Transcription:

Melanie Cole (Host): Welcome. Our topic today is discussing financial and advanced directive planning with patients, and my guest is Dr. Sally Salmons. She's a family medicine physician with the Carle Foundation Hospital. Dr. Salmons, let's start by describing what advanced care planning really is, and what are advanced healthcare directives? Why is this so important?

Dr. Sally Salmons, MD (Guest): So advanced care planning actually encompasses both planning for financial and life changes for patients. The things that individuals think about when these terms are brought forward tend to be focused on only one piece of this. So I think it's really crucial that we talk about the various aspects of this today.

Melanie: Then let's sort it out a little bit. What's the difference between a living will, medical power of attorney, an advanced directive, or a physician order for life-sustaining treatment?

Dr. Salmons: So a medical power of attorney is a document that a patient designates someone to speak for them and make decisions for them in the event that they could not make those decisions for themselves or speak. This is something that patients often do not anticipate that will happen to them, and if we do not have a document in place prior, there are laws that govern who we ask first, but the laws don't take into account that the person who's designated legally in the absence of the patient's documented wishes may not share the same thoughts or desires the patient has.

The living will document is a document that is more of a summation of the patient's overall thought process related to their care. It could specify things like, "I want certain treatments at the end of life, or I don't," or it could be much more general in terms of an outlook or an approach to care.

It is not as specific or directive as some of the other documents, but can be helpful when we are trying to understand a patient's philosophy. Often fortunately, the patients who will fill out this document will have completed other documents as well, although this document can give us a sense of how the patient thinks, and if something's not specifically addressed in one of the other documents, it helps us decide what to do if it's not specifically addressed elsewhere.

So the POLST is often also called a DNR order, which is a very simplistic way of discussing that because it does weigh more than designating whether or not a patient wants to be resuscitated. The POLST form allows an individual to- and it's a document that's signed by the patient, it's signed by a witness- a patient or guardian witness, and usually the primary care or the attending physician, and it essentially defines in a situation where the patient is not breathing or their heart stops, what actions they want or do not want to be taken. It also addresses nutrition as well, and there's also a section where the patient can define what kind of pre-arrest activities they want to have done.

For example, if it looks like the patient's going to stop breathing, or their heart is going to stop beating, what activities they do or don't want to have completed.

Melanie: So for other providers, starting this discussion with patients and their families can be a tough one. Some families do not want to discuss these things you've brought up today, so what would you like providers to know about beginning that discussion and getting their families and their patients to talk about these?

Dr. Salmons: Yeah so you know, I think that we - in my experience at least - we often feel that patients don't want to talk about it, but in fact most of them actually do. You know, when a patient has a chronic disease, they really want to know what the course of that disease is. For example, when someone has heart failure, their first encounter with heart failure, they may not be significantly seriously incapacitated for a long period of time. They may have shortness of breath, slowing of the feet, some things that may require for them to be in the hospital for a day or two, but after that first initial episode is treated, they feel pretty good. But what patients want to know that we often fall down in terms of telling them is heart disease is a chronic disease and it will progress, and it's likely that over a period of time that heart disease could even cause your death.

And so those discussions around what's going to be happening with your disease can help us emphasize to a patient the importance of being a participant and understanding that there will be a point where we're going to need to know what needs to be done. It's best to have some time to think about that, and be able to plan for that in advance, hence the term 'advanced care planning.'

And I think we often in healthcare mistakenly assume that patients don't want to have that discussion, and I think part of that is entrenched in our overall culture in our country where we tend to not talk about death as much as some other cultures do. And it's not just the death portion that we need to focus on. It's those situations where you have a patient that they were active in being able to drive and take care of themselves, but if they have heart failure and they're in the latter stages, they get to the point where they can't even walk to the refrigerator without being short of breath. They need to be thinking about, "What do I need to have and what do I want to have when this happens? Do I want to be in my own home? Or am I someone, I want to be in a living facility. Who's going to do my banking for me? Who's going to do my grocery shopping?"

So planning for things that we might not be able to imagine if we don't understand what's likely to happen to us.

Melanie: It is a good point that you make that providers may mistakenly think that patients don't want to discuss it, but one of the reasons sometimes patients are hesitant is because it's a confusing system. How do they make it official, and what advice can providers- how can they help them to start this process and get the forms that they need and know where to store these forms and who should have copies of them?

Dr. Salmons: And fortunately there are a lot of really good resources, and one of the things we should be doing as healthcare providers, whether we're the person's primary care physician, and advanced practice professional as part of their healthcare team, a nurse, healthcare tech. All of us in the system need to take an active role in helping guide patients to resources to help them accomplish what they need in terms of advanced care planning.

We- at Carle, we offer packets of information which actually the law governs that we provide patients with information, but we need to go beyond that in terms of just performing the perfunctory part of the duty where we just give them the forms. We need to make that an active part of the discussion. And I think some providers feel like, "I don't really know if I know where all of the information, so I don't know all of the answers." And fortunately there are a lot of good resources for us to utilize ourselves or to connect patients to. There are a lot of national organizations that have information. For example, the National Institute on Aging has a lot of good information that's aimed at the patient level. And you know, they have some topics on getting your affairs in order, and then they have topics on discussing financial and life changes with your doctor. The National Hospice and Palliative Care Organization, they have a lot of good information on advanced care planning. So there are a lot of resources both for patients and for people who are in the healthcare arena providing care, touching patients' lives, that we can access to provide more robust information and meaningful information for patients.

Melanie: Thank you so much, Dr. Salmons, for being with us. You've wrapped it up so beautifully and explained to providers the importance of discussing advanced directive planning with their patients, and how to go about doing that. So thank you again. You're listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.