Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Maggie McKay (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice. 

Prior to finding yourself in the hospital unexpectedly, it's always a good idea to have your wishes and documents in order. One document to consider doing before it's needed, is an Advanced Directive. But how much do you know about it?

Let's find out with Dr. Catherine Bree Johnston, Palliative Care Provider. Welcome to Be Well with Skagit Regional Health. I'm your host, Maggie McKay. Thank you so much for being here today, Dr. Johnston.

Catherine Bree Johnston, MD: I'm delighted to be here.

Maggie McKay (Host): I know how confused I was before I did mine. I did not even want to attempt it because, you know, it's a little overwhelming. So would you please tell us, what is the difference between a Durable Power of Attorney for Healthcare, an Advanced Directive, a Living Will, and a POLST or P-O-L-S-T? I don't even know how you say that one.

Catherine Bree Johnston, MD: It gets very confusing, doesn't it? So let's start with the Durable Power of Attorney for Healthcare, which is probably the most important document. And that is a legal document that you can sign where you designate somebody to make medical decisions for you. Now, if you don't do a Durable Power of Attorney for Healthcare, there is a Washington state law that says who's going to make decisions for you.

And there is a sequence. So if you're married, it's your spouse. If you're an adult and you have adult children, all the children have to agree together. And then there are various other people. So it's really best to do a Durable Power of Attorney for Healthcare. And the thing is you want to select somebody who knows you well and can respect your wishes.

That may not be your spouse. It may not be your most beloved person, but it's somebody that you trust to convey your values and speak for you. And here's the thing. If you designate someone to be your power of attorney, you need to have a discussion with that person to tell them what's important to you, which brings us to the next document, which is, an Advanced Directive or a Living Will.

There are different kinds of Advanced Directives and Living Wills. We generally discourage the traditional living will, which is the document that says if two physicians deem me to be in a terminal condition or an irreversible coma, then do X, Y or Z. These documents are rarely helpful because the situations that are described in them being in a persistent vegetative state, that's very rare and we're usually in more nuanced situations.

So we really recommend, other types of values based advanced directives. Two that I would recommend are Prepare for Your Care, www.prepareforyourcare.org, or the advanced directive through Honoring Choices Pacific Northwest. And these two types of advanced directives talk about things like what's more important to you, quality of life or length of life.

Would living in a nursing home be acceptable to you? Would you want to be kept alive long term on machines? So they go through a variety of scenarios that allow you to express what's important to you. And then the final kind of document is a POLST form. That is a green form here in Washington state, it's different colors in different states.

And this is really for people who are in the last year or two of life or have a serious illness and for people who want limitations in care. And that allows you to say whether or not you would want cardiopulmonary resuscitation and whether or not you would want to be transferred to the hospital.

These forms are really useful if you don't want to be resuscitated because these are the forms that will tell the emergency medical personnel that you don't want resuscitation. And these are the only forms that they will recognize. They're also really useful for people who are in a nursing home or on hospice.

Maggie McKay (Host): I always think, what if you are in a tragic accident and you don't have these documents on you? How does that work?

Catherine Bree Johnston, MD: Well, then what happens if you don't have these documents, then usually if the emergency personnel have not contacted anybody, or they don't know who your contact information is, and you're unable to speak for yourself, they always default to providing the most aggressive care. Now, if they do find a family member, then they have to speak on your behalf.

Let me tell you, that is torturous. I was in this situation when my mother was old and she had severe COPD emphysema. I was her Power of Attorney and she had told me on multiple occasions, I don't want to be on life support. I've lived a wonderful life. I'm happy to die whenever it's my time. And when I was faced with having to make those decisions on her behalf, that was such a gift that she gave me because, it's a heartbreaking situation in any event, but if you can make it easier on your loved ones by saying those words, it is a very loving gift that you can give to your loved ones and your family. 

Maggie McKay (Host): Absolutely. And you really have to have these discussions with your spouse because you never know. For instance, my husband and I are complete opposites. He's like, I have a broken leg, let me go. And I'm like, you keep me alive 20 years, whatever it takes. So you never know until you actually have that conversation. You mentioned Advanced Directives. Why are they important?

