Understanding advance directives

Podcast transcript

INTRO
Welcome to Docs in a Pod presented by WellMed. Over the next half hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-hosts Dr. Rajay Seudath and Ron Aaron will share information to improve your health and well-being. And now here are Ron Aaron and Dr. Rajay Seudath.

RON AARON
Well, hello there, and welcome to the award-winning Docs in a Pod. I'm Ron Aaron. WeÕre delighted to have you with us. Our regular host for this show, Carmenn Miles is on special assignment. I'm delighted to fill in for her. We've got a great and important topic today talking about advance directives. If you don't have one, we're going to make sure you know why you should. Dr. Rajay Seudath is our special guest. He's our co-host today and our expert. He's board certified in family medicine and earned his medical degree from the University of South Florida Morsani College of Medicine. He's the lead physician for Optum at the University location in Tampa, Florida. We're delighted to have a chance to talk with him about a topic that he feels very passionate about. Dr. Seudath, what is an advance directive?

DR. RAJAY SEUDATH
An advance directive is one of the most important things that you can create. An advance directive literally tells your health care team, tells your family, what should we do at the end of life? It's very important to have that. Oftentimes people have never even spoken to their health care provider about an advanced directive. They've never spoken to their family about it, their mom, their dad, their grandparents. It's only when things are getting to a very critical situation where they're even thinking about an advanced directive. I hope by the end of this talk, we should be able to flip that on its head and everybody would be able to understand what an advance directive is, understand why it's important, how to go about getting one and how to talk about it with the people who love you.

RON AARON
I know in my parentÕs case, my dad, who developed dementia, never wanted to talk about it before he got dementia, and once he did, it was too late. In my mother's case, she didn't want to talk about it either. Both passed away on their own. They managed to do that, but neither had an advanced directive. They had nobody designated to represent them. They had no decisions made on how their life should end and in what manner. Dr. Seudath, do you need a lawyer to do an advanced directive and what should be in it?

DR. RAJAY SEUDATH
No, you don't necessarily need to have a lawyer. A lot of people get these advance directives mixed in with what's called a power of attorney. Now, that is a legal document. A power of attorney, you need to have a lawyer. I mean, it's got attorney in the name, right? That kind of has to do with your estate. What are they going to do with the car? What are they going to do with the house? Oftentimes your funeral arrangements can sometimes be mixed in with a power of attorney as well. but this is very specifically about health care. So, you can do this with your primary care provider. We do these in the clinic all the time. In fact, I link it to physicals. So, when a person is doing their annual physical, I always want to go over their advanced directive just to make sure it's up to date and the things that they've chosen is what they still want. I think that's important. Advanced directives come in in three different versions, so to speak. Everybody has probably heard of a DNR, a do not resuscitate. We're going to talk about where that runs in comparison to an advanced directive, but I like to think of advanced directives as an umbrella. Under advanced directives, we have all of the issues that deal with end of life. That being a DNR and that being a living will. So, those two are a little bit different, and we're going to touch on the nuances and the differences of those. I think that's important.

RON AARON
I have a great DNR story for you. Years ago, in an agency where my wife was working, one of their coworkers suffered a cardiac arrest. They were able to resuscitate him, get him back together, they got him to the hospital, and they talked with his daughter, who said he's got a DNR. The hospital said, well, we have to see it. So, I went to his house. I couldn't find it. It wasn't in any place it might have been. So, they resuscitated him several times. Later he said, I'm glad you didn't find it.

DR. RAJAY SEUDATH
That can sometimes happen. Most of the time, people who have made a DNR may not know exactly what they want, or they may not have had that explained to them explicitly as to when it comes into effect and what it is. I'll tell you, that's kind of the TV ending. When most people think of a resuscitation, when you see it on TV, it's 98% effective, right? The people get better and everything's fine, but in real life, it's more like 2% effective.

RON AARON
2% percent?

DR. RAJAY SEUDATH
Only about 2% of people who are resuscitated have a full recovery. Most of them pass during the chest compressions and the CPR and the aftermath, and a great many of them do not get better. That's one of the realities that we have to take into account when we're thinking about these things.

RON AARON
WeÕre going to pick that up in a minute. I want to let folks know who may have just joined us, you're listening to the award winning Docs in a Pod. Our podcast is available wherever you get your podcasts. We're also on the radio in several markets in Texas and Florida as well. I'm Ron Aaron, along with Dr. Rajay Seudath, and we're talking about a very important document, which is the umbrella for a lot of other documents. We started off with a DNR, do not resuscitate. When you talk with your patients, how do you explain a DNR?

