I'm caring for a 72-year-old patient in the ICU. When she arrived at the ED unresponsive, she was diagnosed with worsening heart failure and pneumonia. The ED physician wanted to intubate her, but her family refused in accordance with her advance directive, which specified "no heroics." (They'd brought copies with them.) So the physician ordered oxygen via non-rebreather mask and I.V. antibiotics-treatments her family approved as "comfort measures."

The next day the patient regained consciousness in the ICU and asked me, "Why am I still alive? I didn't want any heroic measures." I explained what her family consented to in the ED, and she seemed to accept this.

Later, an internist asked her permission to begin a transfusion because of internal bleeding. He told her that she could refuse the treatment if she wished, but she firmly approved it.

Both my patient and her family seem to be making decisions at odds with her written wishes. Is my patient confused about the meaning of "heroic" measures-or am I?-H.W., VT.

The meaning of "heroic" is very subjective-as is the meaning of "comfort measures." What's heroic (or comforting) for one patient may not be for another.

But you may be more confused about the meaning and purpose of advance directives, which are meant to express the patient's wishes if she can't speak for herself. In this case, your patient regained consciousness and could express her wishes and make decisions, so her advance directive doesn't apply. Remember too that a competent patient can change or revoke an advance directive at any time.

When creating an advance directive, most patients don't specify a list of treatments they'll accept or refuse because they're not knowledgeable enough to consider whether various potential treatments are "heroic" or not. Encourage them to look at the big picture and share their wishes with their appointed decision makers and health care provider. This is a good opportunity for your patient to do just that. She might also want to consider whether hospice care would be appropriate at this stage of her illness. By considering all aspects of end-of-life care, she can set her own priorities and put comfort care versus heroics in perspective.