Maggie McKay (Host): Welcome to Total Health Talks, your Cook County Health Podcast, where we empower your journey to better health. I'm your host, Maggie McKay. And today, we're going to talk with Dr. Sasha Haran, Palliative Care attending physician about advanced directives in end-of-life care. Thank you so much for being here, Dr. Haran. 

Sasha Haran, DO: Thanks for having me. I'm excited to speak with you today.

Host: Let's just dive right in. For people out there listening who may not know the nuance, what is palliative care and how might that be different from hospice? 

Sasha Haran, DO: Sure. So, palliative care, the way I describe it to my patients when they come see me is we're a consulting team like any of your other subspecialties like Cardiology to name one. We provide an extra layer of support for patients who have a serious advanced illness, and we walk along with them throughout their journey to help with any symptom management and to guide their care to allow them to get what they want. It differs from hospice as hospice is a service line that's considered an insurance benefit towards the end of their life when prognosis is likely less than six months. 

Host: So, I know most people don't want to think about advanced care planning, but at what age should you begin that?

Sasha Haran, DO: Any adult above the age of 18 should start thinking about advanced care planning. Yeah, it sounds surprising and it's not something that we typically talk about, but I think it's very important so that your wishes are known If you do have an unfortunate circumstance happen.  

Host: One of the other things I know comes up a lot is the concept of advanced directives. Can you talk a little bit about what that is and who should have one? 

Sasha Haran, DO: Yeah. Advanced directives are meant for any patient or any person to legally write down what they're hoping for out of their care and to allow them to assign someone to be their voice if they become unable to speak to the care teams. In Illinois, there's kind of two main documents that we look at, the healthcare power of attorney and the living will that help patients kind of outline what they would want out of their care moving forward. 

Host: What are the key components of a well-written advanced directive?  

Sasha Haran, DO: Any well-written advanced directive should have who the patient trusts to make their healthcare decisions and what they may want at the end of life. So, would that be that they're kind of focusing on quality? Would they want to focus on their comfort or would they want to be prolonged on machines, and kind of outlining and guiding the care teams in that way? 

Host: I know when my husband and I did ours, we are at total ends of the spectrum. I say, "You do everything you can to keep me alive for as long as possible." And he is like, "You let me go the minute it gets even somewhat uncomfortable." And I'm like, "I can't. So, you're going to have to get like your sister or somebody else." If you don't think you can do it, don't sign up for it, that's what I think. Is that right?

Sasha Haran, DO: Right. Yeah. And you, as your person, you know the people that you live with, and so you're going to know their personality and what they're able to do when the time comes. For me, my mom knows I'm pretty emotional, so she puts actually my brother before me because she thinks he's a little more levelheaded. 

Host: Right. That's why I said to my husband, "You get your sister to unplug it," because I'm not going to do that. I can't do that. Dr. Haran, what is the difference between a durable Power of attorney for healthcare, an advanced directive, a living will, and a POLST, P-O-L-S-T?

Sasha Haran, DO: Sure. So, an advanced directive is the umbrella term for kind of the Healthcare Power of Attorney, the living will, and the POLST, which is a Practitioner Order of Life-sustaining Treatment. Now, the first two that I mentioned are more advanced directives where the patient themselves chooses, one, their power of attorney to make decisions, and then living will, which would outline again, kind of what we've discussed, what they would want at the end of life. 

A POLST is actually more considered a medical order under the umbrella term of advanced directive. And that's a specific order that patient should fill with their medical team. And it should be signed by both the patient and the provider, so whether that's their physician or advanced practitioner, to identify whether they would want CPR or if they would want to focus on natural dying when the time occurs. 

Host: So, which one of those should everybody have no matter what, just to start the ball rolling?

Sasha Haran, DO: Good question because advanced care planning is really a process. And so, to start the ball rolling, every adult should definitely have a power of attorney, and then they can consider discussing with that power of attorney what their living will and what the POLST may look like for them.

Host: What scenarios are covered by advanced directives and how does that factor into palliative care and treatments? 

Sasha Haran, DO: Usually, advanced directives are put into place when patients aren't able to make their own decisions. So if they come in confused or if they come in unable to speak with their care teams, then we would look to see if they've already done an advanced directive. With palliative care, we're able to help guide discussions when choosing advanced directives. Any medical practitioner can also guide in that conversation as well. And so, it's for teams to kind of look at the advanced directive when coming to a plan of care for patients who can't speak for themselves. 

Host: Help us figure out the big question. How do you talk to your family about advanced directives? I mean, how do you get them to even think about it, let alone write it out? 

