July/August 2016

A Geriatrician's Confession
By Leon S. Kraybill, MD, CMD
Today's Geriatric Medicine
Vol. 9 No. 4 P. 34

I have a confession to make.

I am a geriatrician who enjoys working with individuals during the "homeostenosis" phase of life. I talk daily about declining health, disease limitations, and the transition from curative to comfort care. I inquire of my patients about their goals of care and their wishes for treatment approach. I preach about the importance of establishing priorities, documenting goals, and sharing them with the people who will help them make decisions. I have completed hundreds of physician orders for life-sustaining treatment (POLST) documents with my patients and their powers of attorney. And I have too frequently seen the angst of families trying to make decisions when a loved one has not discussed or documented his or her wishes.

But until recently, I had not completed an advance directive for myself. Ironic. Two-faced. Duplicitous. Lazy. Denial. Use the descriptors you wish, but the fact was I had not done my own due diligence.

Yes, I am relatively healthy, have had no health crises, have parents living into their 90s, and saw no handwriting on the wall. There were no major "hard stops" forcing me to face this important detail of my own life.

Conventional wisdom suggests, "It always feels like it's too soon until it's too late." Two events made this personally relevant.

First, my 94-year-old father collapsed and appeared to be imminently terminal. As I discussed this with my mother in the emergency department, she noted his recently completed and available POLST document. There was an immediate and visceral sense of relief on my part, knowing that this had been discussed and documented prior to his decline. I personally experienced the comfort of knowing his wishes and "hearing" his voice about treatment guidelines.

Secondly, I recently sought medical care from a local colleague who works with me in our hospital system to support advance care planning. As he reviewed my chart, he started laughing, noting that I did not have a scanned advance directive on my chart.

I was chagrinned. He was gracious, noting that he did not have his scanned either. It was a light-hearted but seminal point of accountability—a necessary moment of review by outside eyes that allowed me to recognize my own tasks. There was no condemnation, just an identification of what is important.

This is the role that we as health care providers must play for our patients. We must be the mirrors of their words, their self-care, their health tasks, and how they approach life. It must be a collaborative team effort. I cannot do most of their work, but I can sit with them to review how to approach and prioritize health.

Advance care planning is appropriate for me in middle age and for my young adult children. The portions that are completed and the limitations placed on care will vary based on age.

Advance care planning is especially important for our patients with complicated disease and advancing age. These people are likely to face decisions about medical care in the near future. These are the individuals whose medical conditions should trigger flashing red lights in our provider minds if advance care planning has not been done. These discussions are more important than our obsession with blood pressure, blood sugars, and weight.

Advance care planning is not morbid nor primarily about death but rather about how patients want to live the rest of their lives. My older patients are not offended or even surprised by these conversations. They usually seem gratified that someone has taken the time to solicit their wishes.

Advance care planning is not difficult. It can be as simple as describing current health status, considering treatment options, and comparing them with the patient's goals. It does not require special knowledge. It does take a willingness to listen, an ability to look at the big picture, and an acceptance of others' opinions.

Advance care planning has become one of the most satisfying aspects of my professional care. It almost invariably builds rapport and trust with my patients. It helps to guide my treatment decisions. And it fosters care tailored to each individual.

I now have an advance directive completed and digitally available on my electronic health record chart. I just had to be reminded that I am also human, and that an advance directive was equally important for me.

— Leon S. Kraybill, MD, CMD, is a geriatrician with Lancaster General Health in Lancaster, Pennsylvania, where he is the geriatric division chief and medical director of postacute care at Masonic Villages and Luther Acres. He is the immediate past president of The Pennsylvania Society for Post-Acute and Long-Term Care Medicine.