The forbidden discussion topic: MEDICAL ADVANCE DIRECTIVE

How many of us can honestly say we have an advanced directive for health care completed for our loved one as early as their 65th birthday? I think a very few of us would nod our head yes. This includes me - well, I tried, but my dad is stubborn and this is a tough conversation to even bring up. So, I am in the same boat as the majority who struggle to have these conversations.

Advanced Directive is defined as legal documents a person completes while still in possession of decision capacity about how treatment decisions should be made on her or his behalf in the event she or he loses the capacity to make such decisions.

Advanced directives can be revoked orally by the patient at any time so long as they maintain decision making capacity.

The most difficult question for patients and families is "which medical treatment is right for me?"

The answer to this question will vary upon personal reflection of his/her own values and preferences. Clinicians play the role of guiding patients and families in reflecting on these questions. Thus, it truly is a team approach and should be approached in a systematic way. The easiest and most efficient way to go about doing this is to create a advance care planning process. What the heck is that?

Advance Care Planning process (ACP) is an ongoing process where patients, families, and their  healthcare providers reflect on the patients goals, values, and beliefs, discuss how they should inform current and future medical care and ultimately use this information to accurately document their future health care choices. In the most ideal situation, this is all done after exploring the patients and caregiver's knowledge, fears, hopes, and needs.

When do we start this process? Anytime! Sooner the better. Several experts have  advised the following:

1. ACP should be proactive
2. ACP should be appropriately timed
3. ACP should be integrated into routine care
4. ACP should be revisited every time a person's medical condition changes

I find these recommendations very useful. As a hospital medicine physician I have initiated these conversations many times and what I find out is that unfortunately that is the first time the family becomes aware of how ill their loved one is or no one ever thought about it or did not know how to bring it up. The most difficult time to discuss these issues is even more difficult when a loved one is sick; even worse is that the loved one might be too ill to even participate. So, at that point we might find ourselves guessing or assuming what he/she may have wanted to be done.

Point here is - TALK ABOUT IT AS SOON AS YOU CAN AND IT IS AN ONGOING PROCESS. Death is natural and inevitable. We must become comfortable talking about it and sharing our thoughts with one another.

What are the benefits of establishing a ACP? Randomized and prospective studies have shown the following:

1. Higher completion rates of advanced directives
2. Increased chance that clinicians and families understand and follow with patient's wishes
3. Reduction in hospitalization at the end of life
4. Receipt of less intensive treatments at the end of life
5. Increase use of hospice services
6. Increased likelihood that a patient will pass in their preferred place
7. Higher satisfaction with quality of life
8. Improved communication between patient, family, and clinicians with shared decision-making
9. Better prepared families regarding the dying process
10. Lower risk of anxiety, depression, and stress in surviving relatives of deceased persons
11. Reduction of health care costs

Remember to designate a Durable Power of Attorney or a Health Care Proxy. In addition, a Living Will will also help in clarifying a persons wishes regarding their health care management.

So, can Dr. Ahmed help me with this and what benefit does LiveActive Primary Care offer me?

• Establishing care with a physician who will see less than 1000 patients a year will be able to give you personal care, build a relationship with you and your family, fully understand your wishes
• Communicate your wishes to other care providers
• Earlier you start building a relationship with health care providers the sooner and better we understand your view on life and what is important to you. So, if you are healthy - GREAT! I would still like to see you, get to know you, and keep you healthy as long as we can while working towards preventing disease and illness; so you can live a high quality of life!
• Limit unnecessary testing or repeat testing by having a physician that can provide records to you or to the health care facility - so communication of your health care is smooth instead of fragmented. Unnecessary testing leads to complications, extra radiation exposure, delayed care, rising cost.

We all perceive life through a different lens. We are all human beings with our own personal limitations. Life has a definite start and stop time that never pauses in between for neither you or me. So if we all agree that our time is limited, does it not make sense to make the most of our time and enjoy each day? Why not live life to the fullest and a quality of life that is defined only by you alone?

So, why not partner with a physician who is doing whatever they can to preserve that patient-physician relationship so that they can better understand you and be your partner in living a healthy, high quality, fulfilling, and most importantly... FUN life?

Hope you found this post full of reflection and useful. Contact me if you want resources to this post or have any questions. Join our practice now! Our clinic will complete construction by early 2015 we hope.

Take care and happy holidays to all! Enjoy your time with family and friends. Please remember to give your loved ones a nice big hug and remind those whom you love how much you love them at least once a day.

Your internist,

Dr. Ahmed
913-549-3884
[email protected]

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