical intervention. Quality end-of-life care is viewed as not crossing the red line of final wishes that are clearly expressed in Medicare advance directive A, B, or C. Decide today how you’ll die.

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.