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All Veterans, whether healthy or ill, young or old, receiving health care
in a clinic, hospital or at home, deserve to have their wishes heard
and health care preferences honored.
This is one in a series of stories about Veterans’ values, goals, and preferences.
This is Suzanne’s story about making a plan for life- sustaining treatment.
Suzanne spent eight years in the Navy.
Toward the end of her time in the service Suzanne was diagnosed with ALS,
also known as Lou Gehrig’s Disease.
She recently transitioned from using a cane to now using a wheelchair.
While her wife and children understand her speech,
she uses technology to assist in her communication with people outside of her family.
Suzanne adores her kids and enjoys meaningful moments together with her family.
Someone who doesn’t know her may not recognize the dignity that she maintains
with each day and the joy that she continues to experience in daily living.
Suzanne has an advance directive that she completed 5 years ago
outlining her wishes if she got more ill in the future.
She recognizes the need to continue to review and update her advance directive
routinely as her medical condition changes.
Suzanne’s doctor suggested that he and Suzanne have a goals of care conversation
now that her illness is progressing.
Suzanne can share what is important to her now, what she values,
and what her goals of care are.
Suzanne decides that she would want CPR and other life- sustaining treatments.
The doctor explains that now that she has made specific decisions
about life-sustaining treatments for her current care,
it’s important that she have a Life-Sustaining Treatment plan
and orders in her medical record in addition to her advance directive.
Over time, Suzanne’s breathing muscles continue to weaken.
Suzanne and her doctor hold regular conversations to ensure
her health preferences are updated in her medical record.
Suzanne works with her doctor and health care team
to revise her Life-sustaining Treatment plan as her condition changes.
If her muscles were to weaken more, she decides that she would want to stay home
with her family and not be resuscitated if her heart stops,
or go to the hospital where she would be “hooked up to machines”.
Her doctor updates her VA life- sustaining treatment plan and orders
and also completes a state- authorized portable order form, otherwise known as a SAPO,
so that her LST plan can also be honored if she receives health care outside of VA.
Suzanne keeps her SAPO form on her refrigerator at home, so that it’s easy to find.
Suzanne’s goal is to enjoy time watching her two kids go fishing at the local lake.
She has discussed with her wife what that means for her in various medical scenarios
and she appreciates that her loved ones won’t have to make difficult medical decisions
for her because now she has a plan that lays out all of her decisions.
Talk to your health care team about what’s important to you
and how to ensure that your preferences for health care are documented in your
electronic health record.
For additional information,
visit the VA National Center for Ethics in Health Care’s website
at www.ethics.va.gov/veterans.asp.