why people should think about end of-life issues apr 21 2014

© Copyright John M. Cachat

Why People Should

Think About

End-of-Life Issues

John M. [email protected]

Making your healthcare wishes known

© Copyright John M. Cachat

Housekeeping

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Use the question

block for questions Copy of presentation

available upon request

3© Copyright John M. Cachat

Agenda

� Why People Do Not Spend Time Thinking

About End of Life (EOL)

� The Benefits of EOL planning

� The Options

� State and Federal Laws

� Summary & Next Steps

� Q&A


Ask Yourself

What kind of

medical care

would you want

if you were too

ill or hurt to

express your

wishes?


Why?

I don’t want to

think about it

I don’t want to talk

about it

5


We do many things with

modern medicine because

“we can,” but it doesn’t

always follow a person’s

life values.


Patient Self-Determination Act

� The PSDA simply requires that most health care institutions (but not individual doctors) do the following:

� Give you at the time of admission a written summary of your health care decision-making rights and the facility's policies with respect to recognizing advance directives.

� Ask you if you have an advance directive, and document that fact in your medical record if you do.

� Educate their staff and community about advance directives.

� Never discriminate against patients based on whether or not they have an advance directive. Thus, it is against the law for them to require either that you have or not have an advance directive


Some Statistics

� 75% of aging population thinks living

wills are a good idea, but less than 1/3

have them

� More than 25% of elderly patients

become in capable of making end of

life decisions

� Those that have directives, only 2%

wanted aggressive care

� Only 1 in 8 nursing home residents

want aggressive care


Some $$ Statistics� One medical community had 96% of its

residents complete medical directives –

the cost of care decreased from $26K to

$18K

� 1/3 of developed nations annual

healthcare spending goes toward

medical costs for the last year of life

• In the US, only 7% want life sustain treatment, but 68%

will receive it due to lack of directives

• Nearly 30% of Medicaid spending is for treatment

during the last year of life


Why People Do Not Think About EOL

Planning for the end of life can be difficult� I’m afraid to think of it

� It just makes everyone sad

� I’m too young to have to worry about it

� I’m healthy and take good care of myself

� I have to protect my loved ones from discussion

� Does it mean I am giving up hope?

� Will I disappoint those I love?


Communication Is The Single Most

Important Step In Health Care Planning

� No matter what your advance directive says, others will not fully understand your wishes.

� It will help you think about what you want. Others will ask you questions or tell you things that will make you think about your wishes in another way.

� It will help your loved ones make difficult decisions with less pain, doubt, and anxiety.

� It may save money. Sometimes families continue medical treatments long past the point where they are helpful, simply because they are unsure what their loved one would have wanted.

� It may even bring your family closer together.


Illness Trajectories are Different


Starting The Discussion

� “Do you remember what happened to so-and-so and

what his family went through? I don’t want you to

have to go through that with me. That’s why I want to

talk about this now, while we can.”

� “Neither Richard Nixon nor Jackie Kennedy was placed

on life support. I wonder if they had living wills and

made what they wanted clear in advance.”

� Blame it on your attorney “My lawyer, says that before

I complete some legal documents, I need to talk over

with you some plans about end-of -life medical care.”


Resistance Is Common

� “Mom, I don’t see what good it does to talk about such things. It’s all in God’s hands anyway.”

� “Dad, I already know you don’t want any heroic measures if things are really bad. There’s nothing more we need to discuss about it. We’ll do the right thing if the situation arises.”

� “I just can’t talk about this. It’s too painful, and talking about it just makes it more likely that it will happen.”


In Response to Resistance

Be firm and straightforward

“I know this makes you feel uncomfortable, but I need you to

listen, to hear what I have to say. It’s very important to me.”

“Yes, death is in God’s hands, but how we live until that moment

is in our hands, and that’s what I need to talk to you about.”

“If it is too overwhelming for you right now, I understand. But

let’s make an appointment for a specific time to sit down

together to discuss this. All right?”


