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Dr. Miller: Why you should make your health care wishes known, and why everyone should have an advanced directive. We're going to talk about that next on The Scope Radio. This is Tom Miller.

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Dr. Miller: I'm here with Dr. Nate Wanner. He's an associate professor of medicine and internist, and a hospitalist, and the Medical Director of the Palliative Care Service. Nate, what is an advanced directive and why should everyone have one?

Dr. Wanner: An advanced directive is usually a written set of instructions that basically communicates to people what kinds of care a person would want in the event that they became unable to make those decisions for themselves in the future.

Dr. Miller: So you're sort of trying to look ahead to an unpredictable future when you know how you want to be treated.

Dr. Wanner: That's right. And we all know that we're going to die sometime, and a large percentage of people who are very ill lose the ability to make decisions well for themselves. And so this is more than a theoretical concern.

Dr. Miller: But you have a long history taking care of hospital patients, how many of the patients that come in are aware of advanced directives when they hit the door? I mean, how many do you think really understand that, and fill them out?

Dr. Wanner: Less than half of patients have advanced directives. And even those who have them are a fairly small percentage who really understand what they mean very well. And a lot of times people make an incorrect assumption that their advanced directive will answer any questions that the doctors have about their care. In reality, a lot of advanced directives are not very helpful in addressing certain specific medical situations.

Dr. Miller: What are the most common things that a patient would direct a physician to do or not to do in an advanced directive?

Dr. Wanner: One common scenario would be if a patient had a terminal illness, and was not able to have any treatments that could prolong life significantly, whether they would want certain treatments that are more burdensome to be done.

Dr. Miller: These are events where the patient codes, as we say in medical terminology, where they stop breathing and the heart stops beating, do they want to be revived, or resuscitated.

Dr. Wanner: That could be one example. Another example would be if a person were in a coma that was expected to last forever, would they want a feeding tube and artificial hydration and nutrition to keep them alive even if they were unable to communicate or move or function in any independent way.

Dr. Miller: I know that they offer advanced directives to be filled out when they enter our hospital, but how would a patient most reliably get started in filling one out? Do you have suggestions on that for the audience?

Dr. Wanner: What I would recommend is using the advanced health care directive that the State of Utah has created. It's a very helpful form that isn't terribly hard to understand.

Dr. Miller: Would they be able to just Google that and find it?

Dr. Wanner: They can, yes. If you just Google Utah advanced care planning or advanced health care directive you can fairly easily find it.

Dr. Miller: And do they give tips at that website about how to fill it out, or what sort of pertinent things one might want to put down to complete an advanced directive?

Dr. Wanner: There are some tips for that, and we could certainly provide a link to that.

Dr. Miller: Where should a patient once they fill out this form, should they keep it on their person, or do they keep it at home in their safe? Do they take it to the hospital? What's the best way for them to have this to show to their physicians?

Dr. Wanner: We recommend that they keep a copy for themselves somewhere where they can find it when they need to. Probably it's a good idea to give a copy to a family member as well, specifically the person that you would want to be your decision maker if you become unable to make decisions. It's also a good idea to give a copy to your primary care doctor. And those would be the most important steps. But I think it's also worth mentioning that people often think that because they've given one bit of information to one doctor that all doctors have access to that. And unfortunately that's just not the case often. And so having a copy handy if you're in the hospital is a good idea to be able to show the doctors there who may not have access to all your information from your primary care doctor.

Dr. Miller: I think that's a really good point, because a lot of times medical records are not immediately transferable between facilities from one ED to another hospital for instance. And if the patient keeps a copy at home they could easily have a family member bring that in and show it to the health care team, which is a good idea.
Now if you fill that advanced directive out, does that also stay on a website with the state so that they could look it up that way or not?

Dr. Wanner: I don't think there is anything like that right now, but that is being worked on. I don't believe that's in place yet, but I think there is hope that it will be soon.

Dr. Miller: Eventually with cloud technology all of our records will be available to physicians wherever we get treatment within the United States, I think, but we're still a few years away from that, I understand. Any other thoughts about advanced directives and the way that more people could be involved in filling out advanced directives?

Dr. Wanner: Well, I think this is a discussion that people should encourage their family members to have and loved ones. It's something that allows people's wishes to be honored, and it also takes a major burden off of the loved ones who would otherwise have the task of making those decisions.

Dr. Miller: Does the advanced directive also allow the patient to designate someone, a power of attorney, to make those decisions in a particular situation where they are not able to make the decisions?

Dr. Wanner: It does, and that's one of the things that I like about the State of Utah form. It offers an opportunity to say certain things about actual wishes of what kinds of care you would want to receive. And then it also provides an opportunity to assign someone who would be your decision maker if you became unable to. And one misconception with that is some people have is that by designating such a person, a health care power of attorney is the official name for that, that they are somehow giving up control. And that's not the case. Any advanced directive only goes into effect once the person themselves is unable to communicate their wishes clearly. It doesn't give anyone the opportunity to make decisions for you unless you become unable to make your decisions.

Dr. Miller: Some patients might be under the impression that they need a professional to help them fill it out, and I don't think that's the case. They don't need to hire an attorney to fill out an advanced directive or to send a power of attorney to another family member, right?

Dr. Wanner: You're exactly right. And so if you use the state form in particular, it's a legally binding form that's been approved by the State of Utah, and all it requires is a witness who has to have some independence from you to sign and say that they witnessed it. It does not require any need for a lawyer, and it's kind of a funny thing that in America we go to a lawyer for health care planning, I think. It's kind of like going to me and asking for legal advice.

Dr. Miller: So it sounds like the bottom line is to think about how you would want to be treated if you were unable to make your own medical decisions. Go to the website and again, what would they Google if they were going to fill out an advanced directive from the State of Utah?

Dr. Wanner: The official title of it is Utah Advanced Health Care Directive, and if you type that in you shouldn't have any trouble finding it. And it's a four-page form that has one section that allows you to assign someone to be your decision maker if you become unable to. And then it has a second section for expressing certain wishes regarding your health care. And then it talks a little bit about how to change or revoke that in the future if you want to. And then it has a place for signatures to make it legal. So it's a very simple form.

Dr. Miller: So fill it out, and then keep a copy at home, and then maybe give one to your primary care physician, and then each time when you have to go into the hospital bring it in with you so you can have that on file in the hospital where you're being treated. And you would also say that you don't have to be older; that's not a requirement. You could be any age, and probably should have an advanced directive if you're receiving medical care. Would that be your advice?

Dr. Wanner: Yes, and it's certainly a much more important issue for people who are older and have very serious medical problems. But even young healthy people can have unexpected tragic things happen, and if you look at some of the cases that have been in the media and in the legal system that have prompted laws addressing this type of issue, in general they've been young, healthy people who have had terrible things happen to them, and then their family has been put through the wringer trying to figure out what to do.

Dr. Miller: Trying to figure out what they wanted. Because, it does service to your family and your loved ones as well to fill out an advanced directive and keep that on file.

Dr. Wanner: Definitely.

Dr. Miller: Thank you very much, Nate, I appreciate it.

Dr. Wanner: All right, and thanks for having me.

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