Shanna M 00:11
Hello, Welcome to the Adventist HealthCare & You podcast. I'm Shanna

Nimeet K 00:14
And I'm Nimeet

Shanna M 00:15
How are you doing, Nimeet?

Nimeet K 00:15
Good, I'm doing great. How are you?

Shanna M 00:17
Good! Well, I'm really excited for today's topic. We have two very special guests, Dr. Carolyn O'Conor, who's a family medicine physician with comprehensive primary care and a past medical staff president at Shady Grove Medical Center.

Carolyn O'Conor, MD 00:30
Thank you. Glad to be here.

Shanna M 00:31
Thank you. And Dr. Alvin Reaves, a palliative medicine physician, and he's also the medical director at Shady Grove Medical Center for our palliative medicine, supportive care teams.

Alvin Reaves, MD 00:42
Thank you for inviting me to be a part of this podcast.

Shanna M 00:45
Thank you. So we have a topic that isn't talked about enough, I think. And what we're talking about is advanced directives, advanced care planning. So it's not the most comfortable topic in the world. But it's also something I think we need to be comfortable with.

Nimeet K 01:00
Yeah, I agree. I think it's something people don't talk enough about it. I'm glad that we're increasing awareness around it.

Shanna M 01:06
I'll share a little story. I was helping my grandfather through his final years, I was helping him with his medical appointments. He had a lot of this decided ahead of time. So it made things really easy, for me at least. Dr. O'Conor, tell us a little bit about yourself, why you're here today?

Carolyn O'Conor, MD 01:24
Well, I've been practicing family medicine for 36 years. And as I have worked so long in the field, you know, my patients and I have all aged up. And over the years, i've seen more and more how necessary it is to have conversations about these areas in advance of when trouble arises. So what I mean by that is, I think that it is difficult, as you said, to talk about death and dying, and it can be challenging for patients and families. But actually, I think a good place to have that conversation is in the primary care office. When the stakes are low. It's maybe a preventive care visit. And we can introduce the topic and delve into it. And as I've gotten more interested in advanced care planning, i've worked with the team at Adventist HealthCare about National HealthCare Decisions Day.

Shanna M 01:24
Dr. Reaves, you are a palliative medicine physician, tell us what that is and how it relates to advanced care planning?

Alvin Reaves, MD 02:33
Sure. Well, my career started back in 2001, when I finished residency and my primary specialty is internal medicine. So I practiced initially in internal medicine in rural South Carolina, both in private practice and as a hospitalist. And during the eight year tenure that I was there, I discovered that we as physicians, the medical system do not, or at that time did not do a very good job at helping to talk about these very difficult conversations with families, with patients who are undergoing, you know, serious medical illness. And I decided to pursue a fellowship in hospice and palliative medicine. So in 2010, I attended fellowship at the National Institutes of Health and Capital Caring to become more expert in palliative medicine. So I've been practicing this particular sub specialty for the last what is 13 years now. And it's a very valuable, but very often unappreciated, I think, medical subspecialty that can have tremendous impact in reducing the stress of serious illness both for patients and their families.

Nimeet K 03:45
Absolutely. And I think at the end of the day, we want to do what's best for the patient and agreed to their wishes and you know, having those conversations beforehand is is always beneficial to respect we know what their what they want towards the end, and it makes it easier too for the family members as well too, as Shanna you had mentioned earlier. So you know, I think you have great experts here to discuss this topic. Can you just tell our listeners what is it what is an advanced directive and what other terminology may people may know what as?

Carolyn O'Conor, MD 04:13
Well, there are several terms in play advanced directive is one, you can have medical power of attorney, you can have a living will, you can have a MOLST form, which is a medical order for life sustaining treatment. So it goes by several names and the documents may not be interchangeable, but they are all useful.

Alvin Reaves, MD 04:48
I think that's a very good question because in my experience, I believe what often hinders people from having the conversation, even medical professionals, is that we haven't had that opportunity to be self reflective or having that degree of introspection, right in facing the inevitable, right our own mortality. When I've given presentations in the past, i've often suggested to people and their families, when you're gathered at the Thanksgiving table, or when you're together for Christmas, or whatever special holiday, that's a perfect time, right to talk about what your wishes are for the future, right in the event of your incapacity or another serious illness. So to take advantage of those family times when people are together, so that everyone can be on the same page and hear the say what your wishes are at the same time.

Shanna M 05:29
How can we begin to have this conversation with our loved ones, or even begin to just have this conversation with ourselves?

Shanna M 05:39
Yeah, and I can I can speak from experience when my grandparents would do this at family gatherings, I would say, I don't want to talk about this. I don't want to talk about this. They were like, well, but here's where everything is. And I would, okay. And even though I didn't want to talk about it, I knew, as they got older, I knew where everything was, and it gave me some peace, and it gave them peace. So I can, even though it's uncomfortable, and you don't want to talk about it, just say okay, okay, and then, you know, just move on. And then it's there when you need it.

