One of the big changes recently in my practice has been the addition of preventive care visits for Medicare patients (more on this later). Of the greatest benefits has been the opportunity to talk about advance directives. Because of this opportunity, I have talked about it far more than than ever before. But because I am somewhat lazy, and I don\’t want\’ to give the same talk 1000 more times, I wrote my own handout about advance directives for my patients.
I\’ve decided that I will publish any handouts I write to my blog so that I can get comments from readers, and so that others can use what I have written for their own practice.
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Advance Directives: Living Wills and Health Care Power of Attorney
Nobody likes to think about them, but these two things are very important documents for people as they grow older.
What is a living will?
A Living Will answers the question: If I am incapacitated and can’t give my opinion, what do I want done if:
- My heart stops beating – do I want them to shock it to bring it back to beating?
- My breathing fails – do I want to be assisted in breathing using a ventilator?
- My blood pressure drops – do I want to get chemicals to raise my blood pressure?
For most people, the answers to these questions is, “Yes, as long as I won’t get stuck on a machine, and as long as things don’t get hopeless.” In fact, this is the answer that doctors use if there is no living will at all. Doctors aren’t forced to do everything at all cost to save a person, but they will do everything up to the point when it becomes clear that things are “hopeless.”
When is a living will important?
There are two circumstances when living will is most important:
- When a person doesn’t want any or all of the three things on the list done.
- When a person does want them done when other people might think they don’t.
These are often the case when people are elderly or have serious diseases that make life difficult.
Common Mistakes
- Not having a living will when it’s needed – This is bad, as it forces family to guess at what you would have wanted.
- Not understanding life-saving measures – Many people believe that being put on a “breathing machine” is a bad thing, and should always be avoided. In truth, most people put on ventilators come off of them easily. These are the same machines used to assist breathing during surgery, allowing deeper anesthesia.
- Not talking to family about this – People don’t like to talk about death, but avoiding this topic can turn a difficult situation into something that tears apart a family.
What is “Health care power of attorney?”
This is actually the more important decision to make, answering the question: “If I can’t make decisions about my health care, who should do it in my stead?” If a person does not have this issue addressed, the law will assign people the task based on how close they are to the person. The progression goes like this:
- Spouse (or parents, for an unmarried minor)
- Adult children
- Other next of kin, including adult grandchildren and siblings.
The problems happen when more than one person fits one of these categories. If, for example, the spouse is not living or not available, all of the children will have equal rights to have their wishes followed. In other words, the very difficult questions about a parent’s life and death are left to a committee of siblings, which can and has torn families apart.
How is it done?
Health care power of attorney is a designation of who you think will most keep with your wishes, and who will work best with the other family members. It is a legal designation, and so should be overseen by an attorney if at all possible. The process is as follows:
- Choose family member(s) that you feel confident with. Choose a single person to have this responsibility and another (if possible) to take the role if the first can’t do it.
- Let them know that you are doing this and what your wishes are.
- Get the documentation (from an attorney or online – the AARP is a good resource for this kind of thing) and get it filled out, with proper witnesses and notarizing if needed.
Put the documents in a place that is safe and is known to all involved
How would you like that credit to look? Is “doctor Rob” good enough? Or would you like something else with reference to your blog?
Nicely done! The only 2 things that I would add are internet addresses where they can create a living will and power of attorney, and instructions on how to make sure the living will is accessible to doctors who would be treating them.
Agree. AARP has good resources on the web or via mail.
Whatever you do is fine. Dr. Rob Lamberts or doctor-rob.org is fine. I just don’t want people claiming it and making me break copyright by putting up my own handout.
As a resident who deals with hospitalized patients who present without living wills/healthcare proxies all the time, I think it’s fabulous that you’ve incorporated this into your practice and that you’ve created a handout to facilitate both your practice and others’ practices. There are, however, a few aspects of the wording that I would suggest modifying. First, in your list of three questions, you ask “My heart stops beating – do I want them to shock it to bring it back to beating?”. I would suggest adding in “do compressions on my chest” and change it to “in an attempt to bring it back to beating”. Most people don’t understand that CPR has very poor success rates (particularly when you look at rates of meaningful survival), and that CPR is really just “an attempt” at resuscitation rather than a guarantee. Second, from my experience working in ICUs, I have to disagree with the statement “In truth, most people put on ventilators come off of them easily.”. A person’s ability to come off a ventilator (and therefore their appropriateness for intubation) is highly dependent on the reason why they’re intubated. While a healthy 17 year old who is intubated for an elective surgery will almost definitely come off the ventilator easily, an 85 year old with end-stage heart failure will almost never come off a ventilator.
Hope this makes sense! I’m just coming off a 28-hour ICU shift, so I’m not as coherent as I like to think I am under normal circumstances. Once again, while I may disagree with some of the wording in your pamphlet, I really do applaud you for making the effort to address a very important (and all too often overlooked) aspect of medical care.
Good points. I think being a little less specific and encouraging a discussion with the doctor is perhaps the best approach.
Thank you so much for posting this. As a first responder locally it always amazes me what family members DON’T know. My dad put together a red notebook years ago and it’s in the living room with everything we need to know. I always figured he was just being an attorney and … type A. But, I’m grateful it’s there because we actually disagree on some stuff so it’s good to know where his lines are for care. What Dad considers extreme, I don’t necessarily….I think you guys can do extraordinary things but sometimes, at 84 years old, they don’t want extraordinary anymore and I get that now. Anyways – thank you.
Tempting to say something snarky about “death panels”, but I imagine you’re already very tired of that topic.