Advance Directives: Not Just for Your Parents

elderly care photoA recent proposal by Medicare reinforces the importance of advance directives for all – both young professionals and those in or near retirement.

Medicare has proposed to compensate physicians and other health care providers, when asked, to explain and discuss long-term treatment options and advance care planning for chronic diseases. The reimbursement would also cover the time to discuss the patient’s desire for care and treatment if the patient suffers a health event that adversely affects his/her decision-making capacity. It has been reported that private insurers are likely to follow the Medicare rules.

Currently, most health care providers do not have incentives, time, or training to sit down with folks facing life-threatening illnesses and discuss what’s most important to them. In fact, most folks do not have an advance directive that indicates their wishes when they have a terminal illness or are in a persistent vegetative state.

Unfortunately, Medicare and even the American Medical Association has shown that our health care system provides a lot of expensive crisis care as people reach the end of life – care that people, if asked, and engaged, might say they did not want and that can wreak havoc on a family’s finances.

The contents of many advance directives deal with such things as where you want to die (many want to die at home), what’s most important (e.g., pain control), and what treatments to avoid or to make sure are provided. The advance directive document also often name a health care agent in case of temporary incapacity.

The Maryland Attorney General has a good form that explains the types of isues involved with end of life care –such as to your desire for comfort during treatment, whether you’d like feeding tubes, or extraordinary measures that delay death as long as possible. The document governs the care you receive when you are in a persistent vegetative state or are terminally ill.

The Medicare proposal made me wonder about my parent’s advance directive. They assured me some time ago that they had one.  But now I was curious as to their wishes for the type of care they wished to receive.

I asked recently if they would they mind if I reviewed it. Mom said, “sure, have a look.” It was with their will and durable power of attorney documents.

So I went upstairs and pulled them out of the dresser (a very secure place). Not unexpectedly, the documents named my brother – the family practice physician who lives just minutes away – as their health care agent in case of temporary incapacity. Smart choice!

I then reviewed the section that explained their wishes for the type of treatment they expected to receive if they had a terminal illness or were in a persistent vegetative state. The form indicated that the same brother was to make the decisions in these circumstances.

My initial thought was that this statement defeated the purpose of the document. They hadn’t stated some of the things I thought it should indicate about pain management, feeding tubes, extraordinary measures, etc. But I also thought that it did indicate their wish not to decide.

The document also make me acutely aware that I needed to talk with my brother (and the rest of my siblings) to make sure he knew he had this responsibility. I also thought it may be worth a shot to have him discuss the potential treatments that could occur if they were terminally ill or in a persistent vegetative state.  The advance directive could be revised at a later time.

This exercise highlighted to me that the discussion around advance care planning should not be a one-time thing. It can be revisited in the face of new challenges or developments,  Advance directive documents can be revised to guide heath care providers to deliver the care their patients want.

I urge you to think about the care you want in these circumstances.  I know I am going to do so. You should then obtain an advance directive to document them so that these wishes are fulfilled.


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