April 30, 2024 • 29 mins
Talking about death or life-threatening illnesses or injuries is not easy. However, planning for these events makes sure you get the health care you want and offers you and your loved ones peace of mind, helping eliminate difficult decisions in the midst of extreme emotions, confusion and pain. Dr. K and special guest Ramon Mercado discuss important end-of-life planning tools, including advance directives and a health care power of attorney.
Additional resources for this episode:
National Institute on Aging: https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care
Mayo Clinic: https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/living-wills/art-20046303
Johns Hopkins: https://www.hopkinsmedicine.org/patient-care/patients-visitors/advance-directives
If you have a question for Dr. K, email QandAwithDrK@mpqhf.org. Your question will remain anonymous.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Beth Brown (00:09):
Welcome to Q&A with Dr. K, a podcast by Mountain
Pacific Quality Health, where wesit down with Dr. Doug
Kuntzweiler and get your healthquestions answered. Because on
Q&A with Dr. K, the doctor isalways in.
(00:34):
Hello, everyone,this is Beth Brown, your host
and I'm here, as always, withour very good friend Dr. Doug
Dr. Doug Kuntzweiler (00:37):
Thank you.
Ramon Mercado (00:37):
Thank you.
Okay, so today's questionactually does not come from a
Kuntzweiler, Mountain Pacificchief medical officer. But today
patient. We might be cheating alittle bit. But I did get an
is a little bit different,because we also have a special
guest joining us. For our topictoday is also Mountain Pacific
email from one of our colleaguesat Mountain Pacific who often
staff attorney, Ramon Mercado.
So thanks so much for joining usworks directly with patients and
raised this topic as a concern.
both Dr. K and Ramon.
(01:12):
"I have spoken to multiple folksthat either don't know or don't
understand the importance ofpower of attorney and advance
directives. There is a lot ofuncertainty and fear regarding
both. Maybe this could beaddressed on Q&A with Dr. K at
some point." And of course, Isaid, of course it can. And so
here we are. And so let's startas we usually do, Dr. K, with
(01:34):
defining what we're talkingabout. So let's start with the
term advance directives. Sopeople might hear that term,
either advance directives oradvanced care planning. Are
those one in the same? What arewe talking about here?
Dr. Doug Kuntzweiler (01:51):
Well, some of this is semantics. If you're
talking about advanced careplanning, that's sort of an
umbrella term that talks to anyconversation you have with
somebody about what you wouldlike to have happen, you know,
in the event that you can't makedecisions for yourself, but
generally, when people aretalking about advance
directives, they're talkingabout a legal document that
(02:14):
specifies what sort of care theywant, or just as importantly,
what sort of care they don'twant in the event that they
can't make those decisions forthemselves. And people think,
well, you know, I'm 30 yearsold, I can always make decisions
for myself. But if you're in amotorcycle accident, and you're
unconscious, for instance, now,you can't really, you know, if
(02:34):
if you have a severe illness,you might not be able to think
straight in might not be able tomake decisions for yourself. If
you're old, like me, you mightget dementia, and you're not
competent to make decisions. Oryou may have a mental illness
that can flare up and make youmake it so that you're not able
to make decisions for yourself.
So these are legal documentsthat you can fill out and, and
(02:57):
they specify what sort of careyou would like at the end of
life or in the event that youare not able to make decisions
for yourself now.
Beth Brown (03:08):
We don't want to talk about these sorts of
topics. They make usuncomfortable, especially when
we're younger. We're cocky aboutit. We think we're gonna live
forever, we don't need thesekinds of things. And so the
message is planning is betterthan not planning no matter what
your age.
Yeah, none of us are getting outof this alive. And it's you
know, it's it's unpleasant tothink about. But on the other
(03:29):
hand, unpleasant things canhappen if you don't think about
it. So I encourage everybody, nomatter what your age is, it just
will save you and your familysome grief in the long run.
And you mentioned these beinglegal documents or legal
documentation that people canhave. And that's why we have
Ramon on here with us today. Butbefore we dive too deeply into
the legality of some of these,let's talk about all the
(03:52):
different types of advancedirectives that exist, what kind
of planning people can be doingfor the unpleasant or the
unforeseen. So let's start withthe living will. And we also
want to talk about a durablepower of attorney for health
care, there are different powersof attorney. So let's start with
what is a living will?
Dr. Doug Kuntzweiler (04:09):
So I'm gonna give you a little
thumbnail history of livingwills. Up until the 1950s or so,
And so some of the differentdirectives go into that living
this wasn't an issue, becausepretty much medical care wasn't
very good. We didn't have a lotof resuscitative measures. We
weren't prolonging people'slives, you know, by putting them
on ventilators or treating theirheart attacks and their strokes
(04:30):
aggressively. We just simplydidn't have the technology. So
you either lived or died. Itwasn't, wasn't a big issue. But
in the 1960s as medical care gota lot more sophisticated, and we
started putting people who werein comas on breathing machines,
and we started treating themaggressively with all kinds of
medications and new surgicalprocedures, and we started
(04:52):
putting stents in their pluggedcoronary arteries and saving
them from heart attacks, and sosuddenly, it became an issue
because it's not always clearexactly what what we shouldn't
be doing. And so that's whenliving wills, late 60s, that
term sort of came into vogue.
And, and the idea was that, justlike you write out a will that
directs what you would like tohave done with your estate when
(05:15):
you died, the living will wasdesigned to direct the sort of
care that you wanted, or thesort of care that you didn't
want. And so it was written upjust like a will.
will?
Yeah, and, and a lot of peoplewhen they when they did that,
(05:35):
they just said sort of generalthings like in the event that
there's not hope for ameaningful recovery, I want all
care stopped, you know, kind ofgeneral things like that. But
it's a lot more complicated thanthat. And things got a lot more
sophisticated as time went on.
We'll we'll talk about that thedurable power of attorney, and
Ramon, you can you can talkabout this, maybe but as I
understand it, that is basicallya legal surrogate.
Ramon Mercado (05:58):
Yeah, durable power of attorney, it's it's a
document where it's, it's anadvance directive on its own.
But also, it's a document whereyou designate an agent to act on
your behalf, let's say if youbecome incapacitated, or you are
unable to make decisions foryourself regarding your health
care, then that agent steps intointo the patient's role and has
(06:23):
the authority to make, to makeevery every medical decisions,
basically, they're treated thesame as the patient would for
terms, in terms of HIPAA privacyand everything. So they do have
quite a bit of power here.
Beth Brown (06:37):
And people can put different people in different
roles of a power of attorney,correct, Ramon? This is specific
to a power of attorney of healthcare, but you can have a power
of attorney for differentaspects of what's happening with
your life.
Ramon Mercado (06:50):
Yeah, you can have different power powers of
attorney. You can have, and youcan have one for medical
purposes. And then you can haveone for, let's say, handling
your finances or makingdecisions outside of the health
care realm.