Catherine Bree Johnston, MD: They're important because they help your loved ones make the right decisions on your behalf. And as I said, in terms of talking about the situation with my mother, they make it easier on your loved ones because it's a really hard situation to be in. Now the Advanced Directives, one of the things that I see sometimes in terms of Advanced Directives is that people just file them with their lawyer or they keep them in the safe deposit box.

That doesn't do anyone any good. It's important if you have an Advanced Directive to discuss it with the person who's going to be the decision maker, so they know what to do, and to bring it to your doctor or your hospital, so that they have it on file, so they know exactly what to do.

Maggie McKay (Host): I know you mentioned the different types, but can you just go over that again, the different types of Advanced Directives?

Catherine Bree Johnston, MD: Yeah, so the one I really encourage people to check out is Prepare for Your Care. www.prepareforyourcare.org. This is an Advanced Directive and there's also a video online and it allows you to designate a surrogate decision maker, but, it has an Advanced Directive that's at a fourth grade reading level with a lot of pictures and it walks you through things in your current state of health, what's more important to you? Length of life or quality of life? If you had a serious illness, what's more important to you? Length of life or quality of life? And then it kind of walks you and your decision maker through a number of different scenarios so you can think about what would be important to you if you were seriously ill.

Maggie McKay (Host): And what are the key components of a well written Advanced Directive?

Catherine Bree Johnston, MD: A well written Advanced Directive, really talks more about values than specific procedures. Because here's the thing, in medicine, we cannot anticipate every situation that's going to come up. So if I write down in my Advanced Directive, I don't ever want dialysis. What happens if I have a poisoning and one dialysis session is going to save my life?

Well, that's not useful. So it's a lot more useful to write down on your Advanced Directive, what's an acceptable quality of life for you? Now, we can never anticipate everything, and sometimes people's values change. For example, some people wouldn't think it'd be acceptable to live with an amputation, and then find out that it's actually quite acceptable.

But you can begin to anticipate what you think would be acceptable to you. So, a values based Advanced Directive is much more useful than a directive that talks about specific medical interventions.

Maggie McKay (Host): And I know you can do this through a lawyer, but how does someone create an Advanced Directive?

Catherine Bree Johnston, MD: So, actually, you can just download, for example, the Prepare for Your Care Advanced Directive, just off the internet. Fill it out yourself with your loved one and have two witnesses or a notary verify it. And then you make copies and bring one to your doctor, bring one to the hospital and make certain that your loved one has a copy of it.

Maggie McKay (Host): So can an Advanced Directive be updated or changed over time, or are they ironclad the first time you make one? 

Catherine Bree Johnston, MD: They absolutely should be updated, and some people say that they should be updated with any of the Ds happen. Death, so death of the surrogate decision maker, divorce, decade, decline in function, so if you have a new disability, or a new condition or a new diagnosis, that may be a time to update your Advanced Directive. Any of those things.

Maggie McKay Maggie McKay (Host): That's good to know. Dr. Johnston, how can healthcare providers and family members ensure that a person's Advanced Directive is honored during medical decision making?

Catherine Bree Johnston, MD: That's really a tricky situation, and the most important thing is making certain that the Advanced Directive is available at the hospital and at the doctor's office so that we can take a look at it. And having family members bring the Advanced Directive in if the patient's Advanced Directive is not on file is really important.

So again, make certain that this is not a dead document in the lawyer's office or in the safe deposit box. Have ready access to it and make certain that the right people have access to it.

Maggie McKay (Host): In closing, is there anything else you'd like to add that maybe we didn't cover that people thinking about doing any of these should know?

Catherine Bree Johnston, MD: I think the main thing is, none of us like to think about death and dying. It's a really hard thing to do. But remember that in preparing Advanced Directive, you are giving a gift to your family. And it's a gift that your family will appreciate you for and thank you for.

Maggie McKay (Host): Well, thank you so much for sharing your expertise on all these topics. This is very useful information and we appreciate your time.

Catherine Bree Johnston, MD: I'm delighted to be here. I'm passionate about this. I'm always happy to talk about it. And in fact, my family would wish I would stop talking about it.

Maggie McKay (Host): I understand. Thank you so much. Again, that's Dr. Catherine Bree Johnston. And to find out more, please visit skagitregionalhealth.org/aboutus/podcastsandpublications/bewellpodcast. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you.

I'm Maggie McKay. Thanks for listening to Be Well with Skagit Regional Health.