Guest: Dr. Christopher Kearney
Presenter : Neal Howard
Guest Bio: Dr. Christopher Kearney received his medical degree from Albany Medical College and has been in practice for more than 20 years. He is one of 9 doctors at MedStar Good Samaritan Hospital and one of 25 at MedStar Union Memorial Hospital who specialize in Family Medicine.
Segment overview: In this segment, Dr Christopher Kearney, regional director of palliative care, MedStar Health, Baltimore gives advice on advanced care planning for seniors.
Health Professional Radio – Advance Care Planning for Seniors
Neal Howard: Hello and welcome to this Health Supplier Segment on Health Professional Radio. Thank you for joining us once again today. Our guest is Dr. Christopher Kearney. He is Regional Director of Palliative Care at MedStar Health in Baltimore. And he is here today to talk with us and give us some advice on advance care planning for seniors. Welcome to Health Professional Radio Dr. Kearney.
Dr. Christopher Kearney: Thank you.
N: Senior care planning, what type of care are we talking about? Are we talking about healthcare? Financial care? All of that or what?
K: Generally, healthcare would be the concern that we have most prominently in and around our hospital setting. I’m a family doctor actually by training but I’ve been doing geriatric medicine in the city of Baltimore for about 30 years. Very common issues among our older population is this decision-making about their healthcare as their age and as their health progresses. There are options that need to be determined and best determined well before somebody’s seriously ill or in the hospital.
N: So when we’re talking advanced care planning, how advanced are we talking about? And does the patient themselves initiate this planning?
K: Hopefully they would be the one’s doing it and again, in the doctor’s office or even at the kitchen table would be the ideal place not in the intensive care unit or underway to the operating room in a care hospital. The issues have to do with the patient’s’ ability to control their care and that’s one of the things our older patients or all of us actually fear is that somehow will lose control of our care as we get more ill. And so this idea of advanced care planning which actually is not so ancient, it’s relatively recent came up with this Cruzan Case, Nancy Cruzan in 1993, young woman who is vegetative and the Supreme Court in the United States finally said, ‘You have the right to create a document that tells the doctors and your family what you want even if you can’t talk anymore’. So, this happened in all across the United States and this was the beginning of advanced directive and an advanced directive has two parts to it. The first part is you are asked to appoint someone who would be your spokesperson in any event that you are no longer able to speak for yourself that could be a spouse or obviously the adult child or could be anyone that you trust. The idea is that they will know your wishes and if such time comes, they will not be making decisions about your life but they will only be reflecting the decisions you told them you wanted. So, that person would be carrying out your wishes. And that’s a great idea and it has worked very well over the years although it’s not, of course, universal because many, many people don’t get around creating that document. The second part of the advanced directive is used to be called, ‘The Living Will’ and that was a part of the document where you could spell out in detail if you get in certain circumstances you would want this done if you got into another condition maybe you would want something else done. And that’s also a useful document but it’s very hard for us to predict the future exactly. So, that’s why the combination of both the instructions or living will and the healthcare agent we now call it or power of attorney for healthcare is what is the ideal arrangement.
N: And when you say ‘Power of Attorney’, we get pictures of legality. These documents and these directors that you’re talking about, they are always up held legally. Is that correct? Or how many challenges can a person bring and can those challenges (crosstalk)?
K: That’s correct, they are legal documents. The term ‘Power of Attorney’, we moved the way from cause it was confusing because there is a power of attorney for financial dealings as well. So for healthcare, the term ‘Healthcare Agent’ was substituted it in many areas sometimes they call it ‘The Surrogate Decision-Maker’. It is a legal document and in most places, I believe all places now, it is a document that can be created literally at the kitchen table. It does not need to be notarized, it doesn’t need to be done with an attorney or with a court document. The only legal requirement generally is that two adults have witnessed the document and they say that you were in your right mind when you completed the document. Once that’s done, that’s a legal document and you recognized across state lines, generally across United States.
N: Healthcare implies financial cost and responsibility. Should the person who’s executing these documents from a healthcare standpoint also coordinate with whomever is going to be handling the patient’s finances to make sure that those healthcare directives are financed properly.
K: Yes. That’s a very good question. You’re getting into a tricky realm where in general, in our world, we try to keep these things separate although we know they are not separate. Most healthcare decision-making in the United States is actually not honestly financially based. When you get into extreme treatment modalities, transplants, and exotic treatment, finances do come into the picture. But generally, for the routine care that I’ve seen over the last 30 years for seriously ill patients, older patients in the hospital, the actual insurance, the payments for care is usually not the issue. The issue more commonly gets to be the value of the treatment itself. As the patient gets further and long, what will the next trip to the hospital mean? What would the next surgery mean? What about putting a feeding tube in someone who may have stopped eating naturally which all alzheimers or dementia patients eventually get there? What about chemotherapy or the next round of chemotherapy? What about care in the ICU being put on a ventilator, being on a breathing machine, those kind of things. All get to be very important issues for the seriously ill. All of them have great benefit in some cases. In other cases, they proved to be more suffering than anything else.
N: In your experience, talk about how to get the conversation started with the patient if they are maybe a little bit reluctant and have been extremely independent in their entire life, basically taking care of everybody in their family and now all of the sudden the tables have turned. How do you get the conversation started especially if you are the kid or the grand child of the patient?
