Live & Learn; Medical Decision Making

Thank you very much. I didn't know I'd done all of those great things. I am very glad to have all of you here today. I know that all of us came with different agendas and different questions that we want to have answered. I'm going to now give you an overview of what I'll be talking about and hope that your questions will be addressed in that. There will be some time at the end for your questions as well. We will be using the audience response system which is a really cool thing, this is a little box here, and you'll have an opportunity to punch in what you think is the right answer. When I want to tell you that most of the time there is no right answer. But for a few questions there is a right answer and so I'll make it real clear which one

have right answers and which don't. One more thing, if you have questions please pop up. I'd like everybody right now to practice raising your hand. Good, very good. Thank you, thank you. I don't always know when I'm being more technical. So I've tried very hard not to do that, but if I misspeak, raising your hand is a good thing. Now I almost call this the presentation of many titles like Minnesota, the land of 10,000 lakes because we started with to resuscitate or not, DNR which means do not resuscitate and living well. Well that's not really what we're talking about. It's part of what we're talking about. We're talking about graceful exits, decision making at the end of life, meaning how do you make, how do you help yourself if you're in the position of having to make a decision, or how do you help someone

out to make that decision in a way that is full of grace, graceful. But I can tell you from 20 years of practice at which I get the helicopters that come in and also I work at hospice so I have a very bimodal job that Barmer often is an English question. And what I am hoping is that we can transform our anguished questions into graceful exits. Now to say what we're going today just so you'll know in advance, we're going to start with an audience poll, just to kind of get you involved. We're going to talk about DNR's do not resuscitate and I'm going to try and go through that material fairly quickly, mainly because I want to really focus on these other pieces which is advance directives, what's that about. And this very critical question of what do I do if I'm

the one that has to decide because I think that's where people really struggle. And then what can I do so that my relatives don't have to anguish? We're going to close a little bit with living until you say goodbye. So let's start with a poll. Okay, this is where you get to practice. Now the way this works is you look at question and I'm going to click on it and then you will have 10 seconds to pick an answer and during that time you can change your answer but once the 10 seconds arrive it'll show up on the computer, okay? Ready, go. Okay, very good. I was hoping somebody would think the sky was mob but no, it's not, okay.

Now based on my current agent health I believe I will live. You get six choices, one to 10 years, 10 to 25, 25 to 50, more than 50, I don't know and I never think about it. 10 seconds. Interesting. Notice the highest one. I never think about it and actually there is a right answer to this one and it's number five. I don't know. Remember John Ridham? Yeah. Okay, life is no promise to us. Okay, I have written advanced directives. Okay, and I'm going to use the term living well, durable powertrain. Whoops. I'm not sure what I did, okay. 10 seconds.

Okay, those of you that said no, we're not sure. You have come to the right place because we have two organizations here that can help you do this very thing within the next several days. We've got Kansas Health Ethics and Kansas Partners for Life. Those people from there raise your hand. Okay, Kansas Health Ethics. Okay, and there are clinics that you can go to once a week on Tuesday afternoon where you can do these. Okay, I have them and it has been 25. So you need them as soon as you're born. Okay, now I'm going to ask you several questions about serious healthcare decisions and so that you'll know what I'm talking about. This is what I mean.

Someone's going to ask you, should you do resuscitation in the amount of cardiac arrest that's the DNR? Should you dial it? Two fees, antibiotic surgery, stop-life support. Okay, so I'm going to ask you some questions about this, right? Number one, I will make serious healthcare decisions for someone else within the next 10 years. Yes or no? Okay, good. I think the person that said no, would be a lucky person, but nearly all human beings are going to have to do this. And that's why you need to know this stuff. I have already made serious healthcare decisions for someone else who has already done that. Yes, no or not sure. Okay, good. A lot of you have had a lot of experience with this. And last but not least, what are the chances that someone else will have to make serious

healthcare decisions for me sometime in the future? More than 75% chance that someone else will have to do this, 50 to 75%, 25 to 50% or less than 25% chance that someone else will have to make decisions for me in the future. Okay, good. I am glad to see that people understand this because, guess what, I'm going to talk about the facts of death. Now, talking about the facts of death is, as I always use the analogy, it's like talking about sex to your five-year-old, you know, like, oh my gosh, send him to with their mother or something. But, you know, you need to know, you really, and here's the first fact that you're going to die. And only Americans believe that death is optional. In fact,

there is a society for the right to die. And now, that's not what it means. But I always thought that title was kind of a eye because it implied that, well, I could choose to die or not die. The second time is, you're not going to know when. You might think you will, but you won't. As I said, remember John Ritter, that most all death is in the final analysis unexpected. And that is that you might be told that you have six months to live, but I can tell you that I've been doing this for 20 years, and it never happens that way. You cannot walk on the calendar, or it's going to be, you know, June 20th. You could maybe have a ballpark within a few weeks or months, but the bottom line is that when it comes, your family is not going to know. You cannot predict it. That you will not be able to control the manner or timing of your death even with advanced

directives. Now, you can help a lot with advanced directives, so don't hear me saying don't do that because you do need to do that. But that's step one, and we'll talk more about that. Other people will make decisions for you about your death. Now, you can help, and I will tell you how. And the last but not least is that other people can be burdened or wounded by the decisions they must make for you. Imagine the agony, those of you that have had to decide for someone else, perhaps know what that feeling is, to have to second death yourself and say, did I make the right decision? I mean, that is a truly awful thing, and in my experience, that is often the greatest source of suffering. Now, the fact that the person has died,

that you somehow had to choose it, and you feel like an executioner, you know, or you know, can be quite awful. Believe me, you don't want to do that. And as a physician, I don't like that. You know, for a whole lot of reasons. Now, here's one of the many very little secrets I'm going to tell you. I can give you a whole talk on this, but here's the bottom line. We all think that we're going to figure it out ahead time, but the bottom line is that in that moment, you never can't. You're nearly always too sick, and so here's what happens. Either there's the mid-night phone call to the nearest relative who doesn't know what's happening, or you get a patient who's already a DNR, which, you know, to me, I don't know what that means. Okay, and I'll explain that in a minute. And so, you know, I don't know what I'm supposed to do. Or there's been a living room written, but it can't be found, or more commonly it doesn't apply. And so it's disregarded, and the nearest