Beth Brown (07:04):
Can anyone be my power of attorney for health
care? Or do they have certainskills or knowledge?
Ramon Mercado (07:10):
I wouldn't say that they need certain skills or
knowledge. The only requirementsthat they are of legal age to
enter enter into the agreements,because this is basically an
agreement between you and theagent. Also, that they that
they're willing and able to dowhat it's requiring them to do,
(07:32):
you can't you can't justdesignate someone as your agent
who doesn't know about it, or isnot willing to make those
decisions whenever, whenever thetime comes. Usually someone that
lives close, close to you whereyou are, you don't want to be in
Montana and have somebody on theother side of the world making
(07:53):
these decisions for you. That'susually a good idea. Most
importantly, someone that youtrust that they're going to be
looking out for your bestintents, intentions when, when
the time comes.
Beth Brown (08:05):
We're going to talk about some of the different
types of advance directives oradvanced care planning people
can put into place. But let's goback to a high level spot, Dr.
K. What happens if someone doesnot have advance directives in
place, and they're in asituation in a hospital where
they cannot make decisions forthemselves?
Dr. Doug Kuntzweiler (08:22):
Well, I can tell you that I've been
there and done that in theemergency department, which is
why I'm fairly passionate aboutthis whole topic. Because in
that event, all bets are off asto what's going to happen.
People would come into theemergency department by
ambulance, maybe CPR had beenstarted out in the field by the
medics, and if you don't knowthem, and if there's nobody
(08:45):
coming forward and saying I havedurable power of attorney, and
there's no obvious living willanywhere, then you have to try
and make a judgement on yourown. You try and get as much
information about the patient asyou can, for instance, do they
have terminal cancer, and and weprobably shouldn't do anything
to resuscitate them. You know,their age plays into it,
(09:08):
whatever you can learn abouttheir past health care, their
medical condition plays into it.
And I would always just sort ofthink, well, if I were in this
situation or if this were afamily member, what what would I
want done? What do I think wouldbe the best thing to do? And so
that's, that's all you can do.
Sometimes you could try and makephone calls, you could try and
call their their physician ortheir primary caregiver, or if
(09:31):
they have a spouse, you couldtry and contact their spouse
because it's oftentimes theydidn't, you know, the spouse or
next of kin wouldn't come inwith the ambulance, and
sometimes there was no next ofkin. Sometimes it was the
neighbor, you know, and theneighbors would kind of shuffle
their feet and say, Well, Idon't really know him that well,
but we say hi in the morning toeach other and, you know, and so
you wind up just doing what youthink is best, which is an
(09:54):
uncomfortable feeling foreverybody. And I never got sued
over this, but I had people whothought about it, because either
I resuscitated somebody thatthey thought shouldn't have
been, or vice versa. I didn'tresuscitate somebody who they
thought should have beenresuscitated. You know, it puts
the primary caregiver in areally awkward position, because
(10:15):
you have to just try and do thebest thing, you know that you
think at the time. And that'sall you can really do. So if you
have something bad happen, andyou don't have a living will, or
you don't have a durable powerof attorney, it's a crapshoot as
to what's going to happen.
Beth Brown (10:31):
You're sort of at the mercy of someone's most
educated best guess. On the flipside of that, then, if you do
have a living will or advancedirectives in place or a power
of attorney, does that guaranteethat your wishes are going to be
carried out by a doctor who ismaking those decisions?
Dr. Doug Kuntzweiler (10:49):
Oh, in your dreams. Yeah, I wish, I
wish I could say that was thatwas true, but there are no
guarantees. And there certainlyare no guarantees in medicine,
because a lot can go wrong. If,if it happens, let's say you're
in an automobile accident out onthe road, and you come in by
(11:10):
ambulance, and and we don't evenknow who you are, at that point,
you know, you go through theirID, and maybe you can figure out
their name, but you don't knowwho the contact people are. And,
you know, there's all sorts ofsituations come up, where even
though they had advancedirectives, you might not know
that or you might not be able toaccess them in time to make a
(11:30):
decision. And from the ERperspective, is it often you
know, we didn't have much timeto make a decision, those are
usually critical situations. Butthere are there are less dire
circumstances where, cancer isthe one that comes to mind,
where somebody has a cancer andit's been treated. And maybe
it's been in remission for awhile, and then it comes back.
And you know, it's resistant tothe next line of treatments. But
(11:52):
at any rate, you have some time,you have weeks, maybe a month or
two, to think about that and totalk and make sure that
everybody that's important inyour life knows what your wishes
are, and that you make one ofthese legal documents so that
your wishes will be respected.
Then you have a much betterchance of that happening. But
even in that situation, I'veI've seen people who do all of
that, and then there istypically some remote relative
(12:16):
who calls and thinks that theyshould be treated aggressively,
or vice versa. And so the familysometimes has an inner turmoil.
And we would sometimes get stuckin that situation in the ER that
the person had a very welldocumented desire. And we would
try and follow that in the ERand a family member would say,
(12:38):
No, no, no, no, I want you to doeverything to everything. And so
you would have to sit down andsay, Well, I understand how you
feel. But it's quite clear thatyour loved one did not want that
this is what they said they wantit and we're going to honor
that. And sometimes that wascould get pretty uncomfortable
too. But you try and do whatpeople want.
Beth Brown (12:58):
So it sounds like communication is a big part
there, too, once you do getthose advance directives in
place. So from that healthperspective, you know, where
it's uncomfortable when youdon't have them in place, it can
be tricky when you do have themin place. Ramon, from that legal
perspective. Why do you think -you know, Dr. K has said that
he's passionate that peopleshould have advance directives
(13:20):
in place. From your perspective,why do you think it's important
for people to have advanceddirectives in place?
Ramon Mercado (13:26):
Dr. K covered most of them, and the legal
reasons are right, right in linewith what he mentioned there. I
was gonna mention another thingwhen you file an advance
directive you need to have a twowitnesses, at least in Montana,
two witnesses, sign the advancedirective. And also going back
(13:47):
to what Dr. K was saying aboutthe the accessibility of some of
these forms, that Montana haswhat's called the Montana End of
Life Registry. And Dr. K, youcan shed some some light on
this. I don't know if doctorshave this available to them
right on the spot, but medicalproviders and people with the
patient's information can canaccess it, and you file you can
(14:12):
file your medical directivesinto the Montana and a flat
registry. That's a good databasethe state has.
