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Happy-Man-Jumping

By now you’ve surely heard that Medicare is going to pay doctors and other qualified healthcare providers for advance care planning with patients in 2016.

Aren’t you excited?!?

Ok, so if you are not utterly thrilled or even if you are nonplussed about the whole issue, then let me give you a different perspective on why you should rush into your friendly local doctor’s office to make a living will and chat about your future.

Here are 8 unorthodox reasons to create your own advanced care plan in 2016:

 1. You don’t want your Aunt Bertha changing your diapers.

Maybe your Aunt Bertha did change your diapers when you were 6 months old, but do you really want her cleaning your feeding tube and wiping up your poop stains when you are 60? I mean heaven forbid that you end up in a chronically dependent or even vegetative state at such a youthful age, but what if…??? Did you even want to be kept alive in such a state at all…??? Certainly something to think about. Maybe you should give Aunt Bertha a call?

2. The loudest person in your family may not have your best interest in mind.

Oftentimes the loudest relative “runs the show” in the hospital- by guilt, intimidation, and a host of other aggressive or passive-aggressive strategies. If you don’t want “you-know-who” making decisions for you or bullying around your other relatives, while you lie helplessly in the hospital bed, then for Pete’s sake, choose and document your own healthcare proxy today! Make sure they know EXACTLY what’s acceptable and not for you.

3. I’ll bet you know who you DON’T want making decisions for you.

Simply put, some people can handle this kind of pressure and some people can’t. The people who would wilt under life and death decisions on your behalf should NOT become decision makers for you, either by intention or default.

4. Hell hath no fury like your family fighting over your fate or your fortune!

I’ve seen feuds break out around a deathbed that would make the Hatfields and the McCoys cringe. I always want to scream, “What the hell are you people doing? Can’t you see that your loved one is dying here?” (Of course that kind of outburst is never good for the physician professionalism scorecard, so I usually manage to translate the sentiment into something a bit more PC.) So, please, please I beg you to have your fate and your fortunes pre-determined before that fateful and inevitable moment arrives!

5. Grudges can come back to bite you.  

One time the closest available relative to my unresponsive patient on full life support was his estranged wife. She had carried a grudge for 20 years. When we finally tracked her down to make a decision for my patient, with glee she whispered evilly, “Pull the plug.” (YIKES!) I’m pretty sure that guy would have had someone else in mind to make this decision, but IT WAS TOO LATE! No advance care plan was in place with his doctor. (I sense that you are getting my drift…)

6. No one knows your secret priorities.  

During one of my traveling lecture series last year I met a gerontologist who shared some of the idiosyncrasies of his advance care plan with me. He had in writing, that should he become demented and placed in a nursing home: 1) Under no circumstances should he ever be physically or chemically restrained, and 2) He should be allowed to have sex with anyone who is willing to engage him :)

7. No one knows you like you… and you deserve a fitting exit. 

I would like to die on a blanket under the oak tree at bottom of my field. My dad would like to be buried in a bright red racecar motif casket. My husband wants a Viking funeral pyre. I’m sure you have some pretty unique idea about your final goodbye as well… do you have the plan in place?

8. Embracing death will allow you to embrace life. 

Is this too much for you? Think it’s too morbid? Let me tell you the great secret… when you embrace death in its inevitability, then each moment of life itself becomes more precious. Now will never come again. Planning for the end-of-life awakens you to the gift of this very moment of life, this very second. What a gift.

“The doctor will see you now…”

A stunning recent article officially puts Emergency Physicians (EPs) squarely in the middle of end-of-life decisions in modern America.

In the June 2012 edition of Health Affairs, I believe the most important Emergency Medicine article of our generation was published, entitled “Half of Older Americans Seen in Emergency Department in Last Month of Life; Most Admitted to Hospital; And Many Die There.” 1

This longitudinal study (1992-2006) of a large population of people age 65 and older found that:

Over 50% of those who died during the study period visited the Emergency Department (ED) in the last month of life.

• 77% of this group were admitted to the hospital during that same ED visit

68% of those admitted died during this same hospitalization

Continue reading

I just took care of a precious little lady, Ms. King, who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practice at life’s end. Continue reading

“You are a new man now, Daddy”

Friday, 27 Jul 2012 08:15

Mr. Omer had once held a position of social prominence, a moral influence on the lives of individuals and communities; until one year ago. A construction accident changed everything. He suffered injuries that left him in control of only one side of his body and his mind functioning as a 5 year old child.

Most recently, he had resided in an extended rehabilitation nursing facility, until yesterday.

When the nurse tried to arouse him from an unusually long nap, she could not. Upon orders from the facility’s doctor, he was sent for a Cat Scan of his head and then rushed to my care in the Emergency Department. Continue reading

Richard B, was a humorous and charismatic man, who’s toupee flapped at the corners when he turned his head dramatically- and he did so frequently to say, “And another question Doctor…”

Richard B. had made his life fortune as a salesman and owned his own company. He had come to the ER for answers about his apparently failing health, but instead, HE gave ME answers about how to plan for and live life when we are near its end.

I had just spent nearly an hour reviewing old tests, recent test and the tests I ordered on Richard. Pulling them all together, I called two specialists to get clarity on their treatment plans for him and came back into the room to deliver the news. Continue reading

Will your cousin (who lives across the country) choose what you will have for lunch?

Did your mother choose which underwear you are wearing today?

All very unlikely -yet both of these relatives could end up choosing whether you

have a feeding tube placed in you, or whether you are kept alive on a ventilator in

a diaper at the end of your life.

This is sometimes the case when we haven’t created advance directives, and

haven’t spelled out in detail what we want or don’t want, and haven’t selected and educated a healthcare agent(s). Continue reading

When CPR Shouldn’t Be An Option

Tuesday, 15 May 2012 19:23

Those who know and work with me have heard me state without hesitation that it’s morally wrong to do CPR on 90 year old great grandmas (ie. Those who are at the end of their natural lives).    So, it was with great relief that I read the “Do Not Offer CPR” option in a recent JAMA article *urging a revision of our present approach to the use of CPR for those who are unarguably at the end of life.

This is a change from the present expectation (or default) of CPR no matter what (even if is unquestionably “your time”), to a set of recommendations that incorporates the question of whether CPR “harms or helps” individuals. Finally some sanity! Continue reading

When I was in my late 30’s, Multiple Sclerosis had ravaged my body and I came to a point where I felt as though I had been through enough.   So, when my heart and breathing began to fail, and the doctors suggested I should receive a pacemaker and be put on a respirator…

I said “No.”

My 14 year old daughter was standing nearby when the doctors told me that if I didn’t agree to these procedures that I would likely die soon.
I looked to my daughter and said, “I love you.” Then, I made some phone calls…and waited. Continue reading

Dying at Home: A Return to Sanity

Saturday, 28 Apr 2012 19:05

Just as we cannot wait to bring home a new baby, to bathe it in the warmth and love of “home,” so should we seek to bring home our dying.

Why?

Because the beginning of life and the end of life should be centered in the home.  Home is our root, it is the baseline of our consciousness. Our earliest memories tend to be of events at our home, and so should be our last.

There is no comfort greater than that which can be created in our homes, if we but expend the energy to make it so. In our culture, working mothers and fathers take leave from work to be present at home with new life, and likewise, we should create structures in our society which allow us to be at home with others at the twilight of life- when precious lasts breaths are taken. Continue reading