relative gets in the night phone call. Or the closest relative is present, but they've never talked about it. And so when the doctor says, well, what do you want us to do? They're like, I don't know. Anybody ever experienced any of that? Raise your hand. Nobody. Yes, you have. Yes, I can see this. Now, I'm going to tell you a little bit about resuscitation, and I'm going to try to go through this somewhat quickly, but please, you know, we have practiced raising our hands. So, if I leave you in the dust, please say so. The code blue is a term invented by hospital operators about 20 years ago, because they didn't want anybody to know that there was a certain patient in room 903 that needed to have their heart restarted. There's also, by the way, in case you're interested, there's a code red, which is a fire, and there's a code black, which is a tornado, and everything. So that's where the

term code blue came from. It was the disguise, but it has come to be used as a general term. The person is coded or not coded. They are a full code or a no code. That's how that happened. Now, what that means is that you are trying to resuscitate or bring someone back to life, and that's the way to think of it. I'm not trying to prevent death, but to bring back to life, someone who has died. The technical term is ACLS, Advanced Cardiac Life Support. ACLS. That's the term I'm going to use, because it's most accurate. I want to notice that Cardiac is underlying. That's because it's designed to fix the heart, not anything else. So, if the problem is not your heart, it's not going to help. Now, the code blue includes CPR, which I think everybody knows, electric shocks, drugs, and artificial breathing, and there's a standard cookbook that is used. We don't make it up.

We all are trained every two years on how to do it. These are the definitions. The NR do not resuscitate. A better term is do not attend to resuscitation, because of the implications. And then the term code status that I already alluded to, and that's whether the patient has elected to receive or not receive ACLS. Now, this is different than life support, okay, because where people get mixed up. Life support is for the lungs. Remember I said ACLS is for the heart. This is for the lung. In this, you use a breathing machine, and the technical term is ventilator, okay, ventilate, you know, and that's what's considered life support. And it's a machine that puts oxygen in the lungs of somebody who is not able to breathe adequately. It is not the

same as breathing treatments. I've had a lot of people say, oh, well, it's just, you know, the breathing treatment is the thing you get if you have asthma or emphysema, and it's got that little mist. That's not what I'm talking about. This is this ventilator is a big deal, a big deal, okay, and it's considered part of ACLS. So if you are designated as a DNR, you are not going to get this whether or not you need it, okay. The, the converse is that you can be on a ventilator without trying to fix the heart, okay. And that happens occasionally like if someone has pneumonia, it would make sense because the lung is what's the problem. So just to tell you quickly what happens in a code bleeder's team, it's designated every day in the physicians, and usually internal medicine doctors like myself run the code, remember that we run the code called, and usually anesthesia and surgery shows up, and several ICU nurses and a whole bunch of people, usually about 10 to 12,

and notice the chaplain. It's good reason for that, okay. The average code lasts 20 to 30 minutes, and I don't know if you know this, but it's pretty ugly. The patient rarely always bomb it, that when you check somebody, they go, and it's quite unpleasant to watch, okay. I'll end up with broken teeth, et cetera. And the most beneficial part of this whole procedure that takes 20 to 30 minutes is the shocks and the breathing. And so if you say, well, I want to be coded, but I only want the drugs, then you're wasting your time. People do that. Don't do that. You're wasting your time. The only thing that really, really helps is the shock and the artificial breathing. Now, who benefits? Okay. If the problem is you have a reversible heart problem, okay, so there's the rhythm in your heart's fun, haywire, and somebody started CPI right away,

40% survival. It's pretty good. I mean, to me that'd be worth it, even though I told you it was really awful. The problem is the second one, if it's not the heart, at most, in the ICU, you'll get maybe 5% survival. If you're out of the hospital, less than 1% survival. And if you don't begin to see PR immediately, no matter what the cause, less than 1% survival, okay, which is why every human being, I think all of you in here are human beings. If you're not a human being, raise your hand now. And you should know CPR. Why? Because you have four minutes. And you might save somebody's life. Okay. Now, the ventilator, the like the breathing thing that I talked about, it works very well if the problem is a reversible lung problem like pneumonia. Okay, that really works great. But it does not work. If the problem is not a reversible lung problem like you're

dying a cancer, or if the lung problem is a permanent lung problem like the very end stage of some lung diseases. Okay. Now, why is it so ineffective? Well, it was designed in the 1970s and here's the trick is the only procedure in all of medicine that you must offer to everyone, even if it's not going to help. Now, is that crazy or what? Now, that is not true in any other country in the world. That is only true in America. And I meet with a Paley to Met Hospice Docs a lot. And the ones from Germany and England go, you guys are nuts. You know, why are you doing blood? It's a very American thing. And because of this, it has caused a lot of crazy situations, which I'll tell you why. It's considered the standard of care. I.e. the attorneys, if they do

this out. The problem with it is, as I said, it doesn't work if the problem is not your heart. Yes. You're going to do it. You're going to do it, you're going to do it, you know, like offering. Yeah, you're right. In force, it's so to repeat for the thing. He think, well, offer implies that you could decline. And you can decline if you have a written order from a physician right there that says, do not do this. But if you don't have the written order, EMS can and will do it, even if you are begging. And I have been on the phone to EMS technicians telling them on the doctor, don't do it. And they say, sorry, we have to do it. Okay. Now,

that's not because EMS are bad people. That's because that's the way that's their algorithm. But we can fix this. Okay. So, don't despair. All right. So, here we go. This year, O.M. classes at Air has stayed. I'm doing a cheese game. He's a cheese fan and they're losing. Okay. You begin CPR right away in EMS because, you know, they always have ambulance at the stage. And so, they start within five minutes. This chances of survival are, you get to pick. Okay. Very good. This was one of the very hard questions because it depends. If the reason he collapsed was his heart rhythm problem, then 40 percent. If he collapsed for some other reason, like he ruptured an aneurysm. It's less than 1 percent. But you don't know that. So,

therefore, you do CPR. Okay. Now, things this year, O.M., he's watching. He collapses in his nursing home while watching the cheese game. The cheaps are losing again. He's got severe ampacine. He's got lung cancer. And the nurses find him and begin CPR and call EMS and they begin the advanced life support within five minutes. His chances of survival are. Very good. The answer is number four. Less than 1 percent. Okay. Why? Because the problem is not a reversible heart problem. Number two, there will be some delay. But mostly because it's not the kind of problem. So, nearly everybody that dies at a nursing home, they're not going to survive.