Dr. Doug Kuntzweiler (14:19):
Yeah, and that gets back to what I was
talking about that sometimesyou've made one of these
documents, but it isn't reallyaccessible. So it's important to
make the document, but it's alsoimportant then to talk to the
family or your friends orwhoever you expect is going to
be around, certainly to yourdurable power of attorney, if
you execute a durable power ofattorney. Sit down and talk with
(14:40):
them and make sure theyunderstand exactly what you want
and then make sure that thosedocuments, people know where
those documents are so that whenthe ambulance shows up, they can
be produced and then then youknow what to do. But I think
it's it's important to talkabout these things. What do you
really want. As you get older,and if you have, you know, an
(15:03):
incurable illness or what looksto be a terminal illness,
typically you have time. Andpeople often do sit down and
talk with their family aboutwhat they really want done. And
that that's the best casescenario. But even young people
really should have some idea ofwhat they would like to have
done. And you can't just end itthere. You can't write out a
(15:24):
will, get it notarized and stickit in a box somewhere and nobody
knows where it's at. You need tohave somebody who knows what
your wishes were and knows whereto find the documents that
you've executed.
Ramon Mercado (15:35):
Well and also, there's the, what they call the
POLST, that there that's acronymfor physician orders for
life-sustaining treatments,that's actually a physician's
order. And it becomes the firstpage of your medical record. Is
that right?
Dr. Doug Kuntzweiler (15:52):
That's absolutely correct. And there is
a national POLST form. And it'spretty cool. I understand that
some states have their own, sothere's some variations, and you
can get them in foreignlanguages and all sorts of
things. But it goes through invery great detail. It's a
checkbox sort of thing andplaces where you can fill in the
blank, but, but it goes in greatdetail and exactly what your
(16:14):
wishes are. People say thingslike, Well, I'm going to have
DNR tattooed on my chest, do notresuscitate. So nobody will be
pumping on my chest when I dropover. It's a lot more
complicated than that. It's if Ihave a terminal illness, and I'm
kind of failing and people can'ttake care of me at home, and I
go to the hospital. Okay, well,do you want IV fluids? Some
(16:35):
people do. Some people don't.
Some people say, well, that'slike offering a sip of water to
a dying person. That's a carecomfort. Okay, but some people
say no, that's too aggressive. Idon't want to be kept alive by
any artificial means. And somepeople say, Okay, if you have a
pneumonia on top of whateverelse was going on, do you want
us to give you antibiotics totreat that? Or if you have, you
(16:55):
know, a urinary tract infectionas part of your whole medical
complex thing? Some people say,Yeah, sure. Because that's a
simple thing to do. And thatmight make me more comfortable,
and other people say no, I don'twant you to interfere with
nature, let it take its course.
These are things that peopledon't really often think about,
(17:16):
or that it doesn't occur to themthat yeah, can get pretty
complicated. What exactly do youwant? Do you want a feeding tube
in the event that you can't eatlike you normally do? Then even
in pain, you say, well, I don'twant to suffer. Okay, well, what
level of pain control do youwant? Do you want to be
unconscious? And that's, that'sthe old joke that, you know, I
(17:37):
don't mind dying. I just don'twant to be there when it
happens, you know, and so somepeople say, just knock me out,
okay, when other people say, No,I want to be able to talk to
family and friends. And youknow, it can get pretty
detailed. And the only waythat's going to happen, is if
you think about it ahead oftime, and you convey it to
someone and the POLST, I agreewith Ramon. It's a physician's
(17:59):
order. So it pretty much has tobe honored. As long as you know,
it's signed by everybody. Andthat's the closest you're gonna
get to a guarantee, I would say.
Ramon Mercado (18:08):
Yeah, I agree with that.
Beth Brown (18:10):
So it's so objective. There's so many
shades of gray depending on whatan individual wants, and you
touched on so many differentthings. So I don't want to lose
track because you mentioned aDNR. So for those folks who
don't know, that's probably oneof the most common that I know
of the ones we're going to talkabout today. But what is a DNR
and when might a DNR come intoplay?
Dr. Doug Kuntzweiler (18:31):
The DNR stands for do not resuscitate.
And typically, if somebody has aterminal illness terminal
condition, they execute a DNRand they get it notarized and
signed and somebody can speakfor them. So yeah, they didn't
want to be resuscitated. Again,that's still sort of what it
means to me in the ER is I'm notgoing to put a tube in their
(18:54):
windpipe and artificiallybreathe for them, put them on a
ventilator, a breathing machine,I'm not going to do that. If
their heart stops, I'm not goingto do anything to try and
restart it. I'm not going to getthe electricity paddles out and
be, you know, shocking theirheart. Sometimes I leaned
towards IV fluids are a comfortmeasure, you would you would
offer a dying person a sip ofwater. And so I often would
(19:18):
start an IV and I didn't thinkthat was too aggressive. And if
it seemed like they wereuncomfortable or seemed like
they were in pain, and if theycouldn't speak and if you don't
have any advanced directives, Iwould usually give them a little
bit of pain medication or alittle bit of sedation. You
know, just try and do commonsense sorts of things. But it
does get pretty complicated.
Anyway Do Not Resuscitatedoesn't tell you very much. It
(19:40):
means don't pump on their chest.
Don't shock them; don't put atube in their trachea, but then
there's a lot of other stuffthat is that really
resuscitation or is thatoffering comfort.
Beth Brown (19:51):
Lesser known ones maybe are DNIs and DNHs. DNI
stands for do not intubate andDNH stands for do not
hospitalize, so someone doesn'teven want to go to the hospital
in the first place. So whenshould people put these types of
orders in place?
Dr. Doug Kuntzweiler (20:07):
Well, I think they should put them in
place if that's really how theyfeel about things. And sometimes
you I mean, if I'm young, yeah,and I'm, I have, let's say, a
motor vehicle accident, I wantto go to the hospital, because I
don't know, maybe I maybe I'mgonna recover from all of this,
you know, or maybe I will havemeaningful life after. So you
just don't know. But if you are,let's say you're in a long-term
(20:28):
care facility. And you know,you're sort of winding things
down, you're comfortable, thatis your home at that point,
you're comfortable there. Youdon't want to be taken by
ambulance to a noisy ER, andthen sit around in the ER for 12
hours, and then eventually getadmitted to the hospital where
you got a bunch of doctors whoyou don't know, and you know,
(20:48):
it's not very comfortable. Andso some people would just assume
not be hospitalized, whatever'sgoing to happen is going to
happen anyway. And they wouldsay, just leave me in my home or
leave me at my daughter's houseor leave me in the long-term
care facility. These are donots, and they are specific: do
not intubate, don't put me on abreathing machine, do not shock
my heart do not hospitalize me,or some people say, yeah, you
(21:11):
hospitalize me, but I was inintensive care before and it was
a nightmare, and I don't everwant to go back to intensive
care and say, Well, okay, thenthere's certain things we can't
do in a regular hospital bed.
And you know, as long as theyunderstand that, that's fine.
Beth Brown (21:25):
And you both talked about POLST and how helpful that
part can be. I also know there'sa MOLST, which stands for
medical orders for lifesustaining treatment. Are those
the same?
Ramon Mercado (21:35):
I think those are terms are used interchangeably.
Dr. Doug Kuntzweiler (21:37):
Yeah, I agree.