DR. RAJAY SEUDATH
I'm going to go through a scenario. I think it'll help us to see all the different paths and all the different milestones. It's Monday for us here for today, so I usually stay a little bit late after clinic. My staff starts to leave around five. Sometimes I'll stay till six, sometimes I'll to seven. But one of them, they poke their head in my door and say, bye Dr. Seudath. IÕll see you later. I'll see you tomorrow, and I'm on the floor. I'm not breathing. My heart's not beating, and I'm becoming cool to the touch. They have two options. The first option is man Dr. Seudath was a nice doctor. I'm going to miss him because I have already passed. You find a dead body, you call the police, the police come, they say, we may need to get the medical examiner involved. Eventually, they're going to get to my funeral rights. So, that's a DNR. They find me dead, they leave me dead. Do not resuscitate. On the other hand, she pokes her head and she says, oh my God. Dr. Seudath is on the floor. She immediately calls an ambulance. Now the ambulance, wherever they are, will come and they will start CPR. Regardless of whatever's going on, they're going to start CPR. They're going to put a tube down my throat. So, they're pushing on my chest to push the blood to my brain. They put a tube down my throat to bring the air out of my lungs. They give me a shot of adrenaline to jumpstart my heart. If that doesn't work, they put the paddles on and they try to jumpstart my heart like a like a car battery. Wherever I am, they take me to the ICU. Now, in the ICU, 1 of 2 things can happen. I get better or I don't get better. What are they doing? How are they trying to make me better? They're going to hook that breathing tube up to a breathing machine, so it's breathing for me. My lungs aren't breathing on their own. They're going to breathe for me. They're going to give me a bag of medicine to make my heart beat. They're going to try to figure out what happened. Did my kidney stop working? Did I get poisoned? Did I get hit by a bus? What happened? Why is this guy not breathing? Why is his heart not beating? Maybe they find that reason, they do some interventions, they do surgery, they give me medicines. I get better and I go down to the stepdown unit. Wonderful. What if I'm in the hospital, I'm in the ICU and I'm not getting better. What does it mean to not get better in the ICU? For instance, I have a breathing tube in my lungs, and it's supposed to be giving my lungs a break, but now the breathing tube is damaging my lungs. It's causing barrow trauma. It's called ARDS. I got medicines that are supposed to make my heart beat, but now those medicines are damaging my heart. All the interventions they're trying to do, my body is just not taking to it. That could be called a terminal condition or end stage condition. It could also be called organ failure. In that situation, everything they're trying to do for me is not only not working, it's also worsening my condition. That's a situation where I'm not getting better in the ICU.

RON AARON
If you have someone designated as your medical power of attorney, they can call them and that person can say, okay, unplug him.

DR. RAJAY SEUDATH
Well, we're going to get to that. I love an eager student. Another situation moving into where I'm in the ICU and I'm not getting better is when I was down, was I down not breathing, my heart not beating and cool to the touch, was that for five minutes or was it for 15 minutes? Because that's a difference of how much oxygen my brain is getting. As they're resuscitating me, as they're giving me fluids, as they're doing surgery, if they open my eyes and they shine a light in my eye and my pupils aren't responding, they put electrodes on my head and there's no brainwave activity, I have suffered brain death. So, that's another situation where I'm in the ICU and not getting better. Again, I'm already on a breathing machine. I've already had CPR. I've already had surgery. I've already had dialysis. I've had all these things to try and make you better, and they have not worked. In that situation, we have another two choices. One, we stay on those machines until my body finally gives out and when my heart stops beating again, they do CPR again, and eventually I pass during that CPR. Or they stop those machines. Those machines are the only things that are keeping this body here, a brain damaged body, a body that all of these interventions are prolonging what is eventually going to happen. So, we stop those interventions and the person passes.

RON AARON
In that scenario, can you be an organ donor?

DR. RAJAY SEUDATH
Yes, absolutely. You can be an organ donor. That's certainly another aspect of advanced directives and the living well. That's another portion of that. DNR is if I stop breathing, I stop living. Well, don't even start that whole process. If I've passed, let me pass. The next one is the living well. Do I want to have people start and try to resuscitate me, and if it doesn't work after a period of time and my two doctors say I'm in a state where I cannot get better, there's no hope for me. There's no feasible chance that I will improve. I can say, stay on those machines regardless of what the experts are saying. Or I say, let me be with my Maker. Stop that and let me be. If I'm an organ donor, the organs can be harvested, organs can be donated.

