Selected Podcast
Advance Care Planning
Dr. Morgan-Gouveia discusses advance care planning.
Featuring:
Dr. Morgan-Gouveia received her medical degree at the Johns Hopkins University School of Medicine, and completed her primary care Internal Medicine residency training at the Johns Hopkins Bayview Medical Center. She completed a Geriatrics fellowship in the clinician educator track at the Johns Hopkins University School of Medicine.
Dr. Morgan’s passion is improving the care of older adults through education. She spends much of her time teaching residents, medical students, and pharmacy residents. She provides clinical care for patients in the ChristianaCare Home Visit program and the Wilmington Adult Medicine office. She is involved with efforts to improve geriatric clinical care on a national level, currently serving as a member of the American Board of Internal Medicine’s Geriatric Medicine Specialty Board and the American Geriatrics Society’s Clinical Practice and Models of Care Committee.
Melissa Morgan-Gouveia, MD
Dr Melissa Morgan-Gouveia MD is a board-certified geriatrician and faculty member in the Department of Medicine at ChristianaCare. She also holds a part-time faculty appointment at the Johns Hopkins University School of Medicine as an Assistant Professor of Medicine in the Division of Geriatric Medicine and Gerontology.Dr. Morgan-Gouveia received her medical degree at the Johns Hopkins University School of Medicine, and completed her primary care Internal Medicine residency training at the Johns Hopkins Bayview Medical Center. She completed a Geriatrics fellowship in the clinician educator track at the Johns Hopkins University School of Medicine.
Dr. Morgan’s passion is improving the care of older adults through education. She spends much of her time teaching residents, medical students, and pharmacy residents. She provides clinical care for patients in the ChristianaCare Home Visit program and the Wilmington Adult Medicine office. She is involved with efforts to improve geriatric clinical care on a national level, currently serving as a member of the American Board of Internal Medicine’s Geriatric Medicine Specialty Board and the American Geriatrics Society’s Clinical Practice and Models of Care Committee.
Transcription:
Melanie Cole: What kind of medical care would you want if you were too ill or hurt to express your wishes? This is ChristianaCare, Swank Memory Care Podcast series. I'm Melanie Cole, and today we're talking about advanced directives. Our speakers in this podcast series represent the Swank Center for Memory Care and Geriatrics, Delaware's first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers, coping with dementia or other neurocognitive disorders. Joining me is Dr. Melissa Morgan-Gouveia. She's a geriatrician and faculty member in the department of medicine at ChristianaCare. Dr. Morgan, it's a pleasure to have you join us today. For the listeners, please tell them what is advanced care planning and why is it so important?
Dr. Melissa Morgan-Gouveia: Advanced care planning is the process by which you learn about the types of decisions that might need to be made in the future regarding your healthcare, and really consider those decisions ahead of time. Not waiting until there is a crisis and letting others know, both your family and your healthcare providers, about what matters most to you and what your preferences would be if you became seriously ill or at the end of life. These preferences are often put into an advanced directive, which is a legal document that goes into effect if you're not able to speak for yourself. And let's others know what type of medical care you would want. Even if you are in good health it's important to have conversations with your family and your healthcare team about your wishes as your health status can change suddenly and unexpectedly. It's especially important if you have a chronic illness. We know that people with certain diseases such as Alzheimer's disease and others, Dementia, usually lose the ability to make decisions for themselves as the disease progresses. These conversations will evolve over time as your health and life circumstances change, but each conversation helps your family and your healthcare team that are understand what matters to you and give you the treatments that you want.
Host: Well, thank you for that. It is certainly so important. So people hear these terms thrown around living will, medical power of attorney or healthcare, power of attorney, advanced directive, physician order for life sustaining treatment, pulsed, or even regular power of attorney and they're not sure that these things all crossover. So tell us a little bit about what a living will is, what the difference between a living will and an advanced directive or a medical power of attorney? Tell us about some of those terms. Dr. Morgan.