Now, the problem with this, I told you that only in America do you have this procedure that you have to do unless you have an order that says otherwise. Well, technically, that order only means no ACL up. So, you could do everything else, but not that. But that's not what's happened. It's artificially screwed up the whole decision-making because here's what happens. And here I'm the doc. And if they tell me somebody is a full code, what that means to me is my job is to prevent the need for ACLF. In other words, it would make no sense for me to just kind of keep them comfortable. And then after they died to call in this whole team and start pounding on it, that makes no sense. So, if you say I'm a full code, then in my head, your doctors had, that means, okay, you know, we're doing full-core press. And believe me, there's a lot we can do. And that's not long. We just

have to think this through. So, people sometimes say, well, I just want a code. Well, that then worked that way. And the other problem with it doesn't tell me the other things I need to know, like, am I supposed to do surgery on this person? All it says is just this one procedure, but it implies all this other stuff. And it's never overt. And what if I have been made a DNR and all I need is that one shock and all live in other 10 years? That's the whole problem with the gun thing. So, look at that. Look at that. Okay, here you go. Now, this is a hard one. Your uncle, age 70, developed severe pneumonia. Only artificial ventilation and breathing machine, which is part of ACLS, will save his life. But, because you can treat an pneumonia, you think he could live if you just stay on the ventilator seven days, but he can't speak for himself. And the ER doctor is told that his code status is a DNR and they have a written

statement saying this, and no family members are available. And what will the ER doctor do? Will the ER doctor begin life support knowing they have a good chance of recovery or will the ER doctor begin only antibiotics knowing he will probably die? Go. Wow. It would depend on the living will, but in general, I'm sorry, the DNR, but in general, the answer is number two. Okay, now I'm saying, is that really what we want? Okay, so how do we avoid this? I'm now depressed everybody thoroughly, okay?

Now we're going to talk about why we need to be a little bit think, really there's a little more complicated than that, okay? There's three ways you should decide, you should decide this for yourself, you should decide this for your loved ones, and here's how you do it, okay? And I'm going to be doing the rest of this talk, talking about this in some detail. The first way that you decide in the highest level of decision is always the person's wishes, because this is America, autonomy, all right? The second highest is will, the second and third are pre people, the underlying disease, in other words, would a code help? And what are the goals of care? Why are we doing this? You know, I'm going to talk about goals of care in some detail. What are the wishes? I'm going to spend the middle part talking about this in some detail, and we already talked about is it a disease that's going to work to help. We already talked about that, and the third question is, what are we trying to do? Are we trying to save life, prolong it, or keep the person's control? Go to care.

Let me explain this. This is one of the ways that you can decide, that you can help. What are we trying to do? Why are we doing all this stuff? Well, there are a number of possible goals, but I simplified this. You could go on, you could say save life, no matter what, okay? Now, what you got to know is that saving life, if you're going to do everything there is to do, that's going to involve a substantial amount of pain and suffering. But, I mean, there are, you know, most situations, that's good. That's what you want. It's not good that you suffer, but you want to save life. Now, it might be though, that you have a disease where you cannot save life. It's not possible to prevent death, but you want to try to prolong life as long as possible, because this person is, you know, still wanting to, you know, let's keep going. So, you could do aggressive treatment by which I mean, I see you, but then you could stop. So, that's called a trial therapy. That's option two.

I'm going to talk about these some more, I mean, you could prolong life as possible, but you could just use simple things, like you could take pills. And so, you could, you know, give some like these fluids, maybe, but but not do the whole, you know, thing that we can do that I have done many times. But instead, we're going to be kind of keep it simple. And last, we could just say, we're going to focus on comfort. And even if it means that that person's life is shortened, okay? Now, I'm going to emphasize this, that treatment decisions flow from the patient's wishes and the goals, okay? And if you know those two things, it usually becomes pretty easy to figure out what to do. The problem is, nobody ever knows the patient's wishes and nobody ever knows the goals. Okay. You know, the wishes, treatment decisions are obvious. Okay, so I'm going to give you some

examples of it. All right. Go ahead. Why do you say nobody ever knows what the paper works for? That's a really good question. So, you ask, what do I mean, nobody ever knows the patient's decision? That's an exaggeration. People know the patient's decisions, but they're not raised typically in a way that's helpful, okay? And I'll explain that. They are usually phrased in terms of, I want a cobaloo, I want dialysis. And yeah, but see, that's not the right way to do it. The way to do it is to say, I want to live until my granddaughter graduates from college. Okay, and then if you say that to me, that I, and I will say, oh, okay, well, here's what you need to do. Okay, so you're thinking, big picture, what is the goal? Okay, and I'll see if it's a goal. All right. Well, we'll work through this and maybe it'll become a little more clear, okay?

And here's an example, save life at any cost, do everything. So, 40-year-old who's in this car accident, and so you're going to, you're going to do, you're going to pull out every stop. So, indefinite, forever, ICU, and I can tell you, people sometimes are in the intensive care on life support for months. But because, you know, we're wanting to try to save life no matter what we keep on doing it. Another option is to prolong, and this is applies when there's no chance of saving the life. Why? Because either the person is 90, and I wish all of us could live to 110. One of you just reminded me of you told me about your mother to live to 104, and I remember her. But, you know, it really is 4 score and 10. And so, the life expectancy is somewhere around 90, in the 90s. Okay? So, I can't fix that. Okay? Who did I code that I can't?

