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Advance Directives: Make Sure Your Wishes Are Known
Stacey Kendrick talks with Mohana Karlekar, MD, FACP, Medical Director, Vanderbilt Palliative Care about advance directives.
Visit VUMC’s Health Care Decision Making/Advance Directives website for additional information.
The site gives answers to frequently asked questions and has links to advance directives forms and instructions on how to complete them.
Laura Osterman: Welcome to this edition of the Vanderbilt University Health and Wellness Wellcast. In this edition, Stacey Kendrick discusses advanced directives with Mohana Karlekar, Medical Director of Palliative Care.
Stacey Kendrick: Thank you so much for being here.
Mohana Karlekar: Thank you for having me.
Stacey Kendrick: Can you help our listeners understand a little bit more about what advanced directives actually are?
Mohana Karlekar: Absolutely, when I talk to folks in the hospital, very often they think about wills and their financial states, but what we are really talking about here are your ideally written but for sure verbal preferences on the type of care, the goals of care, and qualities of life that you would and would not find acceptable, and I will get an example. A conversation with your loved one, maybe when you are watching a TV show, that if I ever ended up in a coma or what people may consider or alleged to that really would not be okay. A living will or an advanced care directive allows someone to put that down in paper so that information is communicated to your physicians and the people who are taking care of you to ensure that what you want happens and what you do not want does not happen.
Stacey Kendrick: Are there things that we need to think about specifically and why are those things important for us to think about?
Mohana Karlekar: I think the biggest reason why they are important to think about beforehand is that when people get sick, they are in crisis and when you are in a crisis, you do not sleep, you are stressed, and you are not thinking straight. You may not even be able to make your own decisions if it is something like a car accident and you had a brain injury. So, if you want to have a say in what happens to you, then you want to do it at a time when you have the ability to be able to reflect over time and think about these choices and then ideally communicate them to the people around you so they know what your choices are. Choices often change over time, and people will say what if I think this and what I think that later. Well, then you change those just as we all change our views on lots of things. The other reason why I think they are exceedingly important is we do so many things in life to take care of our families. I have a life insurance, so if I die, my house is paid off and my kids do not have to worry, and we have a will to make sure if my husband and I die, there are guardians set in place to take care of them. If you do not fill out an advanced care directive, what you do is you essentially place your family in the hot seat and they have to make probably some of the most difficult decision that they would have to make in guessing what people’s end of lifetime choices might be and that is really hard. So, if you can make those choices for someone and your loved ones you do not actually have to make the decision and they are just communicating their choices, I do not think there is really any greater gift.
Stacey Kendrick: I think it would be easier if they knew that was what you wanted to happen.
Mohana Karlekar: There is a sense of relief when people say this is so hard, but I talked to my dad over and over and he told me this would really not be okay, so I can tell you with the great degree of comfort this is what we need to do, and so I think people have a sense of relief, people have a sense of peace of mind, and their decisions are not as complicated and disastrous sometimes as they can be.
Stacey Kendrick: Are there misconceptions that people need to have cleared up?
Mohana Karlekar: I think a lot of misconceptions now just within the community but I think sometimes in the healthcare establishment is you only need to have an advanced care directive if you are old. People will say only if I am sick that I will need to have an advanced care directive. None of that is really true when you think about it. People get into car accidents all the time, young people get cancers, so really everyone should have an advanced care directive. It is not an implication that your health is poor or you are about to die. It is like we do every other thing, car insurance, home insurance, it is a way to be able to be ensure your choices are heard.
Stacey Kendrick: Is this something that you can just write up yourself or is it a legal document?
Mohana Karlekar: There are lots of different ways to do it. If you ask some of the most expert ways if I was teaching a medical student class, there are forms that you can get online. The Tennessee Department of Health has forms that you can access and print out. They do not require a lawyer, they do not require a notary, and you have two witnesses sign those forms. So, they can be done that way. If you have a conversation with your physician and that physician documents that conversation, that is like an advanced care directive. So, if you cannot get to the computer and print that thing out, if you verbally have that conversation and the doctor writes it out, that is a pretty close step. These forms are variable from state to state, so you want to make sure that the form you are filling out is the state that you are living in, but you do not need a lawyer, it does not have to cost you money, and you do not need to go to a notary.
Stacey Kendrick: Is there are anything else that people need to know about the basics of advanced directives?
Mohana Karlekar: Probably, the biggest thing that I think is important is really focusing on what we consider quality of life and not treatment choices. I hear a lot some people say, “Well, my dad did not ever want to be on a ventilator.” or “My father would not want CPR.” I think most people when they make statements like that they are saying that they do not want to end up in a place dependent on a machine or keep having CPR if they are not going to come back, but I believe that most people want to come back if they can come back to a reasonable quality of life, how they would define that resemble quality of life, and what we know over time, and I know this from my own medical experiences that we have more and more technological advances, so things that we could not do 3 years ago, we can do now, and so if you try to say I want this treatment and not that treatment, you are never going to be able to keep up given the advances. If you are able to say quality of life to me means walking around, communicating with my family, living at home, and being independent, then we can decide as a group what treatments are going to help get you there and what treatments would not or what treatments that once you start are not keeping you in that place that you want to be, so I have people focus on quality of life and not what your perfect quality of life is but what is the quality of life that you can make a life out of. So, maybe perfect is running, walking, exercising, living at home independently, but maybe what you can live with is walking and communicating and thinking in being at home but maybe you walk slower. So, you really want to get people to think about these things and then go back and revisit these discussions.
Stacey Kendrick: And those are great conversations to have with your loved ones. I am so glad that I got to talk with you today about this really important topic, and hopefully, people that have not thought about it yet will start thinking about it.
Mohana Karlekar: Hope so. Thank you so much.
Stacey Kendrick: Thank you so much.
Laura Osterman: Laura Osterman: Included at the bottom of this page are links for more information and access to the forms. In particular, the Vanderbilt University Medical Center Health Care Decision Making/Advance Directives Website linked below has a wealth of information about this topic. Start by completing your “Appointment of a Health Care Agent” form and bringing it to your primary care provider today. Forms can also be obtained at Health Plus events, at the Occupational Health Clinic (where you can also turn in your “Appointment of a Health Care Agent” form to be scanned into your Vanderbilt Medical Record) and your Vanderbilt provider healthcare portal. Thanks for listening.
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