Dr. Melissa Morgan-Gouveia: A living will or an advanced directive is a legal document in which you state your wishes for end of life care. This is completely different from your last will and Testament, which focuses on how your assets will be distributed after your death. A medical power of is different from a financial power of attorney. A medical power of attorney is someone who makes decisions for your health care as opposed to a financial power of attorney who is able to manage your money when you're no longer able to do that for yourself. A physician order for life sustaining treatment, a POLST form or in Delaware. This is referred to as a DMOST form, Delaware medical orders for scope of treatment is different from an advanced directive and that it's an actual medical order, so as opposed to an advanced directive form which you can complete any time when you or over age 18 and when you are healthy, a POLST form or the DMOST form in Delaware is really intended for people with serious medical illnesses or advanced age, whose healthcare providers would not be surprised if they die in one year. This is a medical order that's valid wherever the patient is at home in the hospital or in a nursing home or other care facility as opposed to an advanced directive, a POLST form or DMOST must be completed by a healthcare provider and can be completed with a patient's surrogate decision maker, if the patient no longer has capacity to make healthcare decisions. An advanced directive or living will must be completed by an individual and can't be completed by someone else on their behalf at a later date if they're no longer able to make decisions for themselves.
Host: Well, thank you for clearing that up because that could be confusing to people. So what are some of these decisions that could come up? Are we talking about artificial nutrition, tube feeding, ventilators? Tell us about some of these decisions.
Dr. Melissa Morgan-Gouveia: Yeah, there's many decisions that come up in healthcare and many of these are really impossible to predict ahead of time. It depends on what diseases you end up developing, different circumstances, that we may not always be able to think about in advance. And this is why it is helpful to designate someone as a healthcare decision maker because as long as they know what your general goals and preferences are, they can help speak on your behalf to designate and decide some of these decisions. But there are many decisions that come across eventually for everyone, often at the end of life care and pertaining to life sustaining treatments. And these common things are about CPR or cardiopulmonary resuscitation, ventilator used, artificial nutrition. So to expand on those a little bit, CPR is in the event that your heart stops or has a life threatening rhythm, and we often see in younger people, you know that they can recover from this, but in older adults or people with multiple chronic illnesses who are already very frail, the reality is that they don't recover from CPR or even if they survive CPR, they have significant disability and often aren't able to end up going back home or living independently.
So many older adults when asked say that they would actually rather die naturally then go through the trauma of CPR to only live with increased disability or dependence on others. Another decision that often needs to be made is about a ventilator, which is a machine that helps you breathe when you're having difficulty breathing on your own. This is done by putting a tube down someone's throat to connect them to a machine that forces air into the lungs, and this can be uncomfortable for patients. They have to be sedated generally to be able to tolerate it. They aren't able to speak and while they sometime may be only required for a short period in the setting of an acute illness like a lung infection, pneumonia, some people end up requiring them for a longer period or lifelong.
And end up having a surgical procedure called a tracheostomy where they put a tube in their neck to attach them to the breathing machine for a long-term. Another area that comes up commonly and is included in the advanced directive forms is artificial nutrition, so that is if someone is not able to eat or drink on their own, they can receive fluids or nutrition via an IV for a short period, but for a prolonged period. It often involves inserting a feeding tube into the stomach through which fluids nutrition medications can be given if the patient is not able to take them by mouth. Feeding tubes can be helpful in certain situations such as when a patient has difficulty swallowing after an acute stroke and they can improve from that as they recover from their stroke. However, feeding tubes have not been shown to meaningfully prolong life in advanced diseases like dementia.
Host: So one of the big concerns people have when they're thinking about all this is starting the conversation with a loved one. What do you tell them about bringing this up? Because some people say, I don't want to talk about that or I'm not going to think about that now. Even as you said young people. So how do we start the conversation?
