“Mom, the doctor needs to know if you want to die,” were the words Maggie yelled at her hard-of-hearing 91-year-old mother, Gertrude. The emergency physician cringed to think how many other patients heard this conversation and thought he was an assailant. Gertrude demonstrated very little tolerance for being a patient, yet insisted, “I want everything done to save my life.” This was the extent of her end-of-life conversation. From now on, Maggie might insist that her mother wants to be resuscitated as many times as it takes to prolong her life.
What Gertrude wants, Gertrude gets! This is the ethical rationale for upholding patient autonomy in conversations that involve the end of life.
Many healthcare providers would argue, “These conversations should not be taking place in the emergency department.” Shouldn’t physicians be having these conversations with patients in their offices? With only 1 out of 3 patients completing advance directives, the brunt of the task often falls on ED physicians who tend to admit chronically-ill patients to the hospital with no questions asked. What’s the solution to this never-ending problem.
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Medicare is now paying physicians to speak with patients about end-of-life choices, yet physicians are not prepared for these talks. The role of a physician is to save lives and the American Medical Association just released a statement that does not support assisted dying. Doesn’t end-of-life conversation amount to assisting patients with death and dying? Are physicians being encouraged or discouraged from having these conversations?
It’s clear that healthcare professionals are having the wrong conversation at the wrong time in a person’s life because most patients are still dying in hospitals against their wishes. How can physicians change this situation – turn a negative topic into a positive outcome and helping chronically-ill patients become human beings at the end of life?
It’s simple – stop talking about ending life and begin discussing strategic aging.
Strategic aging is three-fold
Prioritize Quality of Life . . . by listening to patients’ stories
Manage Chronic Illness . . . by telling patients the game plan
Appreciate Palliative Care . . . by describing what to expect
In the emergency department, physicians listen to patients’ stories, tell them the game plan and describe what to expect. By not sugarcoating reality or adding false hope, very few patients are disappointed with their emergency room experience. This same principle can be applied to discussing strategic aging.
A good story follows the same format of describing the Who, What, Where, When, Why and How of pertinent facts. Strategic aging incorporates the facts with helping patients create a narrative and direction for the end-of-life journey:
- Prioritizing quality of life equates to the Who and What
- Managing chronic illness involves the Where and When
- Appreciate palliative care includes the Why and How
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Quality of life
Who ages rapidly? The following list of no-no’s highlights silent killers that often support and sabotage quality of life:
- Sun Exposure
- Maintaining independence
- Having purpose/staying engaged/ being relevant
- Enjoying physical health and well-being
- Aging comfortably in their own homes
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Quality of life means many things to many people. Yet the goal of strategic aging is to unmask one aspect of the person that describes his or her ability to be self-determined and in charge of medical decisions. “I’m a black-belt.” “I was a referee (I’m used to calling the shots).” “I practice yoga.” Is there any doubt who these people are and what quality of life they enjoy? By connecting patients to their identities, physicians might use this information to guide patients through the aging process. By saying, “You know who you,” physicians can bring out the best qualities of the patient and promote self-determination in life-and-death decisions.
Tips that support the aging person’s quality of life:
- Well-being (belief in your spiritual nature) instills confidence in making tough decisions
- Accentuating the positive allows for leaving well enough alone
- A strong-willed support system combats the high-strung medical system
- Self-determination selects quality (of life) vs quantity (of years)
- The ability to overcome fear helps people achieve personal goals
When is the best time to have “the talk?”
- During Medicare enrolment as most deaths occur after age 65
- Before receiving a fatal diagnosis
- At the time chronic illness becomes apparent (three months into an illness)
- Three months into treatment and every 3 months after
- Before, during or after each ER visit or hospitalization
- 60% of Americans die in acute care hospitals
- 20% in nursing homes
- 20% at home
Approximately 80% of Americans prefer to die at home. If that 60 % of patients who died in the hospital had received home-based palliative care, the statistics would match patients’ wishes.
If people frequent physicians’ offices or ED’s during a three-month period, we might as well face it – they’re addicted to being patients. This is a concern for everyone involved. Like with alcoholism, relationships are often destroyed and patients feel increasingly isolated. No one wants to treat these individuals who often feel burdensome.
Steps for patients living with chronic illness:
- Admit you have a chronic illness with no cure
- Believe that a higher power can restore sanity
- Decide to accept the will of God or nature to take its course
- Make a list of do’s and don’ts that will promote serenity
- Reduce stress by participating in activities that lift the heart
- Symptoms of pain, anxiety, and suffering
- Receiving unwanted treatment
- Advance directives may be disregarded
- Physicians may be misleading or giving false hope
- Heart Disease: 611,105
- Cancer: 584,881
- Respiratory Disease: 149,205
- Accidents: 130,557
- Stroke: 128,978
- Alzheimer’s Disease: 84,767
- Diabetes: 75,578
- Influenza and Pneumonia: 56,979
- Kidney Disease: 47,112
- Suicide: 41,149
By including palliative care in the discussion of strategic aging instead of at the end of life, physicians help patients better understand why and how it might benefit them sooner than later. When patients have a terminal diagnosis, they need support systems in place. Palliative care aligns with pain management and holistic care. It adds the necessary spiritual approach to treating medical conditions and supports the “less is more” philosophy.
Tips to help the aging appreciate palliative care:
- Palliative care stands apart from hospice and “shelters” patients from advanced medical care
- It aligns with compassionate, conservative, person-centered home-based care (not end-of-life care)
- It deploys common sense nursing skills over the medical knowledge of highly-trained specialists
- It focuses on treating symptoms and reducing stress, averting the practice of defensive medicine
- Palliative care nurses advocate listening to their patients’ goals and personal values
People don’t really age until they experience
physical limitation or mental impairment.
With age, many people become defensive, fearful and demanding – unlike themselves. They are prone to want everything done despite their insufferable pain and poor quality of life. How physicians can assist patients in acting in their best interest is by showing compassion. Yet, how physicians address the end-of-life conversation can be awkward. Discussing the facts of life is uncomfortable until you create an effective strategy, suggest its normal and make it personal. Patients need to connect having a good story with the experience of both their life and death.
By having patients tell their stories and incorporating their purpose and goals into strategic aging, a win-win solution is achieved. Also, hospital readmission rates will decline while physician-patient satisfaction scores rise.
Kevin Haselhorst, MD
Kevin Haselhorst, MD, Emergency physician, is an expert on advance care planning. He speaks to patients, family members and healthcare providers about advance directives, palliative care and dying with dignity. He’s the author of “Wishes To Die For”, “Is Palliative Care Right for YOU?.” Learn more at: KevinHaselhorst.com