So, but we could try to prolong that life. Now, my mother and I was a great example, but she's 93. Some of you know my mother and I was at birth, and you guys know her. And she's just lively, you know, and she still cleans my house for us once a week, and she's great. And so, you know, but I can't prevent her from not, you know, it's going to happen soon. You know, she's 93. And so, my goal with her would be something like this. You know, we'll do whatever I can, but, you know, here, like here, cancer patient is recurred. You know, that means the cancer is going to win. That's what that means. Okay? But we're, you know, we're not ready to quit. I mean, you know, let's keep going. So, what would be reasonable is to put that person ICU, do the ventilate, do the whole thing, but then say, okay, well, let's do it for a couple weeks. And then if it's not helping that stuff,

that's one option. There are other ways you could do that. That's one option. Another goal would be to say, okay, well, you know, let's say this 40-year-old gets a bladder infection or pneumonia. And the cancer is completely, it's, it can't treat it anymore at all. I mean, there's nothing else you can do. They are going to die from the cancer within the next year, but, you know, they still, you know, they're not done. You know, you know, let's keep going. Well, it would be reasonable on that point to say, okay, well, let's give ID fluids and antibiotics and do all these things. But we're not going to do that really painful, awful things that aren't going to help. Okay? Now, the last option would be the goal was comfort only. And this would be, like I say, we had the same 40-year-old, but in the last two months, that person's already been in the hospital five times and each time, you know, it's just getting worse and worse and worse. And the person says, you know, stop. Don't

do this, you know. And so, you would refer to hospice, I hope. And they say that dying without hospice is like surgery without anesthesia. And hospice is a way, an organization whose goal was to help people die gracefully. But in this case, you could, you know, you would treat pain aggressively, you would do all that you could, but you probably wouldn't do IV fluids and you probably wouldn't do things like two things. Question? So, the question is, if we don't give any IV fluids, does a person feel discomfort? Just for comfort. You know, that's a really good question. And we've all been taught that. I mean, I know I had that pounded into my head in my other training, but the truth of the matter is that, in fact, at the end of life, dehydration is good. And the reason is,

two things. Number one, as one becomes close to death, that it's hard to control secretions. So, you get the death rattle, maybe, no, I'm talking about that. Okay? Now, if you're dehydrated, you don't have that. That's good. The second thing is that the Good Lord made us so that when we're dehydrated, we release endorphins. You know, endorphins is an opium-like substance that our own body make. So, it's made by, like, you know, an animal, the tigers after them, you know. You all have had the experience of, for example, the soldier in war who gets shot and doesn't even feel the pain. Okay? Well, how do you do that? That is endorphins. Okay? Dehydration releases that. So, actually, people are more comfortable. Now, you always really, really thirst. And typically, that can be done with ice or little chips or whatever. And, you know, and if a person wants to drink for him, say,

him drink, but there is not that compelling need to say, you know, they're going to be miserable. They're not well-hydrated. In fact, that's the opposite. It's true. But that's a very good question. Yeah, you know, you would think that. You would think that you would get cramps, but no. Actually, you don't. I'm not saying those of you that have done the hospital work and I've seen a lot of people die in the hospital, but they really don't. Actually, it's good. Okay? So, here you get to participate. Your 70-year-old mother has newly diagnosed treatable cancer. She develops serious pneumonia. Okay? So, the doctor calls you up in the middle of the night and it's always midnight. Okay? Or after. And you're asked whether you want life support, meaning, do you want

them in the ICU on the ventilator? You got it, you got it, you got it. Shock. And you've never talked to her about it. And so, if you were going to do it just solely based on goals of care, that was your only consideration. What would you do? Would you save her life at any cost and keep her in the ICU forever? Would you prolong life if possible with a trial of aggressive treatment, but then stop if it didn't work? Would you prolong it if possible with simple treatments, like IV antibiotics? Or would you say comfort and in cost? Let's call hospital soon. We'll take care of her at home. What's going on? Go back. I don't know what I've done, John. Previous. Okay, ready? Okay, interesting, isn't it?

I would tell you as a doc, what would I do? I would probably do one or two. I might do one because it's newly diagnosed and treatable, but then I might think, well, but there really isn't any. I mean, I would depend on the cancer. So I would, one of the key pieces I didn't give you is the prognosis, and that's one of the things you don't know that you've got to know. Okay, now I've talked about goals of care. Now we're going to talk about advanced directives. And you didn't notice that, first of all, the word is not advanced. It's not like they're advanced in the sense of higher and advanced, like in advance. Okay, and it's a statement prior to need of your wishes for treatment. Should you be unable to speak for yourself? Okay, and there are two main types, and the living well, which has a whole bunch of different names, and I'm going to use the term living well because I think most people know that term,

but it also can be called the treatment directive. And there's another kind called the durable power of attorney for healthcare, durable power of attorney for healthcare, and I'm going to call that the DPOA HC, because that's too long to say all of that. Okay, now the question now is who decides, and remember this is America, so the person that decides is you. Okay, but guess what, when you get to the hospital, you hardly ever can. So then his next, and I'm not making this up, this is the law. It depends on the on the state actually, but in our use, the person that would make the decision is whoever has been appointed as durable power of attorney, spouse, then adult children, then parents, then siblings. I have on many occasions, and people who's only relative as a remote cousin, and to call it midnight and say, what do you want me to do?

Okay, so here you are. You have terminal cancer, and you develop pneumonia. At the hospital, you're short of breath, and you're barely able to speak, but you're conscious. You have a living will and a durable power of attorney. Who will decide if you should be put online support? You, your spouse, your DPOA HC, or you don't need a decision maker since you have a living will. Okay, the right answer is you. The reason is, I just want to emphasize this, that none of these things come into play until you cannot speak for yourself. So, you could have written down, you know, I want Egyptian belly dancers to come in, and that's good. Okay, so, you know, and I want to, you know, have my body cryo frozen and all this,

but as long as you can speak, you know, that applies. And what I tell you, what more commonly happens is, your son or daughter usually hasn't seen you in a long time, or your spouse who loves you very much and doesn't want you to die. We'll say, don't listen to him, do what I say. We were asked which hospital officer, you know, I only work at Westwood, so I can't really say. Okay, let's talk about the treatment directive or living will. Now, in Kansas, this depends on the state, but in general, in general, and those of you that are experts in this can pop up and explain that it's not 100%, but in Kansas in particular, the law is, describes what you want, if, and here's the biggest, your declared terminally ill. Now, West, you get Alzheimer's, then apply.