Dr. Melissa Morgan-Gouveia: Yeah. First of all, it's important to recognize the importance of these conversations. There is a project called the conversation project where they're trying to empower people to have these conversations and what their data shows is. 92% of people think it is important to have these conversations, but less than a third have actually done so. And there are times where certain circumstances or things can trigger a conversation. Often the death of a loved one can be an opening for a conversation. A current event in the news, an article you've read, but also changes in your health status. If someone has been in the hospital or had a new diagnosis, these can be times where you can bring up with your family members and your healthcare team wanting to talk about your treatment preferences. Certainly in the diagnosis of a condition such as dementia or Alzheimer's disease should trigger having these conversations. But you're right, families sometimes don't want to have this or I'm like, no, mom, you're going to be fine. But the important thing is, you know, coming back to it, maybe that's not a good time to talk about it, but maybe we can set up a time to talk about it later. You can talk to your healthcare team and providers, make sure they know your wishes. They can give you some tips for discussing with your family, and there's also many resources available online to help guide these discussions. The conversation project that I mentioned is one where there's lots of resources and things to help you prepare and have these conversations with your family and your healthcare team.
Host: Well, thank you for that good advice. Now, considerations when we're choosing our medical power of attorney, this is a big deal. It's a big decision. How do you select your healthcare agent?
Dr. Melissa Morgan-Gouveia: It's important to select a healthcare agent who you think A, would be comfortable serving in that role as your healthcare decision maker and will respect and follow your wishes for your care. Many people, you know will end up selecting someone as their healthcare agent who may not be the default person or the person closest to them, such as a spouse or child because they're worried that that person would be too emotional and would not be able to follow their wishes, and remember that a good death means different things to different people. So if someone doesn't share your views or you don't think can respect your wishes, then they won't be a good healthcare decision maker, it's also important to note that it's generally helpful to just select one person as your primary healthcare decision maker. You can have a second agent as a backup, but it often can create conflict if you have multiple decision makers.
Host: Well that's a very good point. So after you set it up, where do you keep it? So emergency medical technicians can know whether they're going to administer CPR. Where do we keep these things? As you mentioned, a few of them are legal documents. Do we keep this right out in the open? What do we do with them?
Dr. Melissa Morgan-Gouveia: Good question. It's important to have an advanced directive somewhere that's easily accessible for you. Easy to remember where it is. Certainly your healthcare power of attorney, whoever is your decision maker, as well as your healthcare provider should both have a copy of it, but this is not something you want to keep locked away in a safety deposit box or it's not easily accessible. It's also important to know you asked about EMTs emergency medical technicians. They actually cannot follow advanced directives in emergency situations as these are not signed by a physician. So this advanced directive different to the physician orders for life sustaining treatment that I talked about earlier. So without a do not resuscitate order assigned by a physician, EMTs are actually required to provide every possible treatment to help keep you alive. Whereas if you have the POLST, DMOST medical order form and then you have yourself as a do not resuscitate on that form, this is a medical order that the EMTs will follow and they're trained to look for this form on the refrigerator or you can have it, you know, by your bedside or wherever you think is the most easy to find place in the house. In Delaware, it comes in a bright pink envelope. So it's easy to identify. But I think this distinction is key for people who are really at advanced stages in their illness and in their life having a POLST or DMOST form. So they actually have a medical order that EMTs can follow.
Host: Well that's great that it's pink. It is easy to find that way. So before we wrap up, how does someone get started with all of this? What's the first step to make it official?
Dr. Melissa Morgan-Gouveia: So the first step is to have these conversations with your family and your healthcare team and decide what your wishes are and then put those in writing. In Delaware, there's an advanced directive form that's available for free on the Delaware Health and Social Services website. You can also get forms through your doctor's office or through the hospital. In Delaware, the advanced directive forms do not need to be completed with an attorney and they do not need to be notarized. They do need to be signed by two witnesses, and those witnesses can't be related to you or be a beneficiary.
Host: So do you have any final thoughts for people when they're thinking about starting these conversations and putting all this paperwork in order because it really is such a good idea. And as you said right at the beginning, advanced care planning is important even if you're young and healthy because it does state your wishes and kind of set everything up, should there be something that happens out of the blue. Do you have any final thoughts? What would you like to tell the listeners?
