Helping patients with end-of-life planning can have a profound impact on patients’ lives. It can also enhance the doctor-patient relationship. In this Q&A, geriatrician Swarnalatha Meyyazhagan, MD of Cleveland Clinic’s Center for Geriatric Medicine, provides guidance and resources to make that discussion a little easier.
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Has it been a concern when people don’t have advance directives during this time of COVID-19?
Yes, it is a concern when people are ill and do not have advance directives. In this period of uncertainty when a serious illness can progress in a matter of days, it is imperative to have this discussion before a health crisis arises. Otherwise the care provided may not be what is preferred by the patient. Advance directives (ADs) are an excellent tool for providers and caregivers to help patients discover what matters most to them.
Can you provide doctors a general overview of ADs and how to learn about them and provide patients with information?
Discussion about advance directives can feel difficult for providers, especially if the patient is new to them or right in the middle of a health crisis. But inviting patients to think about them and discussing the importance of setting up ADs before an emergency, makes it more comfortable for both patients and providers in the long run. An advance directive has two components in one document. It is a living will to express the person’s wishes for their healthcare, and it includes a medical power of attorney, which appoints someone they trust to make decisions on their behalf.
When is the best time to discuss ADs?
The best time to discuss advance directives with patients is NOW. As they say in The Conversation project, an initiative from the Institute for Healthcare Improvement, “it is always too soon, until it is too late.” I always recommend that patients do their advance directives as soon as possible when they have a chance to talk to their provider. At the same time, the patient should talk to their loved ones about their decisions. The Values worksheet provided by the nonprofit organization Compassion & Choices via their website is a great tool to help patients understand what is important to them. To make the conversation more comfortable, there is also the REDE Communication Program from Cleveland Clinic’s Office of Patient Experience.
Aside from the challenging topic, why do you think people don’t complete advance directives?
There are so many myths about preparing advance directives and we can help dispel them. Here are some of the common ones I hear:
- They are not needed until I am old or sick.
- I have a will, so I don’t need to do them.
- My loved ones know my wishes.
- I lose control over my healthcare decisions once I fill out the paperwork.
- Advanced directives mean “Do not treat.”
- The conversation about advance directives is upsetting to the patient.
- Once done, they are set forever—what if I want to change my mind?
So, advance directives can be changed after a patient has completed them?
Yes, they can be revisited and reviewed regularly. There are the “Five Ds” to revisit AD according to the American Bar Association Commission on Law and Aging as follows: Death of a loved one, Divorce, a new Diagnosis, Decline in health, and a new Decade in age. Other situations include life events such as entering college, getting married, having children or going on a major trip.
What resources can you give to patients to get information on advance directives?
There are many online resources for learning about the AD process and free online forms. Here are four of them:
Cleveland Clinic Overview of Advanced Directives
AARP Advance Directive Forms
Tool Kit for Patients from the American Bar Association
Do you have any final thoughts?
I have many examples in my years of practice where advanced directives would have made a big difference in the quality of care and the patient having the desired end-of-life-experience. Talking about advance directives will actually help to reinforce your doctor-patient relationship. You may be surprised to learn your patients’ priorities and preferences. In a majority of cases and for so many reasons, you will both be glad you had the discussion.