In Response to Resistance

� Point out the possible consequences of not talking now

“If we don’t talk about this now, we could both end up in a

situation that is even more uncomfortable. I’d really like to avoid

that if I could.”

� Ask someone to be your spokesperson

If you are able to connect well with one family member or friend, ask this person to initiate and lead the discussion with other family members or your doctor. This may make your job of explaining, clarifying, and answering questions easier.


The Benefits of EOL Planning

But by deciding what

end-of-life care best

suits your needs when

you are healthy, you can

help those close to you

make the right choices

when the time comes


Reflect

Talk

Appoint

Act


What Should Be Documented?

� What concerns do you have about

making decisions for yourself later in

your life?

� What concerns do you have about

your health or future healthcare?

� Where do you want to receive care?

� Who do you want to be with you?


Why Can't I Just Tell My Doctor?

� Both legally and practically, it is

far better to do a written

advance directive.

� The written advance directive

will carry more weight and is

more likely to be followed,

especially if it supports and

affirms your continuing

conversation.

� Be aware of state specific laws


Types of Documents

� Durable Power of Attorney for Health Care

� Do-Not-Resuscitate (DNR)

� Living Will

� Advanced Health Care Directive


What is a Power of Attorney?

Another form is a specific type of power of attorney or health care proxy, in which the person authorizes someone (an agent) to make decisions on their behalf when they are incapacitated. People are often encouraged to complete both documents to provide comprehensive guidance regarding their care.

Note: Needs to follow state laws


What is a DNR?

� A "do not resuscitate" or

"DNR", sometimes called a

"No Code", is a legal order

written either in the hospital

or on a legal form

� The DNR request is usually

made by the patient or health

care power of attorney

� Over simplification of the

myriad of options


What is a Living Will?A living is generally a philosophical statement of your goals.

“If I suffer an incurable, irreversible illness, disease, or condition and my attending

physician determines that my condition is terminal, I direct that life-sustaining

measures that would serve only to prolong my dying be withheld or discontinued.”


Standard Forms versus a Process

� Standard Forms

� Provide very limited options

� Have no concept of time – it is either Yes or No

� Hard to find / retrieve when needed

� Processes

� Are a interactive thought process

� Have the ability to apply time restrictions

� Can be easily updated

� Provide many ways to access quickly when needed


What is an Advance Directive?

Summarize preferences for

life-sustaining treatment

and surrogate decision-

maker in the event that one

loses decisional capacity

and requires medical care


Advanced Health Care Directive

• A comprehensive process that combines the living will

and the health care power of attorney into one

document.

• You may include any other directions, including organ

donation or where and how you prefer to be cared for.

• Because it is more comprehensive and more flexible than

the other tools, it is the preferred legal tool.

• Includes knowledge of local federal & state rules


The AHCD Process

DMS

App

Engine

Education

Creation

Authorization

Storage

Distribution

Maintenance

& Revisions


Re-examine Whenever Any Of

the “Five D’s” Occur

� Decade – when you start each new decade of your life.

� Death – whenever you experience the death of a loved one.

� Divorce – when you experience a divorce or other major family

change.

� Diagnosis – when you are diagnosed with a serious health

condition.

� Decline – when you experience a significant decline or

deterioration of an existing health condition, especially when it

diminishes your ability to live independently.


Other Terms / Documents

� MOLST - medical orders for life-sustaining treatment

� MOST - medical orders on scope of treatment

� POLST - physician orders for life-sustaining treatment

� POST - physician's orders on scope of treatment

� ACP - advanced care planning

� ADIL - Advanced Directive Intervention List

� COLST - Clinician Orders For Life Sustaining Treatment

� MAD - medical advance directives

� PAD - psychiatric advance directive

� TOPP - transportable physician orders for patient preferences

� DNH - Do not hospitalize


Summary

• You owe it to

yourself

• You owe it to your

family & friends

• You owe it to your

country


Why People Should Think

About End-of-Life Issues?

&

Contact:

John Cachat

[email protected]

Copy of Presentation

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