Dr. Melissa Morgan-Gouveia: Yeah. I think the most important first thing for people to realize is while these conversations may be hard and no one really wants to think about or talk about death or end of life, it is really important to have these conversations when people are healthy and able to participate, and express their wishes for what they want. We're not good at necessarily understanding or predicting what people would want neither physicians nor family members and often family members are put in the role of making those decisions for their loved ones and saying, we never talked about this. We don't know what their wishes are and that can be really hard and can leave family members with a lot of guilt. Whereas if they have a conversation and they said, no, you know, we talked about this, my mom said she never wanted to live on machines. This was not quality of life. I know that I'm respecting her wishes and this is what she wanted. It actually ends up making things much, much easier on families and making it more likely that you get the care that you prefer or at the end of the life, if you have these conversations and document them in an advanced directive, then if you don't,
Host: Thank you so much, Dr. Morgan, really great information and so much usable information that people can listen to you say and do right now, today they can get started. So thank you again. And that concludes this episode of ChristianaCare Swank Memory Care Podcast series. To learn more about programs and services, or to schedule an evaluation at the Swank Memory Center, Delaware's first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers coping with dementia or other neurocognitive disorders, you can call (302) 320-2620. Or you can visit Christianacare.org/swankmemorycare, for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other ChristianaCare Swank Memory Care podcasts. I'm Melanie Cole.
Melanie Cole: What kind of medical care would you want if you were too ill or hurt to express your wishes? This is ChristianaCare, Swank Memory Care Podcast series. I'm Melanie Cole, and today we're talking about advanced directives. Our speakers in this podcast series represent the Swank Center for Memory Care and Geriatrics, Delaware's first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers, coping with dementia or other neurocognitive disorders. Joining me is Dr. Melissa Morgan-Gouveia. She's a geriatrician and faculty member in the department of medicine at ChristianaCare. Dr. Morgan, it's a pleasure to have you join us today. For the listeners, please tell them what is advanced care planning and why is it so important?
Dr. Melissa Morgan-Gouveia: Advanced care planning is the process by which you learn about the types of decisions that might need to be made in the future regarding your healthcare, and really consider those decisions ahead of time. Not waiting until there is a crisis and letting others know, both your family and your healthcare providers, about what matters most to you and what your preferences would be if you became seriously ill or at the end of life. These preferences are often put into an advanced directive, which is a legal document that goes into effect if you're not able to speak for yourself. And let's others know what type of medical care you would want. Even if you are in good health it's important to have conversations with your family and your healthcare team about your wishes as your health status can change suddenly and unexpectedly. It's especially important if you have a chronic illness. We know that people with certain diseases such as Alzheimer's disease and others, Dementia, usually lose the ability to make decisions for themselves as the disease progresses. These conversations will evolve over time as your health and life circumstances change, but each conversation helps your family and your healthcare team that are understand what matters to you and give you the treatments that you want.
Host: Well, thank you for that. It is certainly so important. So people hear these terms thrown around living will, medical power of attorney or healthcare, power of attorney, advanced directive, physician order for life sustaining treatment, pulsed, or even regular power of attorney and they're not sure that these things all crossover. So tell us a little bit about what a living will is, what the difference between a living will and an advanced directive or a medical power of attorney? Tell us about some of those terms. Dr. Morgan.
Dr. Melissa Morgan-Gouveia: A living will or an advanced directive is a legal document in which you state your wishes for end of life care. This is completely different from your last will and Testament, which focuses on how your assets will be distributed after your death. A medical power of is different from a financial power of attorney. A medical power of attorney is someone who makes decisions for your health care as opposed to a financial power of attorney who is able to manage your money when you're no longer able to do that for yourself. A physician order for life sustaining treatment, a POLST form or in Delaware. This is referred to as a DMOST form, Delaware medical orders for scope of treatment is different from an advanced directive and that it's an actual medical order, so as opposed to an advanced directive form which you can complete any time when you or over age 18 and when you are healthy, a POLST form or the DMOST form in Delaware is really intended for people with serious medical illnesses or advanced age, whose healthcare providers would not be surprised if they die in one year. This is a medical order that's valid wherever the patient is at home in the hospital or in a nursing home or other care facility as opposed to an advanced directive, a POLST form or DMOST must be completed by a healthcare provider and can be completed with a patient's surrogate decision maker, if the patient no longer has capacity to make healthcare decisions. An advanced directive or living will must be completed by an individual and can't be completed by someone else on their behalf at a later date if they're no longer able to make decisions for themselves.