Beth Brown (21:39):
Okay, great. So we've talked about living wills,
we've talked about power ofattorney and DNRs and DNIs and
DNHs and the POLST. Where doessomeone get started? And Ramon,
maybe you can kind of give somedirection here. What should
someone do to start with someadvanced care planning and get
getting some of these orders andthese directives in place?
Ramon Mercado (21:57):
The first step will be to talk to everybody
that's going to be involved withthis in this process. The more
people you talk about it, thebetter. That's how I would
approach it both professionallyand personally. The then the
next step, once you haveeverything in order, and you're
you know exactly what you want.
There's there's a lot of formsonline that people can find on
(22:19):
how to do estate planning andadvance directives. I know that
Montana for Montana DPHHS,Department of Public Health and
Human Services has, uh, has allthese forms available on their
website. Also, in Montana, agood resource to that we have is
the Montana State UniversityExtension program, they have a
very comprehensive estateplanning section, that mean they
(22:42):
have every single form that youcan possibly imagine. And they
keep coming up with new stuffalmost every year. So you can
download forms for powers ofSo a lawyer isn't necessary but
could be helpful if needed couldattorney. I have used some of
those myself for some clientsbefore. And it's it's very
useful. So Montana does have alot of resources. I don't know
about other jurisdictions. Butlet's say you do all the
(23:06):
research, you find a bunch offorms online, they all kind of
do look a little different. Ifyou find yourself in a spot
where you don't really know whatyou're doing, or you feel like
there's something wrong, justtalking to an estate planning
attorney is probably a goodidea. Most times, it won't get
to that point because some ofthese forms are pretty self
(23:29):
explanatory. And most of theforms have a package that out
that describes, you know, lineone means this, line two means
that you know, it's, that'sthat's how I would approach it.
be helpful.
Yeah.
Beth Brown (23:48):
Okay. And for those listeners who are not in
Montana, their State Departmentof Health is probably a good
place to go at least initially.
Ramon Mercado (23:55):
Most likely.
Yeah.
Dr. Doug Kuntzweiler (23:57):
I would add that I think most primary
care physicians or primary carepeople will have dealt with this
know in their practice and sothey should have some knowledge
about where you can acquiretheir forms and you probably
should sit down and talk withhim anyway and make clear that
if you have a primary care givermake make it clear that they
(24:18):
understand what your wishes are.
Beth Brown (24:20):
Perfect. Okay, so that's another great resource -
your primary care maybe orDepartment of Health. So once I
have my documents that I thinkthey're complete, I'm I'm ready.
You talked about sharing thoseor having that communication.
Sounds like primary careprovider is definitely someone
you want to talk to. Who elseshould have these forms either
(24:40):
on file or saved somewhere sothat they're accessible and
ready to reference should anemergency or something happen?
Ramon Mercado (24:47):
If you are designating an an agent to be a
power of attorney, that person,that person should have all
these documents. One thing Iwould not ever recommend would
be putting these things in asafe or a safety deposit box.
It's just not a good idea justto same with a will, getting it
get into it when you'reincapacitated is is just a
(25:09):
nightmare. So most people keepthem on their fridge or on the
on, like behind their door intheir bedroom. I mean, I've,
I've heard many spaces wherepeople who are accessible, I
would just let the people thatare involved in this whole
process know. Everybody who wasinvolved.
Dr. Doug Kuntzweiler (25:30):
Yeah, if there's somebody else in in your
home with you, you know, makesure that they know where the
documents are. If you're in along-term care facility, you
know, the nurses should haveaccess to that. It should be in
your chart. If you waited tillyou got in the hospital, it's
going to be in your chart, thetypically a hospice nurse or
(25:51):
somebody like that will come andsit down and talk with you and
help you fill out the documents.
And then it'll be on your chart,but but you have to make sure
that there's somebody who'slikely to be around. If it's not
somebody that lives with you,maybe a neighbor or a friend or
somebody, much like you would dowith an emergency number to
call, you know, people ask youthat all the time, in case of an
(26:11):
emergency, who should we call,and you tell them oh, call my
daughter, call this person orthat first of all, those people
should probably have a copy orhave access to it or at least
know where it's at.
Beth Brown (26:25):
Good advice. Can you think of a time when someone
might need to change theiradvance directives, or they
would want to edit their formsfor any reason?
Dr. Doug Kuntzweiler (26:34):
Oh, yeah, sometimes a medical condition
changes. Yeah. Sometimes thingslook better. Sometimes they look
worse. Sometimes they're grim.
But yeah, so sometimes a changein your medical condition may
may change your thoughts on what
Ramon Mercado (26:51):
Yeah. Also, same thing goes with power of
you want done.
attorney if, let's say theperson moved out of the area, or
you are no longer in good termswith that person, I mean, things
happen. And you might want toswitch your power of attorney,
you know, a couple years fromnow.
Beth Brown (27:07):
Okay, so let's close like we always do with some good
resources for folks. I thinkwe've provided some with the
Department of Health and talkingto your primary care doctor. Are
there other places where peoplemight want to go online to learn
more about these advancedirectives, or maybe find some
examples of the forms that theywant to fill out?
Dr. Doug Kuntzweiler (27:26):
The National Institute on Aging and
their website, that they havesome good information, places
like Mayo Clinic, Johns Hopkins,Cleveland Clinic, they they all
will have some information ontheir websites.
Beth Brown (27:38):
Any final message before we wrap up for today?
Dr. Doug Kuntzweiler (27:41):
Well, I've already written my own obituary,
so I'm not pressing anything toanybody else. So if you feel
strongly about what happens toyou, as as you near the end of
your life, whether that comessuddenly or coming slowly, I
think you would do yourself abig favor to put a little
advanced planning and and it'snot just that, then your wishes
(28:04):
are followed. It also makes itso much better for the family.
Because if the family if you'venever said anything about I
don't want to be on aventilator, if you've never said
anything like that, and it comesto that, then the family
sometimes doesn't know what todo. And they it's very stressful
for them. And if on the otherhand, you have told them in no
uncertain terms, I don't want tobe intubated. I don't care. If
(28:25):
that's the end, that's the end.
I don't want to be kept aliveartificially. And a lot of
people feel that way. And if youlet the family know that then
they feel comfortable saying no,they did not want to be
intubated.
Beth Brown (28:37):
Ramon, anything to add to that.
Ramon Mercado (28:39):
I forgot to do the standard disclosure that
this is not legal advice. And ifyou have any legal questions,
please go to your attorney,
Dr. Doug Kuntzweiler (28:48):
I was giving medical advice, and I
stand by it.
Beth Brown (28:54):
All right, thank you, both. And thank you to our
listeners for tuning in. We'regoing to put some of these
resources that both Dr. K andRoman have provided with this
episode so that you can accessthem. And if you have a question
for Dr. K or for any otherexpert that we can trick into
coming onto this program, pleaseemail us at
Q&AwithDrK@mpqhf.org. And thatemail address will be provided
(29:19):
with this episode as well.