That's a big deal. Question. Yes. And are no longer able to speak. Yes, yes, you have to be both this and that. And you're right. Good question. The big advantage is it gives some idea of what you had mine. The disadvantage is it doesn't apply in most illnesses and it does not apply in acute illness because you're not terminally ill. It doesn't apply in Alzheimer's. It's very inflexible. So, of the two, to me, this is the least useful if it's done in this form. You know, I have one that does quite a bit more than this, which we'll talk about. Okay, so here you are. Seven-year-old man's brought to the hospital. In this case, you're the ER doc, okay? His living will is on the chart. He

requests, you know, he's ATLL sir. He develops a life-threatening heart rhythm that could probably be successfully shocked. There is no durable pattern. Nobody's there. You have no idea. And there's no records because that's usually what happens, okay? And the ER doc, what would you do? Would you do the shock or would you not apply the shock since they have a living well? This is a hard one. And the right answer is number two. Actually, I misspoke. No, no, no, no. I retract that. The right answer is number one. I misspoke. Why? Because he is not terminally ill. Yeah, and we have to assume that he can, and I, you know, there's lots of the ups and whatever,

but, but, you know, I apologize for mistaking the right answer, even though you have this thing on the chart because there's no, you don't know that they're terminally ill. And remember, my default mode is always, I'm going to try to save your life, okay? And that's my job. Plus, when you're dead, you know, you're dead a long time. I mean, you know, I don't want to be crude, but, you know, you always make the reversible decisions. So, if we want to stop treatment, that's a lot easier than you, I can't bring the dead back to life. Okay, the durable pattern for health care. This is the more useful document, but you need both. Okay, it appoints a surrogate decision maker or someone to decide for you if you cannot speak for yourself. Now, this is important. People, a lot of people come to me and say, oh, I've got a durable pattern, and they bring this long thing that's been written by an attorney, usually, and it starts, you know, whereas, you know, and, but, you know, after I've kind of waited through the whole thing, I find out that it doesn't cover health care decisions. And a lot of times, you'll have a durable

power attorney for, like, your finances, but all that a durable power attorney is, is there's a body that has been decided to make some decisions for you. It could be anything. It could be whether or not you want Greek belly dancers, okay? So, it has to be for health care, or it doesn't count. And so, don't get that fooled that way. Now, the advantages of this is it's much more flexible because, you know, I, as a physician, I have somebody I actually talked to. And it works, it's useful for all situations in which you can speak for yourself. We don't have to be terminally ill. So, that's a big advantage. The disadvantage is your surrogate could decide anything. And most people don't tell their surrogate what they want them to do, okay? Now, I have been, I, as one of my jobs as I worked for Heinz Hospice. We have been in the awful situation of having

someone have a written document saying, I don't want this, but then have the durable power of attorney person say, I don't care, do it anyway. And then we get called in, we're supposed to, like, fix this. And I think, you know, I'm just not wise enough for that. I don't know what you do. You know, I don't know what to do. I know what I do is I keep talking and try to figure out what the problem is. The other big thing is, I don't know how many times people they've signed up, somebody they don't even know, you know, much less, explain what they want. So, that's why they're not a perfect answer. Most people don't have them. They have them, they can't find them. Doesn't, the living well doesn't help in acute illness or non-terminal treatment. And I think this is regarded. Not fully disregarded, but it doesn't apply. If they have a durable power of attorney, they don't tell them what they want. And, you know, somebody ends up making

decisions based on what they think you would have wanted. And this is the cooker. They've studied this a lot and asked people, okay, what do you want? And then they've asked their durable power of attorney what they think that person wants. No correlation. And that kind of scary. Those of you that are married know that I for one have not yet learned to read my spouse's mind. And your durable power of attorney also hasn't learned to read your mind. Okay. Yes. The first thing about the Alzheimer's is a firm family. And in health Alzheimer's, I'll know that we will all have been talked about with different children or whatever. And, you know, after the yellow climbers in the thumbnail, it doesn't work. So living low would not apply unless the person with Alzheimer's

was declared terminally ill. Okay. Now Alzheimer's is a terminal disease. But it's a long terminal disease. So most of the time it doesn't apply unless you get someone who's got them in hospice. And being declared. But the more that this is why it's, you know, why if you have a person to speak for you, then you don't have to be declared terminally ill. All you have to be is unable to speak for yourself. So that would apply. Okay. Problems with the Alzheimer's. Wishes change over time. Has anybody ever said, you know, it's time to remember being 25 and deciding I was going to be dead by the time I was 30. Because, you know, 30 is like, man, you're really over the hill. And I mean, just think about it. All the things that you have accepted that you once thought were unacceptable. And I was talking

with my husband about this yesterday. And I said, well, you know, I explained we went over again what I want. You know, it's well, yeah, but you don't know that. Because what, you know, what if you were to get breast cancer, which is when I'm sure I'm going to die from because everybody in my family has it. And, you know, you don't know because maybe you'd want to keep going. So that's why it's an ongoing discussion. It's like you don't just tell your spouse you love them once. You know, you got to keep doing this. Well, if you do, you don't stay married very long. They don't cover a lot of situations. They focus excessively on what you want, which is not the real issue. Great areas. You might not agree. One of the things one of my friends and partners here at KU does not have her spouse as her durable path of turning white because she thinks he's not going to do what I want. He's going to keep me alive no matter what. So you've got to get

somebody and it's going to pretend to be you. And it might well not be your spouse. You can pick anybody. Good answer being. And of course, it's never really possible to get. Okay, I don't know if I have time to really go through these. These are just in cases. Number two, I am not making these up. These are things that I have actually run into. Number two, you know, DNR, tattooed on the chest, brought into the ear and then got cardiac arrest. And you could fix them with a single shack. Okay, you know, what do you do? You know, that's what I'm saying. Just so many great areas. Now, here's one. This is the classic one. The durable path of turning and it usually hasn't seen them. And usually it's the son or daughter in California who hasn't seen them in 10 years and feels guilty. So you call them and then say, well, when you want to do this, you do everything. Right? Yeah. Question? Okay. Okay. I have this happen. I had an age patient. His mother said,

don't treat him because he's brought shame and I want him to die. I've also had this happen more than once. Somebody near death from cancer and then the family member believing that a miracle is going to occur in once everything forever, forever. Now, I personally have seen miracles. So I'm not saying there's not that I'm not saying you can't have a miracle. But on the other hand, there's a balance here, you know, and that is, that's not right. Okay. So make Vance directives immediately. We've got people here that can help you do it. You've got to have both. Make them as soon as you're born. Well, you don't need in that turn. You can buy the forms of office max. You can like, can this help ethics have them? Can this project for life has them? They have this clinic. Okay. What Tuesday afternoon? Three to five something like that.