K: I think generally, this is isn’t everybody’s favorite topic. Although in my experience again, particularly as people get older they tend to be much more realistic and they know something’s coming. So they do have distinct ideas about this and you’re right, there has to be permission. Someone has to say, ‘This is okay to talk about these kind of things’. So it wouldn’t be uncommon for me to say, let’s for an example, if you’re out shopping at the giant supermarket tomorrow afternoon and you fall out in the parking lot, you will find yourself in hospital somewhere and if you’re no longer able to communicate or tell people what you want, the doctors, everybody is going to be wondering, ‘What are we doing? What is the right thing to do? What would this person want in terms of their care?’ So I say that you are doing a favor to your family if you at least take time to sit down with them and appoint someone to be the healthcare agent or to be your spokesperson. It clears the air for everyone, it lets the doctors know who to talk to and the gift that I still think it’s the gift, is if you tell your family members what you actually would want. They’re not on the hook. They not having to make a very difficult decision about someone else’s life. They’re just carrying out your wishes. So in some ways, it’s a gift to your family to do it.
N: There at MedStar Health, do you engage in any type of pre-discussion counselling for the adult children of the patient? Maybe the patient is in the throes or Alzheimer’s or maybe getting there. Is there counselling that you offer as the physician who specializes in this type of thing or MedStar as a whole for getting that conversation started?
K: Well I’m not sure. Even though I’m a MedStar personnel and I can’t claim we do it any better than anyone else. I think you’re exactly right in what you’re saying, we should be doing. I think in general, this is an outpatient or let’s say primary care activity, is where this should be happening. I think it is done much more than it had been in the past. I think the availability of the advanced directive in Maryland and in a number of other States, there’s another instrument available now that is called, I see the name, in Maryland it’s called ‘MOLST’ and it stands for Medical Orders for Life-Sustaining Treatment. Now, this thing is an instrument. It was originally used in California, it’s probably roughly 20 states in the United States. This is slightly different than the advanced directive that I was referring to or the appointment of the healthcare agent because this isn’t actually a doctor’s order. It’s a legal order that’s written that would be adhered to, would be respected no matter where the patient was. So, it details even more closely the kind of things I’m talking about and it’s usually reserved for the patient who is closer to the serious problems – maybe a person who’s been in a nursing home, maybe person who’s getting frailer who really maybe facing these serious life-ending decisions. This document with the doctor and with the family, you can actually put orders into the medical record that says ‘I want this’ or ‘I don’t want that’. It’s even a stronger document of what the patient’s wishes are. It can be altered of course. But once it’s done for instance, it is honored even if a patient is at home or if a person is in an ambulance, or we did it in MedStar and the person wind up at John Hopkins or the University of Maryland. The document that has been created would be respected as a legal order, doctor’s order in the state of Maryland or whatever state you’re in. So that’s called MOLST or in some states POLST for physician orders. That’s another modality that you might hear about our people could be aware of.
N: If a patient who has been coming to see a physician for many years, but for whatever reason, they don’t have any family. Is the physician, their general practitioner, in a position to be the person that is going to carry out these directives for that person even if that person is at another facility and another state? Can that facility or that state call on this doctor to be, for lack of a better term that person’s next of kin?
N: That’s right. That would be a little bit unusual for the doctor actually to act in that role that usually discourage that. But you’re pointing to a common issue where what I’ve described sounds very good and very useful and it is when it’s done right. Many patients still arrive in hospital without these documents, without advanced planned documents, certainly without these MOLTS forms. And family, it can be a quite of variety of things now. As we all know, many people arrive without immediate family and without someone knowing exactly what their wishes are. So, the medical teams and the doctors in these hospitals are very often in effect of trying to make good ethical decisions about what is the right thing to do that would still be beneficial but not going too far in continuing suffering. It can be complicated. For instance, a doctor, myself, I can certify in the hospital that something is medically ineffective to do that we won’t do it because it won’t work. And if I have a second doctor agree with me, then we are essentially protected by law and that is in the state of Maryland but many other states have something like this. So doctors can and do when they have to say, ‘Okay, I’m going to make the decision and have and certify that I’d think this is the right care and doing something else will be the wrong care or it will be too far’. So we do that in not unusual, not rare circumstances. Every hospital does that.
N: Where can our listeners go online and get more information about MedStar Health and advanced care planning for seniors?
K: Well, MedStar Health has a very extensive website that you would find many of these questions answered in better details than I just did. I think in the state of Maryland, where we are, in general has very good information but this would be true I think and practically any state. If you went Google, basically advanced directive, you would be overwhelmed with information. The actual forms are available. Every state creates them 5 wishes, a good document that many people are aware of that goes into some very good detail about how to make these decisions for the family, for the patient at home. So those would be places I would look.
N: It’s been a pleasure doctor.
K: Thank you. I’d enjoyed talking about topic I like to talk about.
N: Great. You’ve been listening in the Health Professional Radio, I’m your host Neal Howard, here on this Health Supplier Segment. I’ve been talking with Dr. Christopher Kearney, Regional Director of Palliative Care at MedStar Health in Baltimore. Transcripts and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm, and you can subscribe to this podcast on iTunes and listen it on SoundCloud.