Dr. Doug Kuntzweiler (29:20):
Thank you, Ramon. Thank you, Beth.
Ramon Mercado (29:22):
Thank you.
Beth Brown (29:22):
Yes, thank you, both!
Welcome to Q&A with Dr. K, a podcast by Mountain
Pacific Quality Health, where wesit down with Dr. Doug
Kuntzweiler and get your healthquestions answered. Because on
Q&A with Dr. K, the doctor isalways in.
(00:34):
Hello, everyone,this is Beth Brown, your host
and I'm here, as always, withour very good friend Dr. Doug
Dr. Doug Kuntzweiler (00:37):
Thank you.
Ramon Mercado (00:37):
Thank you.
Okay, so today's questionactually does not come from a
Kuntzweiler, Mountain Pacificchief medical officer. But today
patient. We might be cheating alittle bit. But I did get an
is a little bit different,because we also have a special
guest joining us. For our topictoday is also Mountain Pacific
email from one of our colleaguesat Mountain Pacific who often
staff attorney, Ramon Mercado.
So thanks so much for joining usworks directly with patients and
raised this topic as a concern.
both Dr. K and Ramon.
(01:12):
"I have spoken to multiple folksthat either don't know or don't
understand the importance ofpower of attorney and advance
directives. There is a lot ofuncertainty and fear regarding
both. Maybe this could beaddressed on Q&A with Dr. K at
some point." And of course, Isaid, of course it can. And so
here we are. And so let's startas we usually do, Dr. K, with
(01:34):
defining what we're talkingabout. So let's start with the
term advance directives. Sopeople might hear that term,
either advance directives oradvanced care planning. Are
those one in the same? What arewe talking about here?
Dr. Doug Kuntzweiler (01:51):
Well, some of this is semantics. If you're
talking about advanced careplanning, that's sort of an
umbrella term that talks to anyconversation you have with
somebody about what you wouldlike to have happen, you know,
in the event that you can't makedecisions for yourself, but
generally, when people aretalking about advance
directives, they're talkingabout a legal document that
(02:14):
specifies what sort of care theywant, or just as importantly,
what sort of care they don'twant in the event that they
can't make those decisions forthemselves. And people think,
well, you know, I'm 30 yearsold, I can always make decisions
for myself. But if you're in amotorcycle accident, and you're
unconscious, for instance, now,you can't really, you know, if
(02:34):
if you have a severe illness,you might not be able to think
straight in might not be able tomake decisions for yourself. If
you're old, like me, you mightget dementia, and you're not
competent to make decisions. Oryou may have a mental illness
that can flare up and make youmake it so that you're not able
to make decisions for yourself.
So these are legal documentsthat you can fill out and, and
(02:57):
they specify what sort of careyou would like at the end of
life or in the event that youare not able to make decisions
for yourself now.
Beth Brown (03:08):
We don't want to talk about these sorts of
topics. They make usuncomfortable, especially when
we're younger. We're cocky aboutit. We think we're gonna live
forever, we don't need thesekinds of things. And so the
message is planning is betterthan not planning no matter what
your age.
Yeah, none of us are getting outof this alive. And it's you
know, it's it's unpleasant tothink about. But on the other
(03:29):
hand, unpleasant things canhappen if you don't think about
it. So I encourage everybody, nomatter what your age is, it just
will save you and your familysome grief in the long run.
And you mentioned these beinglegal documents or legal
documentation that people canhave. And that's why we have
Ramon on here with us today. Butbefore we dive too deeply into
the legality of some of these,let's talk about all the
(03:52):
different types of advancedirectives that exist, what kind
of planning people can be doingfor the unpleasant or the
unforeseen. So let's start withthe living will. And we also
want to talk about a durablepower of attorney for health
care, there are different powersof attorney. So let's start with
what is a living will?
Dr. Doug Kuntzweiler (04:09):
So I'm gonna give you a little
thumbnail history of livingwills. Up until the 1950s or so,
And so some of the differentdirectives go into that living
this wasn't an issue, becausepretty much medical care wasn't
very good. We didn't have a lotof resuscitative measures. We
weren't prolonging people'slives, you know, by putting them
on ventilators or treating theirheart attacks and their strokes
(04:30):
aggressively. We just simplydidn't have the technology. So
you either lived or died. Itwasn't, wasn't a big issue. But
in the 1960s as medical care gota lot more sophisticated, and we
started putting people who werein comas on breathing machines,
and we started treating themaggressively with all kinds of
medications and new surgicalprocedures, and we started
(04:52):
putting stents in their pluggedcoronary arteries and saving
them from heart attacks, and sosuddenly, it became an issue
because it's not always clearexactly what what we shouldn't
be doing. And so that's whenliving wills, late 60s, that
term sort of came into vogue.
And, and the idea was that, justlike you write out a will that
directs what you would like tohave done with your estate when
(05:15):
you died, the living will wasdesigned to direct the sort of
care that you wanted, or thesort of care that you didn't
want. And so it was written upjust like a will.
will?
Yeah, and, and a lot of peoplewhen they when they did that,
(05:35):
they just said sort of generalthings like in the event that
there's not hope for ameaningful recovery, I want all
care stopped, you know, kind ofgeneral things like that. But
it's a lot more complicated thanthat. And things got a lot more
sophisticated as time went on.
We'll we'll talk about that thedurable power of attorney, and
Ramon, you can you can talkabout this, maybe but as I
understand it, that is basicallya legal surrogate.
Ramon Mercado (05:58):
Yeah, durable power of attorney, it's it's a
document where it's, it's anadvance directive on its own.
But also, it's a document whereyou designate an agent to act on
your behalf, let's say if youbecome incapacitated, or you are
unable to make decisions foryourself regarding your health
care, then that agent steps intointo the patient's role and has
(06:23):
the authority to make, to makeevery every medical decisions,
basically, they're treated thesame as the patient would for
terms, in terms of HIPAA privacyand everything. So they do have
quite a bit of power here.
Beth Brown (06:37):
And people can put different people in different
roles of a power of attorney,correct, Ramon? This is specific
to a power of attorney of healthcare, but you can have a power
of attorney for differentaspects of what's happening with
your life.
Ramon Mercado (06:50):
Yeah, you can have different power powers of
attorney. You can have, and youcan have one for medical
purposes. And then you can haveone for, let's say, handling
your finances or makingdecisions outside of the health
care realm.
Beth Brown (07:04):
Can anyone be my power of attorney for health
care? Or do they have certainskills or knowledge?