Three. But remember that it's not the last step. Okay. Now, what if you're the one you have no clue and you've gotten that phone call in the middle of the night and you said, I have no idea. You want me to decide for my mother what to do. I don't even like my mother. We haven't talked now. That's not true. Okay. So here's how you decide. First, what would they have wanted? Second, what would they want? Okay, that's the way to say it. Second, if you don't know, based on their values. And I'll show you what that is. Third, moments of clarity. I'll talk about that. Okay. So best. In order, best. Next way to decide, goals of care. What is feasible and reasonable? You can always do a time limit to trial. Okay. Getting farther on the list, lower down. What is in

their best interest and lowest quality of life? The reason is that nobody can tell another's quality of life. And a great example is my husband, he's sitting over there, works with people from cerebral palsy research. And they are sitting there in a chair, you know, kind of drooling. They look really awful. And, you know, you would think that they would have a terrible quality of life. But when you talk to them, they don't think so. Or what about Stephen Hawkins? You know, the physicist who wrote all this. So you can't tell. By looking at another, unless you actually talk, which is a really good thing. So we talked about a ton in the right to decide for yourself. And I'm not going to go into that. But the way to think about it is, what would he or she have

wanted us to do if he or she could be their old self for five minutes right now? The only key point about this is to remember, if you're deciding it's not your decision. It's not me. It's not the doctor's decision. It's the patient's decision. And all you are doing is pretending you're the patient and speaking. Okay. So take that burden off yourself. Yeah. Let's go back to the nurse with the silly tattoo. You know, you're saying that her wishes are going to be destroyed. I'm confused. Yeah, I'm confused too. He's asking about the nurse with DNR tattooed on the chest and what would you do? Okay. That is ambiguous because there's not a written position order that says do not resuscitate. On the other hand, clearly the person doesn't want to be resuscitated. I don't know. You know, in that case, the default would always be on the side of life if it could be done quickly. Yeah. Well, because I as a physician don't want to decide.

But you do decide. Yes. But I advise. And I help people. I help people decide, but the reason that I want you to know is that people haven't already decided when they make the durable powers of attorney and the DNR requests, what is that just playing games? No. I don't mean to be rude. No, no, no, that's a good question. I am confused. Okay. Well, then the person has the right to change their request. Let me kind of go on and then I'll show you. Okay. Because it might well be that what you have written would be perfect. And I as a physician would go great. And I know exactly what to do. But the way to think of it is, here's an example. Let's say I decided that I wanted my car to go 150 miles an hour in a moment of madness. I don't know. I just decided that.

So I went to the car place and I said, do whatever it takes to make my car go 150 miles an hour. Then the automatic can from that goal go, oh, okay. Well, in order to do that, you've got to do the death. And if you do this, it's going to cost you this much and you do this. But see, you have figured out the goal. You know the long shot. That helps. That's what I'm saying. If we say, if I went into the car and the automatic can I can say, okay, I want a new carburetor. I want to use jet fuel, you know, whatever. Then I might not get what I want, which is to go 150 miles an hour. So when you have advanced directives, what you want is you want to say, I'm ready to go, don't do it no matter what, okay, if that's what it is. Which is great. And I would gladly honor that and have honored those many times. So the problem is that if you just say

living well, well, that you're not terminally ill. So then, you know, in durable powertrain, well, you know, what if it's your, you know, son who says, I don't want dad to die. You see what I'm saying? But lost anybody. Okay, so here's one way that we did this. And we, you know, this is going to sound really trivial. Maybe I won't say it. But, okay, let's say my husband and I have dogs. We have no children. We have dogs. And we're very fond of our dogs, you know, they're our kids. So what do you do when your dog gets old? And everybody says, well, just put them down. I mean, I had great agony over this because I'm a hospice dog. And I don't, I don't kill. Well, I need their prolonged, no shorting life. I mean, that's my goal. So, you know, you're just, you know, and of course the dog can't tell you what is quality of life is. And I don't, you never

build an advance directive. So what we did was we said, okay, well, what does our dog value? Well, our dog is a Labrador Retriever. And those of you that have ever had a lab, you know, they love to eat. And they love people. And so we decided that if and when our Labrador Retriever ever got to where he didn't want to eat and he didn't want to be with people, then that was the time. And so we kept, you know, I did my thing, you know, I kept him real comfortable. You know, he, and he was eating great until the night before he died. And then he suddenly stopped eating. Didn't want to talk and you know, and that was the day we said we took him to the bed. Which was a really agonizing decision. And that's why we can't ever give him an euthanasia because what if you had to decide that for your wife? Why don't you just put, why don't you just put your grandmother down, she's no good anymore. That's what the Nazis did. Yeah, you can't do that. That's a slippery slope. So what did they enjoy? And what was

unacceptable? And that's one way you can tell if somebody has never told you what they want. Can I think about that? Okay, I don't know if we've got time for this. We're going to, sorry, you got, you got to make a really quick decision here on your cousin with untreatable lung cancer, who's active in church and he says the Lord still has a job for me to do. If you're right-clicking the box, you can clear that out and we do it and I'm in the box. Anybody want another chance? Okay, your 60-year-old cousin has a wife's friend. The lung cancer is going to kill him. You know, he's going to die in less than six months, but he's still active in church because the Lord's got a job for me to do. He doesn't want to die. He develops life-threatening pneumonia. So wife is all this strength. She says, help me. What should I do? If you were deciding based on his values, what would you decide? Everything? I see you. Same, but you'd stop it after a few days. Same, but you would not do the life support. Same, but you wouldn't, you'd just give them antibiotic. Okay.

