Hi and welcome to our talk on helping your patients determine their Medical
Durable Power of Attorney. My name is Peggy Budai and I am a Clinical Nurse Specialist
and Nurse Practitioner here in Fort Collins. I work in the older adult and palliative care
department and prior to that I worked for 10 years in long-term care. In that role as
the in-house Nurse Practitioner, I really saw how important it
is to help ensure we have our patients choose the right
person to speak for them, to choose the right MDPOA, it really makes all the difference.
I’m Jean Abbott and I work for the Center for Bioethics and Humanities at the Anschutz
Medical Campus, I do a lot of outreach on Advanced Care Planning in the community and
I work with the Conversation Project. I too have learned the importance of patients having
somebody who can speak for them if they can't. So why are advanced directives so essential?
We have learned that when people have a chance to talk about what's important to them that
clinicians and families are more likely to understand and honor patient’s wishes near
the end of life when they can't speak for themselves. In addition, advance directives
sometimes have a secondary effect of reducing unwanted hospitalization at the end of life.
In a time of COVID, a recent study out of New York City said that talking to very elderly
patients even in the emergency department, which is not the best place to have goals
of care conversation, that talking about goals of care and advance directives decreased the
number of people who wanted admission to the intensive care unit from about 80 some percent
down to about 20 percent. Also when advance directives are in place it can help utilize
hospice services appropriately. In Colorado, over half of people die while they're receiving
hospice services but as is true across the country, a third of those patients enroll
in hospice just in the last week of life. Likewise, advance directives help assure that
a patient is more likely to die in their preferred place, whether that's at home in their residential
care facility or in the hospital getting aggressive care, if that is what they wish.
So why is this important? The way I like to present it to my patients is 50 percent of
people will not be able to speak for themselves near the end of their life. And a vast majority
of us will be in a situation where active decisions need to be made at the end of life.
For instance, not continuing with dialysis, not being admitted
to the ICU for sepsis, or something that is a decision
that will result in death. So what is the key question? It really is a very basic question
and when you as a provider talk with your patient, the question is, who would you want
to speak for you if you couldn't? So when we're helping our patients, think about who
they would choose for their agent. Here's some really important questions for them to
consider. The first one: Do they know you?
Do they know you well not only that but are they able to talk to medical folks?
Do they have that ability to advocate for you and if there were potential conflicts
between your family members, would they be able to navigate that landscape?
Are they accessible? They don't have to live in the same town but
would they be able to come and be at your bedside, that's an important factor to consider.
And then really can they speak to your values? The patient's values more than their own and
this ability to speak to someone's values really relies on a really good conversation.
So those are important things for people to know, to be able to do and at the end. We
are providing some resources for you. One of them is a document called how to select
your healthcare agent, it's a really great resource for you to provide to your patients.
So why are we doing this now in the era of COVID-19? Frankly, these kinds of conversations
need to happen at all times but I think that at this time we all have a heightened interest
in talking to our patients. These discussions have become much more real and as providers
have talked to their patients they've discovered that they are much more welcomed in having
these conversations than they might have thought. In addition, even if patients have existing
written advance directives, this crisis of COVID is maybe a different kind of death that
they are contemplating, then you might have foreseen in the past. Perhaps, the patient
thought they would die of a stroke or a heart attack or kidney failure or something like
that. But this death from respiratory failure. Ventilator, ICU sedated, and isolated is a
different death and makes people think about what they would want in a different kind of
way. In addition, because of the isolated ICU kind of death, COVID-19 may be more likely
to require that somebody speak for your patient rather than they be able to make decisions
for themselves. And as we practice talking about death we become more comfortable and
likewise our patients in talking about death become more comfortable with the fact that
we are mortal beings. Now, how do we document this? Patients are able to make a designation
either verbally or in writing and frankly the bar for being able to make these this
decision is a little lower than the one for the content of the decisions or the exact
treatments that they want. They still need to be able to tell you, why it is. I'm choosing
my spouse because I've been married for 30 years and he understands what I want. Or I'm
choosing a friend because I know that my family will fight. So they need to be able to give
a reason but they don't need to be able to manipulate information quite to the extent
that they might for other health care decisions.
There is a Colorado Hospital Association form, you probably have this pamphlet in many of
your offices. It is the usual form but other forms are acceptable and frankly if you document
a conversation well that is as acceptable as the standard form. The documentation should
include the time, the date, and the patient's name as well as why they can't sign the form
which is not all that common in the crisis of COVID-19. A reminder that witnesses and
notary are optional for the MDPOA. They do not need to be done by a lawyer or anybody
formally. What are the challenges of COVID? The challenges are that the time is pressured
and people are isolated, there's nobody in the same room oftentimes and this is done
virtually. Which is why we're urging everybody to try to have these conversations ahead of
time with their patients as we anticipate another surge and more critical illness.
