A Doctor Breaks Down Advanced Care Planning — Dr. Eric Debunks
Today I'm debunking a topic that is often uncomfortable. But it's so, so important. And that is Advanced Healthcare Directives. This is a crucial topic to discuss with our older adult population, but it's not done nearly enough.
Dr. Tam: Hi, Mighty Family. This is Dr. Eric Tam, and welcome back to another episode of Dr. Eric Debunks. This episode is going to be a bit heavy, but stay with me because I believe it can truly make a world of difference in your medical care.
Alright. So first, what is an advanced health care directive? And what is it actually for?
Dr. Tam: It is a legal document that helps you dictate your care and appoint someone to carry out your wishes, in circumstances where you're unable to do so yourself. And in most circumstances, this relates to end of life care.
Dr. Tam: So for example, towards the end of life, would you want aggressive measures like CPR to restart your heart if it were to stop? What you want to be on a ventilator? If you're unable to breathe? Would you want to be on a feeding tube if you're unable to eat?
Dr. Tam: You may be wondering — if this relates to the end of my life, why do I need to discuss it now? The reason being is that I have seen the lasting impact these decisions can make on a patient and their families, both good and bad. And when these decisions are made ahead of time, they can make a world of difference, both to the patient and their families.
Dr. Tam: So I want to share with you two different patient stories. And through them, I hope you can see the importance of having an Advanced Health Care Directive.
Alright, my first story is about a patient that had been repeatedly hospitalized for the progression of her lung cancer.
Dr. Tam: She came into the hospital this time with severe pneumonia. Her condition was critical, and her prognosis was guarded. There was a high chance she wasn't going to make it out. By the time we admitted her into the hospital, she was no longer responsive due to her severe infection. We looked her two children for what their mother's goals of care were. The two brothers looked at each other. And I've seen that look many times. It is one of huge pressure, but also doubt and fear. Their mother had never discussed her preferences with them. The older sibling decided that they will want to do everything to preserve life. The look of the younger brother was one of discomfort and uncertainty. He felt he had to defer to his older brother to make the decision, but told me he knew that heroic measures would only lead to more suffering, and that he wouldn't want that for her mother, given that she was already ill due to a diagnosis of her cancer.
Dr. Tam: We ended up having to intubate their mother and due to a poor lung reserve from the cancer, she became ventilator dependent. This decision ended up creating a huge conflict within the family. Had goals of care discussions been had, this family could have carried out their mom's wishes in unity, rather than in division.
Now I want to tell you a second story.
Dr. Tam: So the contrast to this (aforementioned) story is of a recent COVID-19 patient of mine. He was a very capable 93 year old male that unfortunately caught a severe case of COVID. His condition was severe. And in fact, it was getting to a point he was nearing the need of ventilator assistance. I remember standing in the room, as I broke the news to him and his family. The chances of him surviving and getting off the ventilator would be grim. And in my mind, I did not want to subject this man to such aggressive measures.
Dr. Tam: As breathless as he was becoming. I remember what he said to me.
Dr. Tam: “Dr. Tam, I've had a good life. I have discussed the scenarios with my children, and my son is my primary decision maker. He knows that, in no circumstance, would I want CPR or to be placed on a ventilator. So if my condition does not get better, please give me medication that will address my symptoms, and instead allow me to pass peacefully.”
Dr. Tam: The room fell silent. His eldest son was at bedside and acknowledged his father's wishes, and was in support. So we respected his wishes and then we administered medications to ease his breathing. He soon passed peacefully that night.
Dr. Tam: I hope you can see that the importance of an advanced health care directive goes beyond doctors respecting your wishes. It also acts as a roadmap for your family so that they know exactly what to do in an otherwise extremely high pressure situation that comes with so much fear, anxiety and even guilt. So when these discussions are had and planned for, they can bring a family together in support, rather than create a divide like we saw in the first patient scenario.
So now you may be wondering, how can I fill one out? And what do I do with it?
Dr. Tam: So there's an amazing, amazing website called prepareforyourcare.org. It has an Advanced Health Care Directive template, specific to your state, that will guide you through filling it out step by step.
Dr. Tam: Once you’re done, all you have to do is give it to your primary care provider so that they can add it to your medical file. And once it's uploaded into your medical file, I want you to know that it isn't permanent. These documents can be revised at any time. Our priorities change over the years and these documents can change with it. But it is never too early to start these discussions with your family and loved ones.
Dr. Tam: Alright, Mighty Family. I thank you all for your attention. And I hope you found this episode insightful. I know these conversations are not easy, but it comes from a place of care and love. I look forward to connecting with you all soon.
Dr. Tam: For those that are not part of the Mighty Family just yet, check us out at mightyhealth.com for more. We're striving every day to be the modern holistic home for healthy aging.