RON AARON
Let's pick this up in just a minute. I want to let folks know you're listening to the award winning Docs in a Pod. I'm Ron, along with our co-host and special expert today, Dr. Rajay Seudath. We're talking about advanced directives and everything that flows from that right here on Docs in a Pod.

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RON AARON
Thank you for sticking with us right here on the award winning Docs in a Pod. I'm Ron Aaron, our special guest and co-host today is Dr. Rajay Seudath. We're talking about not only advanced directives, but we also talked about DNR, do not resuscitate, and then we got into the subject of a living will. Pick it up from their Dr. Seudath.

DR. RAJAY SEUDATH
Right. Let's touch back on DNRÕs. The example you had given is the paramedics came and you were looking for his DNR. Now, I heard this on a on a conference, in Texas, it's a little bit different from Florida. In Florida when you have a DNR, the actual document is different. There is a top part and the bottom part. In Florida, the bottom part goes in your wallet and the top part I instruct my patients to put on their fridge. In Florida, paramedics are trained to look in the kitchen, look at a fridge and to go through their wallet to see do they have an advanced directive? Because that's where it should be. We also touched on advanced directives DNRÕs are often with a lawyer's office, and people may have the documents in their safe. I greatly, greatly urge you to have one with your doctor's office because if Friday night at 9 p.m., few lawyersÕ offices are open. If you've got one that's in the chart and you're going to a hospital that's connected to your primary care office, more than likely they have access to our notes. They have access to our system. They can pull that down or the on call physician could do that. So, I think those are important. Now, one of the things that's difficult about talking about end of life in general is it's a difficult subject. Oftentimes doctors will not acknowledge that their patient is going to pass. There's an old saying, science only goes so far, and then God takes over. I'm sure you've heard that saying, and it's true in the sense that we cannot keep our patients alive forever. Everybody must pass. The only two things that are certain are death and taxes, and for some, the taxes don't ever come. So, the only thing certain is death. In marriage, you could say it's till death do us part, but for your family medicine primary care provider, sometimes it's even after that because I'm taking care of spouses. I'm taking care of children. I'm taking care of friends and relatives. So, that person continues to live on through those interactions. I think that primary care providers are very specially poised to talk about this because we're so close to it. I often say, whenever we have these kinds of conversations, I often say, the hand of death is always on my right shoulder. I'm always thinking about that. How are you going to meet the end whenever I'm talking about your care? Because I want you to have not only the longest length of life, but also the highest quality of life. That's another issue altogether. We'll have to do other show on goals of care. We talked about the DNR. The person said, no, DNR is not what I want. We're talking about a living will. Do I want to stay on the machines forever and ever and ever, and I pass during CPR. They're pressing on my ribs. They're breaking my ribs. My last moments on this earth are this kind of traumatic, heroic resuscitation, or do I want them to be where they withdraw those instruments, they withdraw those machines, and I eventually pass. That is a very, very personal question. The way I look at it is every single minute up to the point you make that decision has influenced your decision. Every single experience, every single person you've met, every single memory that you have lived is what allows you to make that decision. You may not be ready to make that decision the first time we talk about it, but it is such a uniquely personal decision. I'll give you an example. I had a husband and wife couple, and I do the same scenario, and we get to the part where, okay, you're on life support, you're in the ICU, you are no longer getting better. Whether it's brain damage or organ failure, what do you want us to do? The wife says, thank you so much for going over this. I've never heard it explained that way. If I'm on machines and those are the only things that are keeping me linked to this body, let me go. Let me be with my God. This was a religious couple. They actually had their own ministry. When she said that the husband looked at her and she said, I can't believe after 50 years of marriage, I heard you say something so blasphemous. What you're saying is tantamount to suicide. I don't know about you, honey, but I believe in miracles. I believe in the power of the Holy Ghost. If I'm going to receive a miracle, I need to be on those machines. So, again, very similar backgrounds. Someone that they've both known each other, but they've never had that conversation. Two very different choices. That's why I want to stress how personal these choices are. You need to have that conversation. It might be a difficult conversation, whoever you have it with, but specifically just having that conversation can be difficult.