Host: Well, thank you for clearing that up because that could be confusing to people. So what are some of these decisions that could come up? Are we talking about artificial nutrition, tube feeding, ventilators? Tell us about some of these decisions.
Dr. Melissa Morgan-Gouveia: Yeah, there's many decisions that come up in healthcare and many of these are really impossible to predict ahead of time. It depends on what diseases you end up developing, different circumstances, that we may not always be able to think about in advance. And this is why it is helpful to designate someone as a healthcare decision maker because as long as they know what your general goals and preferences are, they can help speak on your behalf to designate and decide some of these decisions. But there are many decisions that come across eventually for everyone, often at the end of life care and pertaining to life sustaining treatments. And these common things are about CPR or cardiopulmonary resuscitation, ventilator used, artificial nutrition. So to expand on those a little bit, CPR is in the event that your heart stops or has a life threatening rhythm, and we often see in younger people, you know that they can recover from this, but in older adults or people with multiple chronic illnesses who are already very frail, the reality is that they don't recover from CPR or even if they survive CPR, they have significant disability and often aren't able to end up going back home or living independently.
So many older adults when asked say that they would actually rather die naturally then go through the trauma of CPR to only live with increased disability or dependence on others. Another decision that often needs to be made is about a ventilator, which is a machine that helps you breathe when you're having difficulty breathing on your own. This is done by putting a tube down someone's throat to connect them to a machine that forces air into the lungs, and this can be uncomfortable for patients. They have to be sedated generally to be able to tolerate it. They aren't able to speak and while they sometime may be only required for a short period in the setting of an acute illness like a lung infection, pneumonia, some people end up requiring them for a longer period or lifelong.
And end up having a surgical procedure called a tracheostomy where they put a tube in their neck to attach them to the breathing machine for a long-term. Another area that comes up commonly and is included in the advanced directive forms is artificial nutrition, so that is if someone is not able to eat or drink on their own, they can receive fluids or nutrition via an IV for a short period, but for a prolonged period. It often involves inserting a feeding tube into the stomach through which fluids nutrition medications can be given if the patient is not able to take them by mouth. Feeding tubes can be helpful in certain situations such as when a patient has difficulty swallowing after an acute stroke and they can improve from that as they recover from their stroke. However, feeding tubes have not been shown to meaningfully prolong life in advanced diseases like dementia.
Host: So one of the big concerns people have when they're thinking about all this is starting the conversation with a loved one. What do you tell them about bringing this up? Because some people say, I don't want to talk about that or I'm not going to think about that now. Even as you said young people. So how do we start the conversation?
Dr. Melissa Morgan-Gouveia: Yeah. First of all, it's important to recognize the importance of these conversations. There is a project called the conversation project where they're trying to empower people to have these conversations and what their data shows is. 92% of people think it is important to have these conversations, but less than a third have actually done so. And there are times where certain circumstances or things can trigger a conversation. Often the death of a loved one can be an opening for a conversation. A current event in the news, an article you've read, but also changes in your health status. If someone has been in the hospital or had a new diagnosis, these can be times where you can bring up with your family members and your healthcare team wanting to talk about your treatment preferences. Certainly in the diagnosis of a condition such as dementia or Alzheimer's disease should trigger having these conversations. But you're right, families sometimes don't want to have this or I'm like, no, mom, you're going to be fine. But the important thing is, you know, coming back to it, maybe that's not a good time to talk about it, but maybe we can set up a time to talk about it later. You can talk to your healthcare team and providers, make sure they know your wishes. They can give you some tips for discussing with your family, and there's also many resources available online to help guide these discussions. The conversation project that I mentioned is one where there's lots of resources and things to help you prepare and have these conversations with your family and your healthcare team.
Host: Well, thank you for that good advice. Now, considerations when we're choosing our medical power of attorney, this is a big deal. It's a big decision. How do you select your healthcare agent?