Sasha Haran, DO: Yeah. Writing it out can be daunting. And I think just beginning the discussion of if something were to happen, if your condition were to worsen and the doctors couldn't improve on it, how would you want to approach that. And who do you trust to help guide the care teams as they are coming up with a plan of care? It is difficult and we have to acknowledge that, I think, first to make it a little more normalized for everyone.

Host: Right. Because it is probably the least favorite topic to talk about in life, death, right?

Sasha Haran, DO: Definitely. And it doesn't always have to be around death, I think. So, I think that can be something else we should delineate who you trust at any moment, right?  

Host: Well, how have you seen the absence of an advanced directive play a role in both patient and family's experience with critical illness? 

Sasha Haran, DO: Yeah. So when a patient begins to decline and they're not able to make their own decisions, we can't go backwards and ask them who they choose. And so, unfortunately, for some patients, it may not be their family. And by Illinois law, the medical teams do have to turn to next of kin. And so, that may not be who the patient actually trusts. And so, that's where you run into dynamics and then the patient gets caught in the middle of all of this, and we don't do right by the patient because we're not turning to who they would normally trust. 

Host: Does it vary state to state the laws? 

Sasha Haran, DO: Yeah. Generally, the person that they would turn to first is the spouse, but each state approaches that differently. 

Host: So if something were to happen, how can the ER tell if you have an advanced directive? Because people aren't going around with their advanced directive with them 24/7. 

Sasha Haran, DO: You should be able to have an electronic copy now that we're moving towards the 21st Century. Some people do actually have it and they're able to pull it up. If you are part of that medical system, if you have your primary care there, they may have already uploaded that from your prior clinic visits, which are helpful. When we do complete the practitioner order for life-sustaining treatment, which is the DNR CPR outlining that, we encourage patients to actually put it up on their fridge. So if someone a first responder comes in, they're able to look for it there. 

Host: Is there some kind of app that you could have right on the face of your phone that has--

Sasha Haran, DO: No. Usually, it's downloadable as a PDF.

Host: Okay. How can healthcare providers and family members ensure that a person's advanced directive is honored during medical decision-making? Like we're talking about that. 

Sasha Haran, DO: Having the discussion first when the patient is able to is key. It's really important. Any provider will be able to outline that for a patient. And documenting is really the key there as well, to make sure that everyone is on the same page.  

Host: Why is it so important to spread the word on advanced directives? 

Sasha Haran, DO: So that way, people have one and that their wishes are respected and that medical teams can provide the appropriate plan of care to prevent medical errors really.

Host: I'm just thinking back to when we did ours, we were with our lawyer, but they don't automatically send that to your doctor, so it's up to everybody themselves to send it on to just your doctor or hospitals or what? 

Sasha Haran, DO: Yeah. You should definitely, have a copy for yourself. And you would have to bring it in because we aren't connected with your lawyer. However, we are able within the medical setting to complete with a case manager or social worker, or even the care team themselves, the power of attorney. And so, that way, we would have at least that portion of the advanced directive. 

Host: So, should we each send it to our own general physician just so they have it on file just in case, because you know how when you go to the hospital for anything they say, who's your primary doctor? 

Sasha Haran, DO: Yes, definitely. Because then your primary care physician is able to forward that information over.

Host: And how does someone create an advanced directive? Does Cook County Health offer any resources to do that?

Sasha Haran, DO: Yeah. So, Cook County definitely has, through County Care, case managers and social workers who are trained to be able to walk patients through completing an advanced directive. Any provider that you encounter is also able to walk you through that. And specifically, the practitioner order for life-sustaining treatment can be signed with you and your primary physician, or you and any of your providers at your medical visits.

In addition, National Decision Day is coming up April 16th of this year. And our team is holding a table session in the professional building area where we are going to be providing that service to allow patients walking through and their loved ones really who are there visiting to complete their advanced directives with our team. 

Host: That would be ideal to be there in that setting and have help because you know it's going to be done the right way.

Sasha Haran, DO: Yeah.

Host: Well, it sounds like you have everything covered in this department for patients and they should feel reassured, I would think. 

Sasha Haran, DO: Oh yeah, definitely. We love talking to our patients about how to go about doing this. 

Host: Thank you so much for sharing your knowledge on this important topic that is going to affect our lives at some point. So, everybody needs to know this. 

Sasha Haran, DO: I agree. No, thank you so much for having me.

Host: Absolutely. It was a pleasure. Again, that's Dr. Sasha Haran. And as we wrap up another insightful episode of Total Health Talks, make sure to visit cookcountyhealth.org/podcast and subscribe to our podcast, share and connect with us on social media. Stay tuned for more engaging discussions. This is Maggie McKay signing off from Total Health Talks. Stay well.