Ramon Mercado (07:10):
I wouldn't say that they need certain skills or
knowledge. The only requirementsthat they are of legal age to
enter enter into the agreements,because this is basically an
agreement between you and theagent. Also, that they that
they're willing and able to dowhat it's requiring them to do,
(07:32):
you can't you can't justdesignate someone as your agent
who doesn't know about it, or isnot willing to make those
decisions whenever, whenever thetime comes. Usually someone that
lives close, close to you whereyou are, you don't want to be in
Montana and have somebody on theother side of the world making
(07:53):
these decisions for you. That'susually a good idea. Most
importantly, someone that youtrust that they're going to be
looking out for your bestintents, intentions when, when
the time comes.
Beth Brown (08:05):
We're going to talk about some of the different
types of advance directives oradvanced care planning people
can put into place. But let's goback to a high level spot, Dr.
K. What happens if someone doesnot have advance directives in
place, and they're in asituation in a hospital where
they cannot make decisions forthemselves?
Dr. Doug Kuntzweiler (08:22):
Well, I can tell you that I've been
there and done that in theemergency department, which is
why I'm fairly passionate aboutthis whole topic. Because in
that event, all bets are off asto what's going to happen.
People would come into theemergency department by
ambulance, maybe CPR had beenstarted out in the field by the
medics, and if you don't knowthem, and if there's nobody
(08:45):
coming forward and saying I havedurable power of attorney, and
there's no obvious living willanywhere, then you have to try
and make a judgement on yourown. You try and get as much
information about the patient asyou can, for instance, do they
have terminal cancer, and and weprobably shouldn't do anything
to resuscitate them. You know,their age plays into it,
(09:08):
whatever you can learn abouttheir past health care, their
medical condition plays into it.
And I would always just sort ofthink, well, if I were in this
situation or if this were afamily member, what what would I
want done? What do I think wouldbe the best thing to do? And so
that's, that's all you can do.
Sometimes you could try and makephone calls, you could try and
call their their physician ortheir primary caregiver, or if
(09:31):
they have a spouse, you couldtry and contact their spouse
because it's oftentimes theydidn't, you know, the spouse or
next of kin wouldn't come inwith the ambulance, and
sometimes there was no next ofkin. Sometimes it was the
neighbor, you know, and theneighbors would kind of shuffle
their feet and say, Well, Idon't really know him that well,
but we say hi in the morning toeach other and, you know, and so
you wind up just doing what youthink is best, which is an
(09:54):
uncomfortable feeling foreverybody. And I never got sued
over this, but I had people whothought about it, because either
I resuscitated somebody thatthey thought shouldn't have
been, or vice versa. I didn'tresuscitate somebody who they
thought should have beenresuscitated. You know, it puts
the primary caregiver in areally awkward position, because
(10:15):
you have to just try and do thebest thing, you know that you
think at the time. And that'sall you can really do. So if you
have something bad happen, andyou don't have a living will, or
you don't have a durable powerof attorney, it's a crapshoot as
to what's going to happen.
Beth Brown (10:31):
You're sort of at the mercy of someone's most
educated best guess. On the flipside of that, then, if you do
have a living will or advancedirectives in place or a power
of attorney, does that guaranteethat your wishes are going to be
carried out by a doctor who ismaking those decisions?
Dr. Doug Kuntzweiler (10:49):
Oh, in your dreams. Yeah, I wish, I
wish I could say that was thatwas true, but there are no
guarantees. And there certainlyare no guarantees in medicine,
because a lot can go wrong. If,if it happens, let's say you're
in an automobile accident out onthe road, and you come in by
(11:10):
ambulance, and and we don't evenknow who you are, at that point,
you know, you go through theirID, and maybe you can figure out
their name, but you don't knowwho the contact people are. And,
you know, there's all sorts ofsituations come up, where even
though they had advancedirectives, you might not know
that or you might not be able toaccess them in time to make a
(11:30):
decision. And from the ERperspective, is it often you
know, we didn't have much timeto make a decision, those are
usually critical situations. Butthere are there are less dire
circumstances where, cancer isthe one that comes to mind,
where somebody has a cancer andit's been treated. And maybe
it's been in remission for awhile, and then it comes back.
And you know, it's resistant tothe next line of treatments. But
(11:52):
at any rate, you have some time,you have weeks, maybe a month or
two, to think about that and totalk and make sure that
everybody that's important inyour life knows what your wishes
are, and that you make one ofthese legal documents so that
your wishes will be respected.
Then you have a much betterchance of that happening. But
even in that situation, I'veI've seen people who do all of
that, and then there istypically some remote relative
(12:16):
who calls and thinks that theyshould be treated aggressively,
or vice versa. And so the familysometimes has an inner turmoil.
And we would sometimes get stuckin that situation in the ER that
the person had a very welldocumented desire. And we would
try and follow that in the ERand a family member would say,
(12:38):
No, no, no, no, I want you to doeverything to everything. And so
you would have to sit down andsay, Well, I understand how you
feel. But it's quite clear thatyour loved one did not want that
this is what they said they wantit and we're going to honor
that. And sometimes that wascould get pretty uncomfortable
too. But you try and do whatpeople want.
Beth Brown (12:58):
So it sounds like communication is a big part
there, too, once you do getthose advance directives in
place. So from that healthperspective, you know, where
it's uncomfortable when youdon't have them in place, it can
be tricky when you do have themin place. Ramon, from that legal
perspective. Why do you think -you know, Dr. K has said that
he's passionate that peopleshould have advance directives
(13:20):
in place. From your perspective,why do you think it's important
for people to have advanceddirectives in place?
Ramon Mercado (13:26):
Dr. K covered most of them, and the legal
reasons are right, right in linewith what he mentioned there. I
was gonna mention another thingwhen you file an advance
directive you need to have a twowitnesses, at least in Montana,
two witnesses, sign the advancedirective. And also going back
(13:47):
to what Dr. K was saying aboutthe the accessibility of some of
these forms, that Montana haswhat's called the Montana End of
Life Registry. And Dr. K, youcan shed some some light on
this. I don't know if doctorshave this available to them
right on the spot, but medicalproviders and people with the
patient's information can canaccess it, and you file you can
(14:12):
file your medical directivesinto the Montana and a flat
registry. That's a good databasethe state has.
Dr. Doug Kuntzweiler (14:19):
Yeah, and that gets back to what I was
talking about that sometimesyou've made one of these
documents, but it isn't reallyaccessible. So it's important to
make the document, but it's alsoimportant then to talk to the
family or your friends orwhoever you expect is going to
be around, certainly to yourdurable power of attorney, if
you execute a durable power ofattorney. Sit down and talk with
(14:40):
them and make sure theyunderstand exactly what you want
and then make sure that thosedocuments, people know where
those documents are so that whenthe ambulance shows up, they can
be produced and then then youknow what to do. But I think
it's it's important to talkabout these things. What do you
really want. As you get older,and if you have, you know, an
(15:03):
incurable illness or what looksto be a terminal illness,
typically you have time. Andpeople often do sit down and
talk with their family aboutwhat they really want done. And
that that's the best casescenario. But even young people
really should have some idea ofwhat they would like to have
done. And you can't just end itthere. You can't write out a
(15:24):
will, get it notarized and stickit in a box somewhere and nobody
knows where it's at. You need tohave somebody who knows what
your wishes were and knows whereto find the documents that
you've executed.
