Some of the most important — and most difficult — conversations
you'll ever have are about your wishes for end of life. During a free
online health lecture, BCH Ethics Committee Member
Jean Abbott, MD, and BCH Chief Medical Officer
Ben Keidan, MD, broached the topic of why you should talk about wishes for your final
days, and how to go about it.
Not One, But Many Conversations With Your Doctor
Many people avoid discussions about end-of-life treatment, largely because
talking about death can be uncomfortable and scary. In fact, one study
found that only 7 percent of people have talked with their doctors about
what’s important to them.
“It’s one of those things people don’t like to talk about
and then we have this black box,” said Dr. Keidan. “We want
to take your wishes into account, but we'll never know what they are
if you don't share them with us. So, it’s important to have
Dr. Keidan said at the heart of these kinds of conversations is finding
out what matters most to you. “We don’t take a side on this.
If your preference is that you’d rather your life be potentially
shorter but not suffer, that’s critical for us to know. If comfort
is less important than extending your life, we want to know that, too.
Don’t feel reluctant to tell us either way.”
Keep in mind that "the conversation" with your doctor usually
ends up being a series of conversations — all of which become easier
once you start. You can initiate the first conversation at your next wellness
or routine office visit. But you don't need to cover everything right
then. You can schedule more lengthy discussions later during what are
called advance care planning appointments.
"Your wants and priorities are then included in your medical record
in case you're unable to speak for yourself," Dr. Keidan explained.
He said another thing to keep in mind is that what matters most to you
for end-of-life care can change over time, so the conversation with your
doctor needs to be ongoing.
Designate a Medical Decision Maker
Talking with your loved ones and designating a medical decision maker is
another important step in making your wishes known.
"Over half of us will not be able to participate in decisions near
the end of our lives, which is why it is so important to designate someone
who can talk about your goals, values and preferences. It’s also
important for the family, because a limited understanding of a loved one’s
end-of-life care wishes can lead to serious distress,” Dr. Abbott stated.
There’s a Colorado law that makes it especially important to name
a person who would speak on your behalf.
Dr. Abbott explained, “In Colorado, if you don’t designate
the person who you want to make decisions and you haven’t put it
in writing, the law says no one can automatically make decisions for you
– not even your spouse or adult children.”
Instead, Colorado law tells doctors to locate all “interested persons”
– usually family members, but also close friends – and select
one to serve as a patient's health care agent.
“The health care provider gathers people who care about a patient
and, with the doctor, they decide as a group who can best speak for the
patient. Everyone has an equal voice at the table. Unfortunately, family
members often disagree,” said Dr. Abbott.
Watch Drs. Abbott and Keidan's lecture- "Talking About End-of-Life Care."
How Do You Prepare?
Start thinking about who you would you want to make medical decisions for
you if you couldn't. Dr. Abbott said you should choose someone who:
- Knows what matters to you.
- Can make difficult decisions based on what’s learned from your medical team.
- Can speak for YOUR interests (rather than their own, perhaps).
- Is available and, in the best case, geographically close by.
As you prepare for your end-of-life conversations with your medical-decision
maker, consider what matters most to you such as:
- What kinds of treatment would you want or not want (for example, resuscitation
if your heart stops, breathing machine, feeding tube)?
- How long do you wish to receive aggressive medical care?
- Where would you want or not want to receive care (at home, in a nursing
facility, in a hospital)?
- When would it be okay for your doctor to shift from a focus on treatment
to a focus on comfort care alone?
“There are no correct answers to these questions. But sharing the
answers can relieve your agent or loved one from having to make very hard
decisions without knowing what your answers would be,” said Dr. Abbott.
Put Your Wishes in Writing
In Colorado, there are four main types of
advance directives, which are written instructions for a person’s end-of-life health
CPR directives are a medical order that instructs providers not to attempt resuscitation
if a person’s heart or breathing stops.
Living Will tells medical providers what treatments you would want them to use or
not to use if you are “terminal” or in a vegetative (permanently
unconscious) state. However, living wills are not enough to allow someone
to make medical decisions on behalf of another.
Medical Orders for Scope of Treatment (MOST) is for those who are seriously or chronically ill and in frequent contact
with providers and convert your wishes into orders to be followed by health
care professionals based on your current health.
Medical Durable Power of Attorney (MDPOA) allows people to name a person to make medical decisions when they are
Medical Durable Power of Attorney (MDPOA) form is the written instruction for who you want to be your decision maker
– the person who speaks for you and knows what makes life meaningful
for you,” Dr. Abbott said. “And this is the most important
document you should complete.”
Dr. Abbott also stressed that you should consider providing your medical
decision maker leeway.
“We aren't good at predicting what we might want in the future.
What you wrote down five years ago may not be in your best interests right
now,” she said. “To give your surrogate leeway, you can write
in the MDPOA form ‘I’d like my agent to be able to make decisions
with my doctor that are in my best interests knowing what my values and
what matters me - and not necessarily the numbers I put in my advanced
She also stressed not to forget to talk to your agent with MDPOA authority
about what is important to you.
(Click here to down load a Medical Power of Attorney form.)
How COVID-19 Has Impacted Conversations
COVID-19 has pushed end-of-life care planning as a key topic of conversation.
“The pandemic is making people seriously reflect on how they want
the end of their lives to look,” Dr. Keidan said.
According to Dr. Keidan, a lot of conversations are about ventilators.
With national attention on shortages of ventilators as a result of COVID-19,
people are now thinking about the possibility of ending up on one.
Dr. Keidan added, “We’ve had a small number of COVID-19 patients
treated at BCH, and engaged in these end-of-life conversations. Many tell
us they do not to spend their last week of life in the ICU on a ventilator.
And, we honor their wishes.”
Take the time now to plan for your future. Schedule an advance care planning
appointment with your doctor. If you are a Medicare beneficiary, Medicare
will cover an appointment for advance care planning.
View a PDF of slides from Drs. Abbott and Keidan's lecture on “Talking to Your Doctor
About End of Life Care.”
Medical Durable Power of Attorney (MDPOA) form