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National Healthcare Decisions Day: Have The Conversation

By Susan Nelson, MD, LaPOST Coalition Chair (@geripaldoc)

As a geriatrics and palliative care physician, my focus is on improving the quality of life for patients with serious illnesses, and knowing what my patients’ goals of care and treatment wishes are, is a necessary component in that process.

While many of my patients are able to engage in meaningful discussions with me about their diagnoses, prognoses and personal preferences, many others cannot. And unfortunately, a significant number of these patients have no one to speak for them, and even worse, some of them have no advance care plans in place, leaving their loved ones to make decisions about their care with no knowledge of what their wishes might be.

Thus, I’ve become a vocal advocate for advance care planning. In my role as chair of the Louisiana Physician Orders for Scope of Treatment (LaPOST) Coalition, I’ve traveled the state educating health care professionals, patients and families about advance care planning and the importance of discussing and documenting our health care wishes and goals of care.

And perhaps unsurprisingly, I am also a proud supporter of National Healthcare Decisions Day. Observed annually on April 16, NHDD serves to inspire, educate and empower health care providers and patients and families about the importance of advance care planning. It is an initiative focused on educating patients about how to express their wishes regarding their health care and encouraging health care providers and organizations to respect those wishes, whatever they may be. And in recognition of NHDD, I’d like to express a few thoughts of my own about advance care planning.

It’s Not Just For Old People

Illness is difficult to predict, and it’s non-discriminatory. It can happen at any time, at any age, when you least expect it, and it can leave you unable to make your own decisions about your care. Making health care plans for the future – even if you aren’t sick now – can help to ensure that if a medical crisis does occur, you will receive the care you want in the setting you prefer.

It’s Okay If You Aren’t Sure What You Want

There is no ‘one size fits all’ approach to advance care planning. What is right for you may not be right for someone else. The key is to identify what’s important to you, and you can start that process by asking yourself what matters most to you in your life, who you would want to make decisions about your care if you became unable to do so and what types of medical care you do and do not want.

“Conversations Change Lives: A Guidebook to Advance Care Planning” is a wonderful free resource that can help you to prepare your thoughts before you begin the advance care planning process.

It All Starts With A Conversation

Advance care planning begins with a conversation. This conversation may be with your physician, your loved ones, your spiritual leader, your neighbor – whomever you choose, wherever you choose and in whatever location you choose. There are no rules for discussing your end-of-life care wishes, there are no right or wrong answers, and it’s not a discussion that has to be completed in a single day.

For many, it won’t be an easy conversation to have. Death and dying can be an emotional and frightening subject, and some of your loved ones may not be ready to discuss it with you, or they may have different opinions than yours. What you must remember is that as difficult as this conversation may be, it would be even more difficult for your loved ones to have to make those decisions for you without knowing what you would and would not have wanted.

Taking The Most Important Step

Once you’ve decided what you want and discussed your wishes with the people important to you, you must take the next step and document your wishes. Here in Louisiana, there are three advance care planning documents available: the advance directive, or ‘living will,’ the health care power of attorney and LaPOST.

Advance directive:This is a legal document that states what kinds of treatment should be given to you when you can no longer make decisions or speak for yourself. It only goes into effect if you are terminally ill and have lost decision-making capacity, and it is usually completed in advance of any known illness. You complete it yourself, and unless there are other known facts, it must be honored. To become valid, it must include the signatures of two witnesses.

Health care power of attorney: This document authorizes someone else to make decisions about your health care when you are no longer able to make those decisions or speak for yourself. This document must be witnessed by two people to become valid. In Louisiana, if no health care representative has been appointed by you, the law establishes a very specific order of who can make decisions for you – those individuals are, in order, your legal guardian (if one has been appointed); spouse (unless legally separated); the majority of your children; your parents; the majority of your siblings; antecedents/descendants; special friends; and your attending physician (under certain circumstances).

LaPOST:The LaPOST document is designed specifically for patients with serious, advanced illnesses. It is more than an advance directive or health care power of attorney. It's a medical order that is completed only after you - or your health care representatives - have discussed your goals ofcare and treatment preferences with your physician. As a medical order, it travels with you across health care settings. When completed, it must be followed by all health care professionals. The LaPOST document may also be used to translate your advance directive into a physician's order.

Having Said All That…

I’ll ask you this: do you want your loved ones’ last memory of you to be the one of them making decisions about your care at the end of your life? If it’s not, please – for their sake as well as your own – make those decisions now, tell them what you want and document your wishes.

Remember, the worst plan you can have is no plan at all.

Editor's Note: Dr. Susan Nelson will be the featured guest in a National Healthcare Decisions Day-themed chat on Twitter at noon CST on April 16. Please follow LaPOST at @LouisianaPOLST and use the hashtag #NHDDChat to join the conversation.

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