Ramon Mercado (15:35):
Well and also, there's the, what they call the
POLST, that there that's acronymfor physician orders for
life-sustaining treatments,that's actually a physician's
order. And it becomes the firstpage of your medical record. Is
that right?
Dr. Doug Kuntzweiler (15:52):
That's absolutely correct. And there is
a national POLST form. And it'spretty cool. I understand that
some states have their own, sothere's some variations, and you
can get them in foreignlanguages and all sorts of
things. But it goes through invery great detail. It's a
checkbox sort of thing andplaces where you can fill in the
blank, but, but it goes in greatdetail and exactly what your
(16:14):
wishes are. People say thingslike, Well, I'm going to have
DNR tattooed on my chest, do notresuscitate. So nobody will be
pumping on my chest when I dropover. It's a lot more
complicated than that. It's if Ihave a terminal illness, and I'm
kind of failing and people can'ttake care of me at home, and I
go to the hospital. Okay, well,do you want IV fluids? Some
(16:35):
people do. Some people don't.
Some people say, well, that'slike offering a sip of water to
a dying person. That's a carecomfort. Okay, but some people
say no, that's too aggressive. Idon't want to be kept alive by
any artificial means. And somepeople say, Okay, if you have a
pneumonia on top of whateverelse was going on, do you want
us to give you antibiotics totreat that? Or if you have, you
(16:55):
know, a urinary tract infectionas part of your whole medical
complex thing? Some people say,Yeah, sure. Because that's a
simple thing to do. And thatmight make me more comfortable,
and other people say no, I don'twant you to interfere with
nature, let it take its course.
These are things that peopledon't really often think about,
(17:16):
or that it doesn't occur to themthat yeah, can get pretty
complicated. What exactly do youwant? Do you want a feeding tube
in the event that you can't eatlike you normally do? Then even
in pain, you say, well, I don'twant to suffer. Okay, well, what
level of pain control do youwant? Do you want to be
unconscious? And that's, that'sthe old joke that, you know, I
(17:37):
don't mind dying. I just don'twant to be there when it
happens, you know, and so somepeople say, just knock me out,
okay, when other people say, No,I want to be able to talk to
family and friends. And youknow, it can get pretty
detailed. And the only waythat's going to happen, is if
you think about it ahead oftime, and you convey it to
someone and the POLST, I agreewith Ramon. It's a physician's
(17:59):
order. So it pretty much has tobe honored. As long as you know,
it's signed by everybody. Andthat's the closest you're gonna
get to a guarantee, I would say.
Ramon Mercado (18:08):
Yeah, I agree with that.
Beth Brown (18:10):
So it's so objective. There's so many
shades of gray depending on whatan individual wants, and you
touched on so many differentthings. So I don't want to lose
track because you mentioned aDNR. So for those folks who
don't know, that's probably oneof the most common that I know
of the ones we're going to talkabout today. But what is a DNR
and when might a DNR come intoplay?
Dr. Doug Kuntzweiler (18:31):
The DNR stands for do not resuscitate.
And typically, if somebody has aterminal illness terminal
condition, they execute a DNRand they get it notarized and
signed and somebody can speakfor them. So yeah, they didn't
want to be resuscitated. Again,that's still sort of what it
means to me in the ER is I'm notgoing to put a tube in their
(18:54):
windpipe and artificiallybreathe for them, put them on a
ventilator, a breathing machine,I'm not going to do that. If
their heart stops, I'm not goingto do anything to try and
restart it. I'm not going to getthe electricity paddles out and
be, you know, shocking theirheart. Sometimes I leaned
towards IV fluids are a comfortmeasure, you would you would
offer a dying person a sip ofwater. And so I often would
(19:18):
start an IV and I didn't thinkthat was too aggressive. And if
it seemed like they wereuncomfortable or seemed like
they were in pain, and if theycouldn't speak and if you don't
have any advanced directives, Iwould usually give them a little
bit of pain medication or alittle bit of sedation. You
know, just try and do commonsense sorts of things. But it
does get pretty complicated.
Anyway Do Not Resuscitatedoesn't tell you very much. It
(19:40):
means don't pump on their chest.
Don't shock them; don't put atube in their trachea, but then
there's a lot of other stuffthat is that really
resuscitation or is thatoffering comfort.
Beth Brown (19:51):
Lesser known ones maybe are DNIs and DNHs. DNI
stands for do not intubate andDNH stands for do not
hospitalize, so someone doesn'teven want to go to the hospital
in the first place. So whenshould people put these types of
orders in place?
Dr. Doug Kuntzweiler (20:07):
Well, I think they should put them in
place if that's really how theyfeel about things. And sometimes
you I mean, if I'm young, yeah,and I'm, I have, let's say, a
motor vehicle accident, I wantto go to the hospital, because I
don't know, maybe I maybe I'mgonna recover from all of this,
you know, or maybe I will havemeaningful life after. So you
just don't know. But if you are,let's say you're in a long-term
(20:28):
care facility. And you know,you're sort of winding things
down, you're comfortable, thatis your home at that point,
you're comfortable there. Youdon't want to be taken by
ambulance to a noisy ER, andthen sit around in the ER for 12
hours, and then eventually getadmitted to the hospital where
you got a bunch of doctors whoyou don't know, and you know,
(20:48):
it's not very comfortable. Andso some people would just assume
not be hospitalized, whatever'sgoing to happen is going to
happen anyway. And they wouldsay, just leave me in my home or
leave me at my daughter's houseor leave me in the long-term
care facility. These are donots, and they are specific: do
not intubate, don't put me on abreathing machine, do not shock
my heart do not hospitalize me,or some people say, yeah, you
(21:11):
hospitalize me, but I was inintensive care before and it was
a nightmare, and I don't everwant to go back to intensive
care and say, Well, okay, thenthere's certain things we can't
do in a regular hospital bed.
And you know, as long as theyunderstand that, that's fine.
Beth Brown (21:25):
And you both talked about POLST and how helpful that
part can be. I also know there'sa MOLST, which stands for
medical orders for lifesustaining treatment. Are those
the same?
Ramon Mercado (21:35):
I think those are terms are used interchangeably.
Dr. Doug Kuntzweiler (21:37):
Yeah, I agree.
Beth Brown (21:39):
Okay, great. So we've talked about living wills,
we've talked about power ofattorney and DNRs and DNIs and
DNHs and the POLST. Where doessomeone get started? And Ramon,
maybe you can kind of give somedirection here. What should
someone do to start with someadvanced care planning and get
getting some of these orders andthese directives in place?
