Advance Directive

by Liam Davenport
News-Medical
February 5, 2013

Advance care planning (ACP) for older adults results in improved quality of care at the end of life, with less in-hospital death and the increased use of hospice services, the results of a study indicate.

“There appears to be utility in each aspect of ACP that was studied-completing an AD [advance directive], assigning a DPOA [durable power of attorney], and having an ACP discussion with next of kin-albeit in somewhat different ways,” says Kara Bischoff (University of California at San Francisco, USA) and colleagues.

The team looked at data from 4394 Medicare beneficiaries enrolled in the cohort Health and Retirement Study who died between 1993 and 2007. Individuals were at least 50 years of age at enrollment and did not die before age 65 years.

Overall, 76% of participants engaged in ACP, with 2.8% having an AD only, 9.3% a DPOA only, 13.9% an ACP discussion only, 9.4% an AD and a DPOA, 5.9% an AD and an ACP discussion, 8.8% a DPOA and discussion, and 26.0% all three components.

The mean time from completion of an AD to death was 61 months, while the time to death after DPOA completion was 56 months. The use of ACP increased after 1993, with more than half of patients who died during or after 1997 engaging in ACP.

Patients who engaged in ACP were significantly less likely to die in the hospital, more likely to be admitted to a hospice, and less likely to have a hospice stay of no more than 3 days than those who did not engage in ACP.

Furthermore, having an AD alone was linked to a 69% reduced risk for hospital stays of more than 14 days in the last month of life, while having an AD or a DPOA was associated with an increase in hospice admission (67% and 40%, respectively) and a reduced likelihood of a hospice stay of 3 or fewer days (12% and 7% reduction, respectively). More

by Lydia S. Dugdale, MD
Over 65
February 1, 2013

I glanced at the chart. New patient, female, age 72.

I have adopted the practice with new patients of quickly scanning the medication list before opening the door to greet them. In the old days patients hand wrote their medications on a paper intake form prior to the office visit. Now I click the “medications” tab in the electronic health record to review the data already entered.

A medication list can tell a doctor a lot about a patient. One glance and I know immediately what active health problems a person has, what risk factors she might have for heart disease or stroke, whether I should worry about lung cancer, whether our interaction might be complicated by mental illness, and how quickly I should move through any aspect of the office visit.

Christina Cook (name changed) recorded no medications on her form.Great! I thought. An opportunity actually to talk with my patient! I wasn’t very far into my primary care career when I realized that medical complexity is inversely proportional to how well I feel I know a person at the end of our first office visit. Sure, I see patients with complex medical problems more frequently, and over time that does amount to a greater opportunity to build relationships. But such visits typically center around managing medicines, ordering tests, and reviewing the recommendations of the specialists. At least as far as the new patient visit goes, the less complicated the patient, the more I come away with a sense of who she is.

I knocked and opened the door. Ms. Cook sat upright, with a smile on her face. Clad in a sophisticated black, she was true to form for a certain type of New Yorker. She kept an apartment in “the City” and a home in Connecticut. She read the Times and held season tickets to the opera. She was a widow but far from lonely. She had borderline blood pressure which she managed through the salt substitute Mrs. Dash and a daily three-mile walk. Though her cholesterol was probably deserving of a statin, she committed to a life of morning oatmeal: “I will discipline myself not to have to take a pill. I will learn to like that stuff.” And she cut back on red meat to once a month or less.

At some point during the visit, she asked if I would like a copy of her living will. Taking it, I asked casually, “Can you summarize it for me?” I ask this question for a couple of reasons. The first is that I typically don’t have time during the office visit to read the document in its entirety; patients can explain quite quickly if they “don’t want to live on machines if there is no hope.” Also, I like to confirm that patients understand what they have signed. Though far from the norm, I have met some people who have signed living wills that they don’t really understand.

Ms Cook’s response surprised me. She never wanted cardiac resuscitation or mechanical ventilation. “Ever!” she declared. She went on: “Look, I’ve watched friends die hooked up to machines they didn’t want. Besides, my niece and nephews are doctors, and I’ve heard their stories for years. I know that life support can keep me alive, but I’ve lived a long and healthy life. If something happened to me now, I’m okay with dying. Just let me go! And don’t prolong my suffering!” More

by Barbara Peters Smith
Herald Tribune
January 29, 2013

If you want to have your wishes followed before and after the end of your life, it really helps to have the right legal documents prepared. But it’s even more important to have the right conversations, over and over, with the right people.

by Dr. Katherine Jett
Henry County Local
January 23, 2013

There are many gifts that we give to our families throughout our lives – time, love, money, attention; the list goes on and on.  One of the most valuable gifts we can give our families is to have a living will.

I remember when my grandparents had failing health, and my family was caring for them.  They had living wills and had taken the time to let each of us know how they wanted to spend the final weeks and days of their lives.

After they passed away, my mom made a poignant statement about their illnesses.  She said their living wills had been a tremendous gift.
At first I didn’t understand so she explained.  In a time of stress and grief, a weight was lifted off of her shoulders.  The living will changed the dynamic of their passing because medical decisions were about honoring my grandparent’s wishes and not about the decisions of their children.
We spend our lives planning for our education, children, marriage, and retirement, but how many of us plan for the unthinkable?   More

By Ken Russell
Montpelier Bridge
January 24, 2013

When people are faced with serious injury, a terminal illness or any condition requiring heroic measures to stay alive, such as feeding tubes or intubation, sometimes patients, or their families, choose the cessation, or avoidance, of hospital care.

For over 30 years, Bettina Desrochers has given end-of-life care and has attended hundreds of peaceful deaths of old and terminally ill patients. For seven years, she ran Elder House, a small hospice and respite care home out of her house.

These days she travels the country speaking on end-of-life issues and works as an end-of-life coach. Desrochers talked about the importance of deciding, before you get sick, what kind of treatment you want and of finding an alternative to dying in the hospital. Otherwise, you, or a loved one, can risk getting caught in the health care system, receiving unwanted procedures or being in an environment not of your choosing.

“Once you get stuck in the medical field, it’s really hard to get out,” said Desrochers. “It can be a real nightmare. There’s health care and then there’s dying. Sometimes dying has nothing to do with doctors and nothing to do with nurses. Your life is coming to an end. Just being able to go somewhere and die, just being allowed to die, not accepting medical care, making sure the folks around you know what you want and what you don’t want, and having good, honest conversations, long before you even think about being sick. Taking a look at your environment, taking a look at yourself—sometimes that’s the best thing.” More