What do you think? It looks a little bad, but the Lord still got a job for me to do. I think that's interesting. I think one or two is reasonable to say, you know, you're getting a sense that this guy, you know, he's going. This person would not be appropriate for hospice. Okay. I'm going to do that. Now, if you don't know, another way you can tell is you can pay attention to the nonverbal clues. Okay. If your loved one is pulling out the IV or tube beating over and over again, that's a clue, maybe. If the person seems unhappy, is there any evidence that that person likes anything that they used to like? Like I talked about my dog, but, you know, what about grandkids? Always used to, you know, brighten up when the grandkids know that, you know.

So that's a clue that, you know, hey, you know, I'm ready to go. I had a really interesting patient at Heinz hospice who was a sue Indian. And he was dying of cancer, but he could talk he's very verbal, but he would not talk. And he came in and he lie on bed just like absolutely still like this and folded his arms over his chest like this. And would not move or talk or take any pills or anything. Well, we interpreted that as, you know, that's his Native American way of saying, you know what? Now it's a time. So we honored that. You know, we just did what we could for him and kept him comfortable and allowed him to die. It would have been better if you could have said it. But, you know, that wasn't his way. One thing you can do is keep talking to him because every once in a while they might be able to speak for themselves and you want to trust your gut feeling.

So, I want to just give you this. How kind of, how do you know if the person really knows what they're saying? Well, here's how you know. Can they understand this decision right now? What's involved and what are the consequences? Okay? Understand that. All right, so here we go. Your father has a serious heart attack. The surgeon says you should have heart bypass surgery, which you want. The chance of survival with surgery is 75% without it, it's 10%. Your father is confused most of the time. He's gotten, had more things that he becomes mentally alert for a few minutes when the grandkids visit. He says he does not want surgery. He understands that without it he will probably die and says that ever since your mother died, I've been ready to go to heaven. You are the durable power of attorney and you have never discussed this before. Should you authorize surgery? Yes or no?

Okay, look at your body's pretty much in agreement with that. Now, I can tell you that a hospital wouldn't take that as consent for surgery, but you can take it. Okay? Because you know and you love him and in this moment of clarity, you know, he's made it real clear. He understands. He doesn't want you to do it, so don't do it. Okay, we talked about goals of care. What's possible when I'm not going to go into that? One thing though is make sure you know what the prognosis is. Doctors do not like to tell you prognosis. The reason is they don't know. Okay? It is very hard, but they know better than they'll admit. So that's going to make a big difference. If you knew for a fact that that person was going to die in three months no matter what he did, that's going to make a big

difference. Right? As opposed to, well, three months, you know, there's a pretty good chance they'll be all right, and that's going to make a big difference. You really need to know that. Time limited trials, I talked about, you know, you can always do. Let's try it for a few days and see what happens if you're not sure. That's an okay thing to do, and then you have to stop. You have to withdraw. Now, the problem with that is that not starting it feels different than stopping it, pulling the plug. Okay? Now, ethically, there's no difference. Legally, no difference. And the advantage of this is it proves it. You try it, it didn't work, and it also buys you time. So that's a good thing. The bad side is it feels horrible. Right? I am now going to pull the plug. I am going to stop life support. Now, that is not any different ethically, legally, but it feels different. Okay? So, you know, if you're going to do a time limit of trial, you've got to remember

that you might, you might have to stop. Do you give a time limit, you still have to tell what kind of time limit you stop? What you do with the dock, you're asking what, it's the time limit. When I say time limit, what I look for at the position is the slope of the line. Okay? So I say, you know, give it three, four days, and are they going down? And it's clear there's no way. Or, you know, they're the same, in which case I'd probably continue. Or if they're slowly going up, and I continue. So what you're looking for is what's happening here? Are we getting better or getting worse? And then you can say, okay, it's clear that, you know, it's not going to work. Let's just stop now rather than going on for another two weeks. You do. So you have to go back and pull the plug. If you're the prior attorney, you have to be the one to tell the doctor to stop it.

Let me give you an example, and maybe this will help. Okay? First of all, you've got to get a doctor that'll talk to you, and I'm working on this, you know, I'm trying to train. I know, I know. Good health. I know, I know. But, you know, during those secrets, you know, doctors like bullied lists. So if you can come in with your bullied list, and if the more you know, the better off you're going to be. Okay? Alright, so I had a patient bat three weeks ago. I've never seen her before. She was what I call a helicopter patient. That means she was flown in from somewhere out in Kansas on a helicopter. Don't butt, don't butt, don't butt. I have learned to dread that sound. They land on the top of Wesley Hospital, and if they don't have a physician, and if they're not trauma, they go to the university, which will ring. Okay? So I knew I was in a deep trouble when the ER dot calls me and says, you know, you got a really bad one here.

Because believe me, they never call. So, you know, I hop in my car, and I find this very pleasant, delightful looking woman, 70 years old, whose had a massive heart attack. And until that, she was fine. She'd been walking, talking, doing everything she wanted to do. Well, and relatives have started to arrive, and there's about 25 of them. And one thing you got to know about helicopter is that helicopter is faster than the car. So I'm in there trying to save her life. The relatives are driving it. Lord knows what speed, down the freeway, getting to Lord knows what, and they get there. So it's always this awful, you know, they're in great distress. I'm in great distress. Well, it was such a delight to me because they had actually talked. They didn't have a durable habitat. They didn't have a living well. But they had actually talked to another. And her mother, the patient was a really unusual woman. She was a

risk picker. She said, I don't want to be a cripple. I want you to take chances with me. And I would rather, she had actually told them that I would rather have surgery that has a 5% chance of surviving than have you just lean in like support. Now, so that's what we did. Now, I've got to tell you that in 20 years of practice, that's the first time I've ever had a family do that. Furthermore, they all actually talked to each other. And there wasn't like the brother from California who comes in at the last minute and says, no, no, no, no. They all liked each other. And they all were agreement that, you know, mom had said this. And so I didn't need anything written. I had a very clear statement of what she wanted. She could not speak. She was on

