As the end of one’s life approaches, decisions need to be made about distribution of assets and “final arrangements” (a pretty euphemism for planning one’s funeral). Senior citizens tend to feel comfortable writing wills with the assistance of attorneys. And they will make their funeral wishes known to close family. Many even pre-pay for funerals and burial so as to relieve their loved ones of the financial burden.
It is a lot less common for people to discuss medical issues surrounding their final illness. However, many seniors do have firm ideas about what they want and (more importantly, what they don’t want) in terms of medical care as they approach their “terminal event” (another euphemism).
In particular, seniors appear to prefer to pass away at home. In a Time/CNN poll conducted in 2000, 7 out of 10 Americans reported they would prefer to die at home. However, according the CDC, only about ¼ Americans actually do die at home. Many Americans shudder at the idea of spending their last days in an intensive care unit (ICU), hooked up to life-support machines. Yet, this is precisely what is happening, and with increasing frequency. According to the Dartmouth Atlas of Health Care, ICU stays increased by 50% between 1996 and 2005.
Putting it in Writing
Many seniors are clear on their own wishes, but seldom put things in writing. Even if the senior or a family member signs a do not resuscitate (DNR) order, they would be surprised to learn that the order would become void if they leave the hospital or if they are transferred to another facility.
Advance directives are instruments that attempt to solve the problems caused by the shortcomings of the DNR. These are written documents in which a person states what measures and interventions they prefer if they become unable to make medical decisions in the future.
But problems began to emerge with early versions of advance directives. Most were too vague, or too open to interpretation. And too often families and doctors failed to integrate the directive into the patient’s medical record.
Advance Directive Best Practices
Over the last 15 years, researchers have developed a set of best practices regarding creation of advance directives. But physicians had been reluctant to engage their patients in these discussions. Now, thanks to a new initiative by CMS, physicians will be reimbursed for office visits in which end-of-life planning is discussed.
The best practices guidelines suggest that advance directive discussions require only about 15 minutes during a typical office visit. The doctor does a whole lot more listening than talking. Although they discuss medical interventions in very specific detail, the bulk of the conversation centers on the psychosocial needs and lifestyle preferences of the patient.
Getting Seniors, Family, and Doctors on the Same Page
A key to successful implementation of advance directive is involvement of family and other caregivers. With this type of collaboration, the patient can express his or her wish to be cared for at home instead of in a hospital. Options such as home nursing and home hospice care can then be discussed. With the help of the physician, the family can then put the advance directive in writing. In many states, the document becomes a permanent part of the patient’s chart.
Advance directives are not like wills and trusts: It is much easier to change them as the senior’s circumstances change. Advance directives can be amended, added to, or subtracted from, according to the patient’s wishes. The most important step is to get the process started. Doctors and seniors need to sit down, sooner rather than later, and start having difficult discussions.