Tuesday, May 30, 2017

Talking to Loved Ones about End-of-Life Choices

By: Vipul Bhatia, M.D.
Medical Director, Post-Acute Services
WellSpan Health

Advance care planning often starts with a tough conversation. This talk can be difficult for just about anyone. None of us want to consider the likelihood of death, yet a health crisis can come at any time. Following certain steps can make the task of discussing your wishes less daunting. Having the conversation with your loved ones before a crisis can reduce the stress and anguish that could occur if your wishes are not known when a crisis happens.

One tip is to get a head start when you are healthy; advance care planning is not just about old age. A medical crisis can occur at any time, which could leave you unable to make your own health care decisions. If you start this process early, your primary decision will be to identify the person who will make decisions for you if you are unable to make decisions for yourself. The next step is to make sure that person is aware of what you value by discussing your end-of-life wishes.

Once you have identified the key family member or friend who will be your health care proxy, or the person who will hold your durable power of attorney for health care, a bit of preparation on your part can help make the conversation easier. For those of us who find it difficult to broach this topic with loved ones, preparation would include identifying what truly matters to you. You may want to explore why you are thinking about these topics in the first place. Is this due to a particular event in your life or that of someone close to you? Perhaps a car accident or a sudden diagnosis of cancer? What else motivated you to have these discussions and conversations now?

If you can answer these questions, you may be better prepared to have this discussion with loved ones. You might also explore your basic principles and values and how they would still apply near the end of your life. It’s important to keep in mind that the first conversation on end-of-life issues may be the start of a learning process and could continue with more conversations throughout life.

If you have this difficult conversation when you are healthy, it may make the process easier as you age. With advanced age, you may find yourself developing new medical conditions or that your functional ability has declined. As this happens, it is important to revisit your choices and decisions. This self-reflection will help to identify anything that has changed since the last time you talked to your loved one. If that is the case, you should approach your loved one again to explain what led you to change your decisions and choices.

The conversations that can be held with family or closest friends ahead of death can allow you, at any age, to fulfill your five wishes:

1. To be represented by the person you want to make health care decisions if you can’t.

2. To be clear on whether extreme measures should be taken, what life support means and how pain should be managed.

3. To know how comfortable you want to be when you near death.

4. To know how you want people to treat you, including if you wish to die at home.

5. To have the opportunity to share important stories with loved ones; this also includes after-death arrangements that can be clearly expressed before death occurs.

As a physician, I can tell you it is often difficult for health care team members to talk with patients about these issues. However, if our patients give us permission to talk about end-of-life choices, it becomes easier for us–as your trusted health care partners–to guide you through the process. So, once you have done your preparation and have spoken to a loved one, please take the next step and talk with your health care team members.

No one knows your preferences and values better than you do. Your health care team members can help guide you in that decision-making process with key information about your health, but they cannot make decisions for you. With that in mind, the more you share with your health care team about what you value and how you prefer to be treated during the end of your life, the better they will understand your advance care planning wishes.

Everyone has a health horizon, so let’s plan for it. By taking these steps and starting conversations early, you will ensure that your care in the future will be exactly how you planned. More importantly, you will diminish the chances of moral and personal distress that your loved ones could face when making decisions for you. Talk to your loved ones now about your end-of-life wishes. You and your family will be glad you did.

More resources are available at www.yourlifeyourwishes.com.

Vipul Bhatia, M.D. is the medical director for Post-Acute Services at WellSpan Health, and director of WellSpan’s Horizon Planning initiative.

Wednesday, April 12, 2017

POLST: The Actionable Solution to a Universal Question

By: Amy Frieman, M.D.
Hospice and Palliative Medicine

Most of us won’t find it surprising that studies show the vast majority of Americans would prefer to die in their own home, with friends and family by their side, than at a care facility.

When juxtaposed with recent data from the Centers for Disease Control, however, these findings illuminate the sobering reality of the current state of end-of-life care: Although 70% of Americans say they would rather die at home, in actuality, 70% of Americans die in a hospital, nursing home, or assisted-living facility.

Reconciling patients’ care wants/wishes and the reality of care received is part of the rationale behind Practitioner Orders for Life-Sustaining Treatment (POLST), a medical order form that empowers individuals to work closely with their medical team to detail their personal goals and medical preferences when facing a serious illness. 

“It’s a way of honoring the wishes of both the patient who wants the most aggressive interventional treatment to prolong life, AND the patient who wants to spend their last days focused on comfort at home with loved ones,” says Amy Frieman, M.D., Medical Director, Palliative Care, Legacy Meridian Health;  Clinical Assistant Professor, Rutgers and RWJ.

By translating wishes expressed in an advance directive into actionable medical orders, POLST allows patients with serious chronic illness, terminal illness, or those who are elderly and frail to dictate the way that they want to live their remaining days. 

“For physicians, POLST offers an actionable approach for managing the fragile balance between ‘quality’ of life and ‘quantity’ of life,” says Dr. Frieman.  “For patients, it provides an attainable, clinical solution to a universal question: ‘How do you want to live out the rest of your life?’ ”

Thursday, March 30, 2017

Health Care Proxy

By: Celena Romero
Clinical Quality Specialist
Lehigh Valley Health Network

It is very easy to get caught up in day-to-day routine activities. Rarely is there time to think about the “what if” questions until it’s too late. I’m specifically referring to advance care planning. I’d like to share my personal experience that triggered my thoughts of advance care planning at 35 years old.

My husband and I were healthy newlyweds taking our ordinary life for granted until my husband became critically ill with the Swine flu and MRSA pneumonia. Suddenly, I was making health care decisions and signing consent forms on his behalf, as he remained intubated in a medically induced coma. I asked myself, “If we weren’t married who would be making his healthcare decisions? Would it be my husband’s parents; his 18 year old son? Who would these decisions be legally deferred to? Would I be left in the dark as far as his medical care or prognosis?” Fortunately, my husband made a full recovery and is doing exceptionally well thanks to the care he received at Lehigh Valley Health Network. But, I still wonder what things would have been like if we weren’t married during those crucial moments in the intensive care unit.

I also question, “What if I were the one in a coma? Is my husband comfortable making medical decisions on my behalf?” As it turns out, he’s not best suited for the task. I defer my healthcare decision making to my mom. My mom is my health care proxy. Everyone over 18 years old needs a health care proxy - a person who knows your care wishes and will express them to doctors in the event you cannot speak for yourself. This is an example of advance care planning.

The Conversation Project's user friendly guide, How to Choose a Health Care Proxy and How to Be a Health Care Proxy offers facts and tips to make sound decisions about choosing, and being, a health care proxy. This guide can found at http://theconversationproject.org/wp-content/uploads/2017/03/ConversationProject-ProxyKit-English.pdf. For more information about advance care planning, please visit http://yourlifeyourwishes.com/.