Now, the other important thing to know about medical durable power of attorney is that
choosing an agent is particularly important in Colorado. Because in Colorado there's a
hierarchy who decides. A patient who has decision making capacity obviously decides for themselves
what kind of treatments they want or don't want.
If they have a legal guardian, that person decides as the patient, if the patient designates
an MDPOA, an agent who is assigned by them when they have decisional capacity that person
speaks as the patient. However, in Colorado if you don't get a documented MDPOA, as a
patient, our law says that there is no hierarchy that says oh your spouse will speak for you,
or your eldest child. There's no rank hierarchy, it's a strange law and that happened in the
1980s and said wait a minute there are lots of interested people. Some of whom are legally
recognized or not this was the beginning of the AIDS epidemic when some people were estranged
from their family. Some people had partners who are not legally recognized and so the
idea of the law is to say who can best speak in the voice of the patient. Now this can
be challenging when you have a round table of people who all have different opinions
about what the patient would want. The benefit is, I think, that it may be that somebody
who's not an obvious choice is the one who can speak best and I think maybe this law
is good at getting at that best person to speak when the patient can't. So one of the
important things for us to know is that now we can bill for these discussions and there's
really no limit to the number of times that a provider can bill in a given time period.
There's a couple of billing codes that you can see, a couple other caveats, it's
not limited by specialty or location and you don't have to complete an actual form to be
able to bill. I think this is an indication of an understanding of really the most important
part of this is the conversation. And even though there are billing codes, you don't
have to bill separately. You can just include this discussion in a
regular note. And at the end again because billing is a fairly complex issue we have
a really robust resource that will help you with understanding
all the billing and time issues. So let's get down to the actual form itself, a few
practicalities. It's really important we've learned over the years of helping people do
these, make sure that people include their date of birth. This is really essential so
that medical records can make sure they scan it into the right chart. Scanning it in is
a really important caveat when you help patients complete these. It's important to have someone
in your setting help you know how to get that scanned into the medical record. And of course
an important thing is having the most accurate phone numbers for the agents. And then when
you look over there is a place for people to put optional language this is obviously
optional and one of the caveats we tell people is not to put that they don't want attempts
at CPR here or that they wouldn't want certain treatments. For example, on a medical order
for scope of treatment form that this is not the place to document that alone. It must
also be on a MOST form. What I have on my form is that if I'm in a terminal condition
and I've talked to my sister who's my Medical Durable Power of Attorney, that I let her
know that I want to die at home with my pets on the bed with me. It's a place for people
to put things like that to really to put the things that they've had a conversation with
their agent about. It also like Jean said witnesses and notaries are optional, the benefit
of people do want them is that if they travel a lot. Some states do require a notary and
witness but we really want to make sure that this doesn't become a barrier and that we
really get these documents done. Then finally the COVID challenges with signatures, Jean’s
kind of spoken to that because of the challenges now more than ever it's important that the
information regarding who a person's medical power of attorney is whether it's documented
in a note or on a form is communicated to the next level of care or to the other folks
that are involved. Involved so that we make sure we're talking to the right person. So
in closing there's a few pitfalls and complexities. Just to remind you of the first thing, a lot
of people think that if they have a power of attorney, a POA, that they have a medical
power of attorney but the authority for medical decision making is not
part of the general POA. It is important as the provider or the person that's helping
advise your patient to normalize the fact that lots of
people choose people other than their spouse. This is particularly true if your spouse is
frail and/or if they're frightened by such decisions. People have said that the longer
that you are married, the harder it is to let go.
Also, the fact that you don't necessarily talk about these things so it is important
to have the conversation it's important to help them understand that a partner or a friend
is also a consideration because a lot of them may not have thought about that and if there
is no clear choice, no obvious family or friends and that's happening increasingly it's okay
to suggest some other alternatives. Is there somebody in your faith community or somebody
in your apartment complex that you're close to that you can share decision making and
appoint each other agents and have conversations. There are people who are available for a price
to be geriatric advisors and navigators, who will be able to be assigned as your medical
durable power attorney if you wish. It does cost some money. So in conclusion, here are
just a few resources to use that we've referenced. The first one is a simple one-page MDPOA fillable
form. The second one is the billing guide I mentioned. Then the guide to selecting your
healthcare agent. And then the conversation project guide is a COVID specific guide that
was developed by the conversation project and it's a really great guide in the time
of COVID to help people understand how to pick their person, how to talk to them, and
how to think about what they would want if they became seriously ill with COVID. So,
thank you for joining us today to learn about how to help
your patients determine their MDPOA.