Alvin Reaves, MD 06:13
And you can imagine, you know, in the stress of an acute illness or you know, an acute medical situation, that might hinder right, people may not be emotionally, have the emotional sort of capacity to be able to have these conversations. So just as Dr. O'Conor said, you know, when things are low stakes, right or low key, trying to have that conversation earlier on, when you're in the right frame of mind, to think about something like that.

Nimeet K 06:41
And I think Shanna you mentioned that, you know, some of the family events may not be the right place for some individuals. I think, you know, April 16, is National Healthcare Decision Day, and a day just dedicated to talk about this. I know at the hospital setting or community centers, there's a lot of awareness around this, to talk about this more. So you know, if people are comfortable to talk about during that timeframe, as well. And I know Dr. O'Conor, you had mentioned, coming to your regular visits and talking to your provider, but that it's been one of our themes in our a lot of our talks about you know, make sure you get your yearly checkups and having those conversations and building relationships with them, to have these conversations is hugely valuable.

Carolyn O'Conor, MD 07:23
That's right. First of all, I think talking about it, repeating it, bringing it up comfortably, calmly, in different settings, starts to normalize the conversation. And I think in America, we have sanitized death, you know? For so many decades, well throughout history, people passed at home, it was a familiar rite of passage of life. And now with hospitals, it's all seemed so distant and people have become very uncomfortable. And I think we need to bring this back to being understood. And the more we talk about it, the better. Speaking of how to bring up the discussion at home, there is the Conversation Project, which has tools for anyone to use on how to talk to their family and have the discussion. And I always say this is when you fill out an advanced directive, it's a gift to your family, because they will know who is to make decisions if you're unable to make your own decisions. And hopefully have also had the conversation. I always say to my patients, there's a document you want to designate a decision maker, but you also want to have a conversation about what are your values, what's important to you, because the possible clinical scenarios that we can find our patients in are literally infinite. So there's no document that's going to cover all the clinical particulars of what's going to happen to a given person. But if the family member or members understand what's important to you, then when presented with the facts by the healthcare team, I think they're better able to frame it up and abide by the wishes of the patient themselves.

Alvin Reaves, MD 09:11
Dr. O'Conor, you bring up a very great point about not being able to forecast, right what our medical situation might be in the future, right. We're speculating what we want based on where we are right now in our lives. And right now, where we are in our health. But but the fact that we don't know what the future will hold, I think it is it's imperative that each year right, we review the advanced directive, right as our health changes, as we age, right? As our family members may change, right, the person that we have may have named as our medical power of attorney or healthcare power of attorney may have passed. So that you know you bring up a great point that the directive needs to be addressed and reviewed every year to ensure that it is up to date, and still congruent with what our wishes are.

Shanna M 09:59
Yeah, I didn't even think about that my grandparents had decided a long time ago what they wanted. And they kind of kept that up. And we kind of just didn't talk about it. But then later, and as it got closer and closer, it kept coming up more and more, and they were reviewing things. And so I didn't even think about even just, every year trying to just take a look at that and make sure everything's the way it's supposed to be.

Carolyn O'Conor, MD 10:19
You know, I think another aspect of this that I see is so important is the goal of autonomy. You know, sometimes people don't want to talk about these things. But each person should have control over what happens to them. And by doing an advanced directive, you are possibly giving your family a tool where they will know what your wishes are, even in an serious illness in which you aren't able to make your own decisions, you have still exercised your autonomy by preparing in advance. The other thing that's so critical about this is it can reduce the stress and anxiety of families. You know, if there are multiple family members, and maybe people aren't seeing eye to eye on what should be done, if you've made your wishes clear ahead of time, you're reducing what could be a very stressful time for family and can kind of maybe make end of life more peaceful and not leaving a lot of lingering anger or resentment or guilt among family members, exactly right.

Nimeet K 11:34
I think you said earlier, it's one of the best gifts you could give your family members, and thinking during end of life, i'm sure you have experienced this, there's so many decisions to make and you go into your own feelings while making those decisions. And you know, just living with those decisions towards it, whether we made it right or not. I think the advance directive makes it smoothens the process out as much as possible.

Alvin Reaves, MD 11:56
I've had patients in the past when I've brought up the conversation about well, you know, in the event that you're unable to make your own medical decisions for yourself right, in the event of your incapacity, who would you want to make those decisions for you? And people have responded? Oh, well, my children, they know what I want. And I would ask, well have you spoken with your children about it? No, but they know what I want. And that places an undue burden. And I hate to use that word burden. But it can be a burden in a stressful situation to have, to feel like you have someone's life right in your hands. So just as Dr. O'Conor said, the autonomy, right, being able to say and have it written down what your wishes are for yourself to be in control of that, right. It's a treasure that's invaluable.