life support. She's deeply combing us. I never knew her. But it was a great pleasure to work with this family because I felt like I could fight for her, you know, because I knew what I needed to do. And it caught, I mean, I've got to say, the doctor cost me a lot because the surgeons don't want to operate. Are you kidding? 5% chance of survival? They get monitored, you know, like on how many just they have. But they're not going to. But so I said to them, you know, this lady said, I don't care if I die on the table, take a chance. And that really, really, really helped. She died. She died. But and we ended up, we ended up withdrawing care. But you know, we all felt good about it. You know, we did all that we could to save our life. And then when it was clear that it wasn't going to work. Then we said, okay, you know, she's made it real

clear. And so we stopped. And the way that, I mean, I can tell you, we can tell about that, but it's not as awful as it sounds. You know, you just make the person comfortable and you turn off the machine. It's very peaceful. Not as awful as it's happened. And they knew they said, mom's not there anymore. And then, you know, it's kind of like you kind of know. So that was really helpful for me. Okay. All right. Other standards are not going to. Quality of life is not good. Best interest is using kids, interestingly enough. Infants, but not in adults. But I am of the opinion that any, the ultimate lead always comes out to that. I'm going to have to skip this. I'm afraid. Okay. So here's what you can do. You need someone to be your durable power of attorney. And if you don't have one, we have people here that help you.

Okay. You need to have a, you need to talk to them. Actually talk. Okay. And you have to have someone who's going to do what you want, whether or not they like it. You also have to talk to everybody else in your family. And you've got to talk to your doctor. And that you've got to be ongoing. Not just once. General and unforce and brief. Okay. So again, this is like talking to your kids about sex. I mean, you're not going to sit down and have this fight out conversation. You're going to get this little nugget gently over time. Okay. And now one of the things that you can do is instead of the traditional living will, you can have a value or value like goal treatment directive. And this is what mine is. And it says, my values are, I value my God, my family, my intellect. Okay. I want to live. I don't want to die. But at the other hand, I'm not afraid of death. Okay. So if I get run over by a

train, you know, for having sex, do everything. But yeah, you know, if you're judgment and you're love for me, you see that it's clear I'm going to not be this person who values these things. Then let me call. That doesn't say, okay, do explain it. It says here's what and values. This is what and what her life is about, which she wants. Okay. And here's another example. You know, and they have, sometimes they're like a whole page long. You know, I value time with my grandkids. So do whatever it takes. So I could be there for them. But if that's not possible, then let me die naturally as free as pain for possible. Now, if you're the, if I'm the doc and they, they give me this, then I can really help. I can help because I can tell you, okay, well, since this is a goal, here's what we have to do. And here's, here's the options. And I can make, I can really help with that.

Like we did with the patient with the heart attack that I just talked about. Okay. Another thing that you can do is form a family covenant. Now, this is where everybody sits down. And they have this conversation. And it's the just in case conversation. And they have it repeatedly on an ongoing basis. And they say, no, I know I'm never going to die, but just in case I ever do here. And that's usually how you have to phrase it. And something like that. So I think I'm going to, now I get what to me is the fun part, the other facts of death. And then I know what's done. One of the things I did in my life about five years ago was I went to seminary, not because I'm very holy, but because I'm not very holy, but one of the things that I study a lot about was the spirituality of death, okay.

And it was really fascinating to me because of this, the sense that in nearly all religions, the death is the greatest growth experience in life. Not America, but everywhere else. And that in every religion in the world, including Christianity until about 1900, there is a lot said about every day considered it tomorrow you might die. Why? Well, because that will help you. You will really clarify your vision. You'll make it really clear what's really, really important. Because tomorrow is now promised to you. It's now promised to any of us. And I actually, you know, I'm not very good at this, but every once in a while I am. And so somebody will call me up and say, well, we'll be on this committee. And I'll say, you know, with a smile, because I'm going, you know, because I'm terminally ill, you know, and meaning that, you know, I'm not terminally ill and

the classic sense, but in a sense that, you know, I don't know that I'm going to live. And, you know, there's something about being terminally ill, it's not all that bad. And you get to say, you know what all these things, you know, like, you know, and Cuba Ross, who's the person who wrote death and dying book, there's no need to be afraid of death. It is not the end of the physical body that should worry us. Rather, our concern must be to live while we are alive. The denial of death is responsible for people living empty, purposeless lives. For when you live as if you live forever, it becomes too easy to postpone the things you're not going to do. But when you fully understand that each day could be the last you have, you take the time that day to grow. Now, let me ask you, this is our last question. If I had my way, my preferred death would be kill over in the street, six months of illness, my cancer, five years from heart disease,

ten years from all parents disease, okay? Whoa, I did it again. Ready? Ten seconds. Okay, this is a very American answer. Nearly all Americans will say number one. But when you think about it, what is really hardest on your family? I personally would choose number two. Nobody wants to have all kinds of disaster. Okay, now, and we've got two more slides than we're done. At that, in every stage of life, there are things you're supposed to do, like when you're a kid, you're supposed to separate from

your parents, you gotta, gotta, gotta. Here is what you're supposed to do when you're dying. You're supposed to say, I love you to everybody you haven't said it to. You're supposed to say I forgive you to everybody you haven't. You're supposed to say, forgive me, including myself. You're supposed to say, thank you. And at the very last, you're supposed to say goodbye. Okay? Now, I thought, you know, and then a great thing, if you did that every day, if every day you said, I love you, so that's a matter. If you said, I forgive you, forgive me, thank you. I wouldn't, I wouldn't be pretty good. So, since I'm up here and I get to editorial license, three things every human being should do, one learns if you are. You should have advanced directors and talk about them. You should live for today. And I went and closed my famous quote from Kathy Lehman,

he says, I believe you should live every day, if you're last, that's why I don't have any clean laundry, because come on, he wants to wash clothes on the last day of his life. Thank you very much.