aplaceI came across a frightening blog post by A Place for Mom, praising the easy access their senior living sites grant to Compassion and Choices, the nation's most vocal assisted suicide advocacy group.  The article boasted about the "choices" available to seniors who live in their facilities, and the author was especially proud that A Place For Mom would ensure that the families of these seniors were informed of Mom and Dad's right to kill themselves. (The article was written in Washington State, where assisted suicide is legal).  We were first made aware of the post by Wesley J. Smith whose outstanding blog Human Exceptionalism at National Review offers consistently coherent arguments for life and dignity.  He brought our attention to the blog post here and here.

I made the following comment at the post today:

"I am a geriatrician and I think end-of-life planning is very important. I am appalled that A Place for Mom promotes an assisted suicide advocacy group in this article, without presenting the other side of the issue. You are certainly not "neutral" as you claim, and I will never refer my family or any of my patients to A Place for Mom after reading this."

2 hours later, the blog entry was gone.  I'd like to take credit, or give credit to Wesley, or dozens of irate callers, or National Right to Life who also exposed the agenda.  However, it's more likely that the blog entry made its own "choice" to request "aid in dying" from its author at A Place for Mom.  After all, every blog entry has a right to know about this option.  It's cruel to force these blogs to go on living, when their anemic existence is only taking up space on the internet.  Whatever this blog's reason for choosing death, it must have been a good one.  Perhaps it felt that it had become a burden to its fellow blog posts, as it was creating negative press for A Place for Mom.  Maybe it had no sense of purpose, depressed about its pathetic number of visits.  Or maybe it knew that its existence was costing too much bandwidth, and it recognized that the most compassionate choice it could make would be to just go away.  Yes, compassion won in the end.  How wonderful that the blog entry was presented with all of its end-of-life options.  I'm certain that, in its already frail and threatened state, when authoritative end-of-life experts gave the option to commit suicide, it never would have interpreted that as a subtle suggestion.  Never.

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April 16th is National Health Care Decisions Day.  When a health crisis occurs, many individuals and families are unwillingly thrust into a situation where a difficult decision must be made, and the values or preferences that would guide that decision were never discussed.  Don't let this happen to you.  Take time to choose your power of attorney for health care, the one person you would trust to make decisions about your health care on your behalf if you were ever unable to express those wishes.  Let that person know that you would be honored if they would play that role for you.  Talk with them about what is important to you if you ever encounter a scenario in your own health where you cannot verbalize your wishes.  You don't even have to discuss specifics, but it may help that person if they know what type of approach you would want if you were in that situation and you had very little hope for recovery.  Then, complete the Durable Power of Attorney for Health Care form.  It can be downloaded here.  Make copies for your power of attorney, yourself, and give one to your doctor and anyone else you think should have a copy.  If you need help, make an appointment with your doctor to specifically discuss this issue.

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F2CMy thanks to Janet Parshall and Talking it Over for a great conversation today about protecting the rights of conscience for health care workers.  The best source of information that I have found on this issue is Freedom2Care.  Visit this website to learn more about this important issue and to find out what you can do to ensure that our health care system preserves your right to receive care from a physician or health care worker who is freely able to practice according to their deeply held beliefs, whatever those may be.

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Oregon recently launched a state registry for patients who sign a form known as POLST (Physician Order for Life-Sustaining Treatment).  This transferable order set allows patients to give specific instructions on the treatments they would or would not want in certain situations.  For example, a patient may opt for or against resuscitation for cardiac arrest, for or against IV antibiotics, or whether or not to place a feeding tube in different scenarios.  The POLST orders go beyond most states' DNR (do not resuscitate) orders, which only apply in the event of cardiac arrest.  POLST allows a patients to direct their care even when they have become to ill to express their wishes.

One of the biggest problems with advance directives is that emergency crews or hospital staff cannot locate the documents in a crisis, the time when the expressed wishes are most crucial.  Unless medical personnel have a verbal or written directive from the patient, we are obligated to perform certain procedures like intubation and mechanical ventilation, which many terminally ill patients do not want.  POLST tries to ensure that wishes are honored, but even in states where POLST has been implemented, relying on a paper form has its risks.  This program in Oregon would allow medical personnel with a password to instantly access the POLST record electronically, even if the paper document cannot be found.  Many times I have encountered situations when a patient was in a crisis, unable to speak, and we could not locate the advance directive or power of attorney.  Too often the patient had something done that went against his or her expressed wishes, simply because those expressions were not available when needed.

I understand concerns that people may have about an electronic record of private and personally held wishes that can be used to direct medical care.  I believe that this system would give more control to patients, not less.  If you take the time to document your wishes, shouldn't they be available to health care personnel in a time of crisis?  The registry is purely voluntary; Oregon residents are not required to participate. There is no coersion to choose one option over another; patients may direct care however they see fit, even to request all available treatments or procedures be given under any circumstance. While I do not agree with Oregon's policy on legalized physician-assisted suicide, I believe that a voluntary electronic registry of patient wishes is a helpful addition to the health care system, and I hope that more states adopt such a program.

As I have said before, the best way to ensure that your wishes are honored is to name a Power of Attorney for Health Care.  Read more here.

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I have blogged before about the importance of sharing your end-of-life wishes with someone you trust.  Thanksgiving is the perfect time to have that conversation as you gather with family.  The fine folks at Engage with Grace have put together a slide of 5 questions that will make this process easier.

If you have the gizzards to bring up these questions at the Thanksgiving dinner table, you deserve the Myles Standish Award for Bravery.  Even so, I find that once the ice is broken, these conversations can be quite cathartic, and you and your family will feel like you accomplished something important at Thanksgiving besides overloading on poultry and dozing off into a tryptophan-induced haze.  So, after you engage with gravy, Engage with Grace this holiday.  You can thank me later.

...would love to hear your comments on how it goes...

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Today's article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

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Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn't it? What they don't mention is that these documents are already available for free, and you don't even need a lawyer in order to complete them.

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Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an "advance care planning" discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will "start us down a treacherous path toward government-encouraged euthanasia". I disagree.

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I don't have all the answers to health care reform. American medicine is a complicated web of economic, political, and social factors. I believe that everyone engaged in this debate wants the best health care for the most people; we just disagree about how to accomplish that goal. President Obama's recent statements about Medicare tipped me off that he is about to damage our health care system in ways that may not be reversible.

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