Nimeet K 12:43
Yeah, absolutely. So what are some of the information specifically that is in an advanced directive? What are some of the examples that you know people have a decision to make towards for themselves?

Carolyn O'Conor, MD 12:52
Well, I would like to bring up that in Maryland, the Maryland Attorney General's Office has a packet of information that people can use to create an advanced directive. And that document has questions that you can answer about different medical treatments. But you can also choose not to answer a particular one, if you're really not sure. That document has to have the signature of two witnesses who are not people who are part of your estate, the other good resources, MyDirectives.com, which you can do online, I have done it myself. You designate your decision maker and your secondary backup person that is recognized by the State of Maryland. So another great tool. And in doing it, it does ask questions about intubation, and ventilators and different kinds of sub questions that you may or may not have an idea. As Dr. Reaves said, this is something you may want to update with time as your health changes. And as you get older, but some of it, I really did skip over. But I have tried to have those conversations with my husband and my kids about knowing me and what, what do I care about and what brings meaning to my life because I always say for example, if I couldn't recognize and communicate with my children and had no hope of recovering that ability, that would be my cut off. And that is the value that I hold, but each person in each family has to look to themselves to see.

Shanna M 14:31
And those resources are free of charge right? So anybody can access those. And we'll put those resources in the show notes of today's episode so that those listening can access those resources. Are those places a good place to start then for people if they're just wanting to see those questions and see what all they would need to you know, write down and designate?

Alvin Reaves, MD 14:54
Absolutely. You know, I my practice setting is inpatient, right and in the hospital, I don't practice in the community. So when I have these conversations with patients and families, it's in the setting of an acute hospitalization and stress. And sometimes, you know, we are able to help patients to complete them. But more often than not, you know, it's the outpatient setting or home, that's a better area, right? To be able to complete them.

Nimeet K 15:23
And I think I like the fact that he could, you know, pick and choose the ones you're familiar with, or once you know, for sure what you want to, you know what decision you want to make. And then having a yearly updates, you know, you know, what I do want to get ventilator support, I don't want to get ventilator support and having that ongoing conversation with your family. And I think more often you do it and look at it, the more familiar you are with the you know, with the form or with the different procedures and options. And the clearer you are about what you want to do.

Alvin Reaves, MD 15:31
And another, you know, point to consider is that in the presence of a disease, right, it's important to think about or to have the discussion in the context of what's going on medically. Right? Not just you know, if your heart stops or if your lungs stop, if you stopped breathing, would you want CPR or resuscitation. But having that conversation in the context in the medical context of what the person is experiencing, will help will help to have a more meaningful conversation and completion of the directive.

Nimeet K 16:27
Absolutely.

Shanna M 16:28
So not an easy topic today. But a really important one. And this information has been really helpful. Dr. O'Conor, you know, what is one of the most important things we want to leave our listeners with today?

Carolyn O'Conor, MD 16:39
Well, I think that advanced care planning, advanced directives are very important, and a conversation I have with my patients every year, especially at Medicare annual wellness visits. And I think that the more we talk about this, and by observing National Healthcare Decisions Day, I think we're going to make the public much more comfortable with this. And this will become a normal conversation to have and not one so fraught with anxiety and stress.

Nimeet K 17:12
Absolutely.

Shanna M 17:13
Dr. Reaves?

Alvin Reaves, MD 17:14
Sure, I'll say, give two closing remarks. Number one, as important as advanced care planning is as important as advanced directives are in establishing what patients want, right? Honoring their autonomy. I think it's also to consider the caveat, that there are certain cultures that do not believe necessarily in autonomy and want their family members or a community of people to make their decisions. So sometimes I have encountered my colleagues who have met resistance with having the conversation. So I just want people to understand that there are culture, that that there's a cultural context in which, you know, an Advanced Directive may not be as important as western, you know, medical ethics. And the other thing that I want to say is that people, you know, often feel that it's too early or I don't need to have this conversation now. But there's a saying that it's never too early until it's too late.

Shanna M 17:14
This was, like I said, not an easy topic. And it's not an easy conversation for people to have, but it's a really important one. And one that I think, as you say, is really going to is a gift to your family to do. So, if you haven't had the conversation with your grandparents or parents

Nimeet K 18:31
or with yourself

Shanna M 18:32
or with yourself, that's true, yes Nimeet. Or with yourself. To begin to think about it, and broach it, whenever it's possible. So thank you guys for coming on today. We really appreciate your time and all this great information.

Alvin Reaves, MD 18:45
Thank you for having us.

Carolyn O'Conor, MD 18:46
Thank you so much.

Shanna M 18:47
To find out more on this topic, please visit AdventistHealthCare.com and search for advanced care planning. There's some information there, we will also link to some of the wonderful resources that Dr. Reaves and Dr. O'Conor talked about today. Don't forget to subscribe to the podcast so you get all your new episodes. Thank you and be well.