Ramon Mercado (21:57):
The first step will be to talk to everybody
that's going to be involved withthis in this process. The more
people you talk about it, thebetter. That's how I would
approach it both professionallyand personally. The then the
next step, once you haveeverything in order, and you're
you know exactly what you want.
There's there's a lot of formsonline that people can find on
(22:19):
how to do estate planning andadvance directives. I know that
Montana for Montana DPHHS,Department of Public Health and
Human Services has, uh, has allthese forms available on their
website. Also, in Montana, agood resource to that we have is
the Montana State UniversityExtension program, they have a
very comprehensive estateplanning section, that mean they
(22:42):
have every single form that youcan possibly imagine. And they
keep coming up with new stuffalmost every year. So you can
download forms for powers ofSo a lawyer isn't necessary but
could be helpful if needed couldattorney. I have used some of
those myself for some clientsbefore. And it's it's very
useful. So Montana does have alot of resources. I don't know
about other jurisdictions. Butlet's say you do all the
(23:06):
research, you find a bunch offorms online, they all kind of
do look a little different. Ifyou find yourself in a spot
where you don't really know whatyou're doing, or you feel like
there's something wrong, justtalking to an estate planning
attorney is probably a goodidea. Most times, it won't get
to that point because some ofthese forms are pretty self
(23:29):
explanatory. And most of theforms have a package that out
that describes, you know, lineone means this, line two means
that you know, it's, that'sthat's how I would approach it.
be helpful.
Yeah.
Beth Brown (23:48):
Okay. And for those listeners who are not in
Montana, their State Departmentof Health is probably a good
place to go at least initially.
Ramon Mercado (23:55):
Most likely.
Yeah.
Dr. Doug Kuntzweiler (23:57):
I would add that I think most primary
care physicians or primary carepeople will have dealt with this
know in their practice and sothey should have some knowledge
about where you can acquiretheir forms and you probably
should sit down and talk withhim anyway and make clear that
if you have a primary care givermake make it clear that they
(24:18):
understand what your wishes are.
Beth Brown (24:20):
Perfect. Okay, so that's another great resource -
your primary care maybe orDepartment of Health. So once I
have my documents that I thinkthey're complete, I'm I'm ready.
You talked about sharing thoseor having that communication.
Sounds like primary careprovider is definitely someone
you want to talk to. Who elseshould have these forms either
(24:40):
on file or saved somewhere sothat they're accessible and
ready to reference should anemergency or something happen?
Ramon Mercado (24:47):
If you are designating an an agent to be a
power of attorney, that person,that person should have all
these documents. One thing Iwould not ever recommend would
be putting these things in asafe or a safety deposit box.
It's just not a good idea justto same with a will, getting it
get into it when you'reincapacitated is is just a
(25:09):
nightmare. So most people keepthem on their fridge or on the
on, like behind their door intheir bedroom. I mean, I've,
I've heard many spaces wherepeople who are accessible, I
would just let the people thatare involved in this whole
process know. Everybody who wasinvolved.
Dr. Doug Kuntzweiler (25:30):
Yeah, if there's somebody else in in your
home with you, you know, makesure that they know where the
documents are. If you're in along-term care facility, you
know, the nurses should haveaccess to that. It should be in
your chart. If you waited tillyou got in the hospital, it's
going to be in your chart, thetypically a hospice nurse or
(25:51):
somebody like that will come andsit down and talk with you and
help you fill out the documents.
And then it'll be on your chart,but but you have to make sure
that there's somebody who'slikely to be around. If it's not
somebody that lives with you,maybe a neighbor or a friend or
somebody, much like you would dowith an emergency number to
call, you know, people ask youthat all the time, in case of an
(26:11):
emergency, who should we call,and you tell them oh, call my
daughter, call this person orthat first of all, those people
should probably have a copy orhave access to it or at least
know where it's at.
Beth Brown (26:25):
Good advice. Can you think of a time when someone
might need to change theiradvance directives, or they
would want to edit their formsfor any reason?
Dr. Doug Kuntzweiler (26:34):
Oh, yeah, sometimes a medical condition
changes. Yeah. Sometimes thingslook better. Sometimes they look
worse. Sometimes they're grim.
But yeah, so sometimes a changein your medical condition may
may change your thoughts on what
Ramon Mercado (26:51):
Yeah. Also, same thing goes with power of
you want done.
attorney if, let's say theperson moved out of the area, or
you are no longer in good termswith that person, I mean, things
happen. And you might want toswitch your power of attorney,
you know, a couple years fromnow.
Beth Brown (27:07):
Okay, so let's close like we always do with some good
resources for folks. I thinkwe've provided some with the
Department of Health and talkingto your primary care doctor. Are
there other places where peoplemight want to go online to learn
more about these advancedirectives, or maybe find some
examples of the forms that theywant to fill out?
Dr. Doug Kuntzweiler (27:26):
The National Institute on Aging and
their website, that they havesome good information, places
like Mayo Clinic, Johns Hopkins,Cleveland Clinic, they they all
will have some information ontheir websites.
Beth Brown (27:38):
Any final message before we wrap up for today?
Dr. Doug Kuntzweiler (27:41):
Well, I've already written my own obituary,
so I'm not pressing anything toanybody else. So if you feel
strongly about what happens toyou, as as you near the end of
your life, whether that comessuddenly or coming slowly, I
think you would do yourself abig favor to put a little
advanced planning and and it'snot just that, then your wishes
(28:04):
are followed. It also makes itso much better for the family.
Because if the family if you'venever said anything about I
don't want to be on aventilator, if you've never said
anything like that, and it comesto that, then the family
sometimes doesn't know what todo. And they it's very stressful
for them. And if on the otherhand, you have told them in no
uncertain terms, I don't want tobe intubated. I don't care. If
(28:25):
that's the end, that's the end.
I don't want to be kept aliveartificially. And a lot of
people feel that way. And if youlet the family know that then
they feel comfortable saying no,they did not want to be
intubated.
Beth Brown (28:37):
Ramon, anything to add to that.
Ramon Mercado (28:39):
I forgot to do the standard disclosure that
this is not legal advice. And ifyou have any legal questions,
please go to your attorney,
Dr. Doug Kuntzweiler (28:48):
I was giving medical advice, and I
stand by it.
Beth Brown (28:54):
All right, thank you, both. And thank you to our
listeners for tuning in. We'regoing to put some of these
resources that both Dr. K andRoman have provided with this
episode so that you can accessthem. And if you have a question
for Dr. K or for any otherexpert that we can trick into
coming onto this program, pleaseemail us at
Q&AwithDrK@mpqhf.org. And thatemail address will be provided
(29:19):
with this episode as well.
Dr. Doug Kuntzweiler (29:20):
Thank you, Ramon. Thank you, Beth.
Ramon Mercado (29:22):
Thank you.
Beth Brown (29:22):
Yes, thank you, both!
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