RON AARON
In that conversation, if you have kids, do you involve them in that decision?

DR. RAJAY SEUDATH
Absolutely. For me, there was a study where they tried to see who would pick what you wanted. They did a study where they asked the spouse, the children and the best friend, what would this person want? In the study, the best friend was the best at guessing what the person wanted. So, I think it's important that you have that conversation with your proxy. On our documentation, it says, have you had a conversation with your proxy? Two, does your proxy acknowledge what you want? And three, does your proxy agree with what you want? So, I think it's important that once we know what you want, whether it's DNR, whether it's stay on the machines forever, whether it's stop the machines, that once your health care team knows about what you actually want and we've explained it, now you have to let the people around you know. Now, for proxies, there's typically a primary and secondary. The way I say is, okay, if you're in the hospital, you're in the ICU, you're not getting better, who should I call? Call this person. Now, if you and that person are in a in a car accident and you're both on life support, who do I call? That's the second person. That's your secondary. What I often say is, the primary and the secondary, it doesn't matter who, I talk to them all at the same time. I had a gentleman who said, well, doc, I like this primary and secondary thing, but I got five kids. Somebody is going to get their feelings hurt. Who do I choose? For that instance, I said what I want you to do, I want you to get them all together. If it's on the phone, if it's in person, doesn't matter. I want you to ask everybody, hey, what should I do? If I'm in this situation, what would you want to do for me? The answer should be, well, whatever you want, Papa. He went through and some said, whatever you want. Some said stay on the machine. Some said whatever you want. He got to his oldest, who was the last one, and he said, pop, we got to pull that plug. I want to get your insurance money. It was a joke, but his choice was to stay on the machines. So, I said, well, that's probably not the person you want to choose to make this decision. The other way is, well, how do you say it to these people? It's a sensitive situation. It's a sensitive topic. Some people are ready to hear that. I don't want to lose my mom. You used to tuck me in. You used to ride me on your shoulders. I don't want to lose my dad. How can I even think about that? No, don't even think like that, dad. Don't even think like that. Everything's going to be fine. You're going to live forever. You're Superman. You have to think about this. How do you say it to your family? This is what I've told many patients. The way I have them say it is if I'm in a situation where I'm in the hospital and not getting better, there is no hope for me to make a recovery or if I recover, I will be so damaged that my quality of life will be miserable. In that situation I want you to, and then you say what you chose.

RON AARON
Pull the plug.

DR. RAJAY SEUDATH
Right. Stop the machines. Pull the plug or keep me on those machines forever and ever and ever. Resurrect me on the third day. Whatever they got to do, that's what I want. I'll tell you, when I go through this situation, most people end up saying, well, yeah, if I'm brain dead, if there's no hope for a referral, let me be with my Maker. But there are some people who don't say that. I had one guy who was like, I got a pension, and as long as I'm on that machine, my wife gets the pension. Well, yeah, but also, she'll still get some sort of widow benefits from the VA, even if you pass. That's neither here nor there. What you want is what I care about. When it comes to making that decision of what to do, if your proxy doesn't know what you want, then they're going to choose what they think is best for you. Just as I said, going from the entirety of your life to the moment you make a decision has influenced your choice, the same applies to your proxy. If you have two proxies, if you have two people who love you, three people love you, ten people who love you, they might not come to the same decision unless they hear it from your words. So, what does that look like? That looks like a person's been in the ICU for two weeks. They're at a point where they're not getting better. Do I kill that person right now or do I torture them until they die? That's a hard decision for a loved one to make.

RON AARON
We've got about a minute left. What would you like to add?

DR. RAJAY SEUDATH
I would say instead of that decision, make the decision, do I protect what my loved one wants, or do I not protect what my love wants? Because that's a far easier choice to make. If you know what that person wants, if you say it clearly to your kids, it's one thing that they won't have to worry about. If they're going to be grieving for your loss, regardless of what happens, take that off their plate. Let them be able to celebrate your memories and your life.

RON AARON
And talk to your PCP. IÕm Ron Aaron, alongside Dr. Rajay Seudath. We appreciate you for joining us on the award winning Docs in a Pod.

OUTRO
Executive producer for the Pod is Dan Calderon. The producer is Cherese Pendleton. Thank you for listening to the Docs in a Pod presented by WellMed. Be sure and listen next week to Docs in a Pod presented by WellMed.

DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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