By Ernst Lamothe Jr.
Physician Brian Clemency has been involved in prehospital care for nearly 20 years, beginning his career as a firefighter and emergency medical technician. He discusses five things people should think about before their end-of-life care.
He is the clinical assistant professor of emergency medicine at the University of Buffalo as well as the associate medical director of the Rural/Metro Medical Services of Western New York.
1. Have a conversation with your doctor about your condition and treatment.
Often, people don’t think about what kind of intervention they want when it comes to their end-of-life treatment. Most people don’t even want to discuss the issue whether that’s because of fear, discomfort with the topic or sheer misinformation about the need to put things in order before death. However, having even a brief talk with your physician is vital so it’s clear the kind of life-saving or non-life-saving treatment you desire.
“Patients don’t understand the scope of overall options they have available for their care,” said Clemency, a double board-certified physician in emergency medicine and emergency medical services. “It’s important to understand what your current medical conditions are and what type of invention you want. Do you want CPR administered if your heart stops? Do you want to be intubated? Do you want long-term health care if you are in a coma? Those issues can’t just be thought about for the first time when you come into the emergency room.”
2. Sharing the information with your family.
After the long discussion with your physician to create an end-of-life plan, the next step must be letting your family know about your plans. Medical officials believe they often are the last to know about their own family member’s wishes. Family members may have the best of intentions to advocate for a certain treatment that may be contradictory to what the patients wants. Early discussion can eliminate those issues.
“Sometimes, there is confusion and stress when end-of-life is coming. The patient may not be able to make decisions on their own and family members don’t know what they want to do either,” said Clemency. “But if you have a plan in place and you have already discussed it with your family, then you already know what they would want and there is a clear viewpoint. The last thing you want is for important decisions to be undecided and family members to be fighting about which treatments to do during the most critical times. It just adds stress to an already stressful situation.”
3. Filling out your medical order for life-sustaining treatment completely
A medical order for life-sustaining treatment form — or MOLST — is designed to improve the quality of care patients receive at the end of life by translating patient goals for care and preferences into medical orders. MOLST is based on communication between the patient, his or her health care agent or other designated surrogate decision-maker, and health care professionals that ensures shared, informed medical decision-making.
“Patients must understand if they don’t list any limitations of treatment or don’t have a MOLST form then the emergency departments will perform the most aggressive treatment possible to bring them back to life and sustain them,” said Clemency. “If you leave anything open to interpretation, then physician must make that assumption for you even if you wouldn’t want the most aggressive treatment. You have to fill out the form completely and make sure no detail is left to interpretation.”
Clemency said one of the biggest issues is conflicting information. There are patients that say they don’t want any additional measures to keep them alive, but on that same form they write down yes to questions that would force a doctor to do extra measures to keep them alive.
“When a physician sees that, it can be confusing as to what the patient actually wants,” Clemency added. “You have to treat the form like a complete puzzle that must be put together thoroughly with each piece making sense.”
4. Discuss the difference between quality of life and duration of life
Because of modern healthcare technology, there are more ways to keep a patient alive longer than ever before. However, just because that is an option doesn’t mean every patient wants it.
“When thinking about certain interventions, it is critical to know the difference,” said Clemency. “Do you want your care to focus on keeping you alive as long as you want? If so there are a list of treatments that could make that possible. Modern medicine allows us to do that, but some invention can also cause more issues.
5. Make sure the form is with you
Clemency believes while this last step might seem to be the simplest, it often is overlooked.
“If the patient is moving from one nursing home to another, they have to make sure their form is with them,” he said. “Unfortunately the MOLST form is not in electronic form so you have to make sure that paper is with you when you travel or if you move. You need to make sure the form follows you wherever you go.”