Ninety-six percent of the people of La Crosse, WI, die with an advance directive. The national average is about 30 percent, so why is La Crosse different? The answer is education and opportunity. (NPR. March 5, 2014; http://n.pr/2nTNN1I.)
We held a seminar on geriatric emergency medicine a few years ago, and one component was a panel discussion with retired members of the community. We asked them what they wanted when they needed medical care. They said we should carefully explain their options so they could participate in making decisions about their care.
I asked what I thought was a simple question, “How many of you have a living will?” Only one raised her hand. She had been an administrator in our hospital for many years before retiring, and she counseled patients on setting up advance directives and naming a power of attorney (POA). When I asked the others why they did not have either, the general response was denial: “I don't want to think about it,” they each said.
A gravely ill patient near the end of life presents on nearly every emergency department shift, and it is clear to everyone he will die soon if we do not intervene. It is a testament to our specialty that extending these lives is relatively routine. Nearly all of us, however, will silently ask ourselves within the first few minutes of caring for these patients, “Does he have a DNR?” We know all too well that many of the interventions we undertake with critically ill patients can also prolong devastating suffering. It is interesting how few residents take this lesson to heart.
Wellness has become a hot topic for all of us in post-graduate medical education. It began with ACGME establishing duty-hour limits in 2001, and now a collective push seeks to identify the unhealthy components of physicians' lifestyles. The obvious subjects repeatedly come up: diet, exercise, and sleep. There is also increasing awareness of the need for personal finance education. Not a bad idea when the average debt of an emergency medicine residency graduate hovers around a quarter of a million dollars. But what about legal wellness? How many residents have prepared basic legal documents?
Ignoring the Obvious
The answer is troubling. I asked our residents how many of them had set up an advance directive or a POA. Only one resident raised his hand. He was in the military before going to medical school, and a mandatory assignment before deployment into a combat zone was to get your affairs in order. In short, you are forced to write out a will and choose a POA. But what about the rest of my residents? Why are they waiting? Are they immune to tragedy?
I suspect they think they are. Let's face it, they are in residency training because of good luck. Stable families and great schools allowed them to flourish in their academic and professional lives. But will their luck run out? They know better than anyone that the drive home from work could be a disaster. No one thinks they will be the victim of a traumatic brain injury leaving them on a vent with a feeding tube. We all know, however, that it is possible. What happens then? Do they want treatment to extend their lives? Would they prefer someone pull the plug? Who will speak for them? Their parents? Their spouse? Do they think their family would make the right decisions, or are they too emotionally attached?
It is ironic that doctors encourage patients to be legally prepared for disaster but do not do it for themselves. Of course, they recognize that it should be done but take an easier path—procrastination. When you are young, it is difficult to imagine the end is near, and truth be told, it is unlikely. But if it does happen, this lack of appropriate planning will exponentially increase the misery of your family by forcing them to make decisions that should already have been made.
To encourage my residents to act, I contacted the legal department of our hospital to see if they could help. It turns out they have relatively simple forms for creating an advanced directive and naming a POA. Making a will is a bit more work because an attorney outside the hospital needs to be involved. It appears, however, that this can be done at little or no cost to the residents. This spring I will ask each of them to consider taking this step into responsible adulthood by putting the forms in front of them. I also hope to get our office of graduate medical education to be proactive with all of the residents at our hospital on this issue. We may never be as prepared as the folks in La Crosse, but it is our responsibility to encourage residents to think about how their actions today will protect them from a future of unknowns.
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