Dr. Melissa Morgan-Gouveia: It's important to select a healthcare agent who you think A, would be comfortable serving in that role as your healthcare decision maker and will respect and follow your wishes for your care. Many people, you know will end up selecting someone as their healthcare agent who may not be the default person or the person closest to them, such as a spouse or child because they're worried that that person would be too emotional and would not be able to follow their wishes, and remember that a good death means different things to different people. So if someone doesn't share your views or you don't think can respect your wishes, then they won't be a good healthcare decision maker, it's also important to note that it's generally helpful to just select one person as your primary healthcare decision maker. You can have a second agent as a backup, but it often can create conflict if you have multiple decision makers.
Host: Well that's a very good point. So after you set it up, where do you keep it? So emergency medical technicians can know whether they're going to administer CPR. Where do we keep these things? As you mentioned, a few of them are legal documents. Do we keep this right out in the open? What do we do with them?
Dr. Melissa Morgan-Gouveia: Good question. It's important to have an advanced directive somewhere that's easily accessible for you. Easy to remember where it is. Certainly your healthcare power of attorney, whoever is your decision maker, as well as your healthcare provider should both have a copy of it, but this is not something you want to keep locked away in a safety deposit box or it's not easily accessible. It's also important to know you asked about EMTs emergency medical technicians. They actually cannot follow advanced directives in emergency situations as these are not signed by a physician. So this advanced directive different to the physician orders for life sustaining treatment that I talked about earlier. So without a do not resuscitate order assigned by a physician, EMTs are actually required to provide every possible treatment to help keep you alive. Whereas if you have the POLST, DMOST medical order form and then you have yourself as a do not resuscitate on that form, this is a medical order that the EMTs will follow and they're trained to look for this form on the refrigerator or you can have it, you know, by your bedside or wherever you think is the most easy to find place in the house. In Delaware, it comes in a bright pink envelope. So it's easy to identify. But I think this distinction is key for people who are really at advanced stages in their illness and in their life having a POLST or DMOST form. So they actually have a medical order that EMTs can follow.
Host: Well that's great that it's pink. It is easy to find that way. So before we wrap up, how does someone get started with all of this? What's the first step to make it official?
Dr. Melissa Morgan-Gouveia: So the first step is to have these conversations with your family and your healthcare team and decide what your wishes are and then put those in writing. In Delaware, there's an advanced directive form that's available for free on the Delaware Health and Social Services website. You can also get forms through your doctor's office or through the hospital. In Delaware, the advanced directive forms do not need to be completed with an attorney and they do not need to be notarized. They do need to be signed by two witnesses, and those witnesses can't be related to you or be a beneficiary.
Host: So do you have any final thoughts for people when they're thinking about starting these conversations and putting all this paperwork in order because it really is such a good idea. And as you said right at the beginning, advanced care planning is important even if you're young and healthy because it does state your wishes and kind of set everything up, should there be something that happens out of the blue. Do you have any final thoughts? What would you like to tell the listeners?
Dr. Melissa Morgan-Gouveia: Yeah. I think the most important first thing for people to realize is while these conversations may be hard and no one really wants to think about or talk about death or end of life, it is really important to have these conversations when people are healthy and able to participate, and express their wishes for what they want. We're not good at necessarily understanding or predicting what people would want neither physicians nor family members and often family members are put in the role of making those decisions for their loved ones and saying, we never talked about this. We don't know what their wishes are and that can be really hard and can leave family members with a lot of guilt. Whereas if they have a conversation and they said, no, you know, we talked about this, my mom said she never wanted to live on machines. This was not quality of life. I know that I'm respecting her wishes and this is what she wanted. It actually ends up making things much, much easier on families and making it more likely that you get the care that you prefer or at the end of the life, if you have these conversations and document them in an advanced directive, then if you don't,
Host: Thank you so much, Dr. Morgan, really great information and so much usable information that people can listen to you say and do right now, today they can get started. So thank you again. And that concludes this episode of ChristianaCare Swank Memory Care Podcast series. To learn more about programs and services, or to schedule an evaluation at the Swank Memory Center, Delaware's first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers coping with dementia or other neurocognitive disorders, you can call (302) 320-2620. Or you can visit Christianacare.org/swankmemorycare, for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other ChristianaCare Swank Memory Care podcasts. I'm Melanie Cole.