To his final hours, Richard M. Nixon wanted to remain in control of his destiny.
And he did, through a living will.
That Mr. Nixon had a living will, also known as an advanced directive, was confirmed by his chief of staff, Kathy O'Connor, in an interview with The Associated Press. Neither she nor hospital officials were at liberty to discuss its specifics.
But Dr. Fred Plum, chief of neurology at the New York Hospital-Cornell Medical Center and an authority on coma who treated the former President, said Mr. Nixon's living will had allowed the former President to maintain authority over his life's end.
"This was his last chance to exercise moral leadership, and he did it," Dr. Plum said. "Mr. Nixon made it apparent that persons of high order and dignity and position were quite able to sit back on the oars and make a decision that if they could not lead, if they could not contribute, and if they could not participate in society, then it was not worth living."
Mr. Nixon is arguably the most prominent individual whose care was governed by such instructions. People generally make such living wills when they are able to think clearly about their future medical needs, to protect themselves and their families. Many people also discuss their intentions with their doctors.
The general instructions left by Mr. Nixon guided his final treatment. He died in intensive care four days after suffering a devastating stroke at his home in New Jersey. Over his last three days he developed severe brain swelling and fell into a deep coma.
Mr. Nixon let his doctors and family know that if he developed a serious illness that would leave him debilitated, especially intellectually, he did not want extraordinary medical measures taken to keep him alive or to resuscitate him.
Mr. Nixon suffered the stroke about 5:45 P.M. on Monday while relaxing on the deck of his house in Park Ridge, Kim Taylor, a spokeswoman for the former President, said he was in high spirits after having spent the day working on a speech for Republican fund-raising events.
When stricken, Mr. Nixon dropped a glass of Pellegrino water that he was holding and went to the kitchen, where the housekeeper, Heidi Retter, was preparing dinner. She helped him to a sofa and called an ambulance. Mr. Nixon was taken to New York Hospital, which, Ms. Taylor said, he chose because he and his family had long received care there. Paralysis and Other Effects
When Mr. Nixon was admitted to an intensive care unit about two hours later, doctors found that the stroke had paralyzed the right arm and right leg, impaired speech and caused some loss of vision. A CAT scan x-ray revealed no brain damage, but visible damage can be difficult to detect soon after a serious stroke.
The stroke was believed to have been caused by a blood clot that formed in an upper chamber of Mr. Nixon's heart, broke off and, carried by the blood, lodged in an artery in the brain. The breakaway clot, known as an embolus, cut off the usual supply of oxygen and nutrients to the cells nourished by the artery.
For many years, Mr. Nixon had had an irregular heartbeat, atrial fibrillation. Such abnormal rhythm facilitates formation of a blood clot and, thus, put him at risk for developing a stroke. As standard therapy to reduce that risk Mr. Nixon regularly took an anticoagulant drug, coumadin.
The stroke had made Mr. Nixon severely aphasic, a condition in which speech and expression are impaired. The severity of the aphasia and paralysis would have probably permanently affected him, had he survived.
A living will cannot anticipate every possible medical scenario, so many decision have to be left to the judgment of doctors and families in executing a patient's advanced directive. Many people would choose to live if paralyzed by a stroke. But many would not want aggressive therapy if the stroke left them unable to talk or communicate. Use of Second Anticoagulant
Because people do survive severe strokes, Mr. Nixon's doctors did what they could to prevent further damage. As part of standard therapy, they administered a second anticoagulation drug, heparin.
On Tuesday afternoon, less than 24 hours after being admitted to intensive care, Mr. Nixon appeared to be doing well enough to be moved to a private room. But two hours later he took a turn for the worse.
A second CAT scan showed extensive damage in the area nourished by the middle cerebral artery on the left, and dominant, side of the brain. He was becoming drowsy, an effect produced by the brain swelling, a common complication of a stroke.
A swelling results when damaged arteries begin to break down and fluid leaks into the brain. That further damages cells that have already been harmed by the lack of oxygen when the stroke occurred. The extent of swelling is generally directly related to the severity of the stroke.
It is clear from the limited reports about Mr. Nixon's stroke that it was devastating, one for which there was perhaps a 10 percent chance of survival. It is also clear that had he survived, Mr. Nixon would have most likely been severely impaired intellectually and physically.
