“Don’t Resuscitate This Patient!”

John Ross and Lisa Shoalmire Radio , , , , , , , ,
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Elder Law Attorneys discuss the details of living wills and what exactly is a life-continuing procedure?

John

Live on Facebook about to get started on the show, got Annette with me. So here's the opening music.

John

Not Lisa.

John

: John: All right, here we go.

John

: Welcome to "Aging Insight" everybody, this is your host John Ross, here Live in the studio. You are listening to the number one place to get information on your health, housing, financial, and legal needs. I'm John Ross, and I'm your host, normally here in studio with my co-host Lisa Schoalmire who apparently just likes to go off and do things on the weekends. So once again, I am here not with Lisa Schoalmire, but I have brought in a guest. So today joining me is Annette Mugno with Dierksen Memorial Hospice.

Annette

Who has no life and nothing to do on the weekends.

John

Clearly.

Annette

There you go.

John

So there you go, and you have been on the show before.

Annette

Been a long time. Glad to be back.

John

Excellent, so lots of good stuff going on out there. I spent quite a bit of last week out running my mouth. I think I was in Camden one day, I was in Marshall one day, I was in Carthage one day because we like to get out there and get you all the information that we need. And as far as that goes, coming up on the 23rd which will be in about two weeks, we'll be back with our Eggs and Issues Breakfast over at Trinity Church. It's free breakfast about 0830 in the morning over at Trinity, right there off the interstate. And it's a great program. Topic, I believe is going to be, scams on seniors. Particularly, we're gonna be talking about some of the more modern takes on it because we're seeing them get more and more advanced as they go along.

Annette

I did not. So I'm sitting here doing the walk of shame, I promised you I would. Unfortunately, I got a call that said I was gonna be in Charleston, South Carolina, so I'm not gonna be there.

John

Surely there's somebody with Dierksen that needs to go over the edge.

Annette

There's a lot of them I can think of that need to go.

John

Well, we're gonna have to pick us one, we're gonna pick us one with Dierksen because...

Annette

But it is work that's taking us there so a lot of us are gonna be going.

John

Because you know one of the things that we have…and this goes to all the listeners'. Maybe you work at a shop or whatever, you got your job. We have a thing that we're calling Toss the Boss. So sign up the boss, get all the staff people to throw in the money, hit that $1,000 mark, and they're going over unless they match it.

Annette

Gotcha.

John

And if the boss matches it, then they can pick somebody else to do it. So maybe...

Annette

But all the bosses are gonna be there, so none of us are gonna

John

Come on, we are gonna figure something out. Somebody's gonna do it. All right, so that's coming up. It's gonna be a great program. And like I said, if you're not interested in doing it yourself, we've got lots of edgers, that's what we're calling them, lots of edgers out there who would love to have your support. And of course, all the money goes to the Tri-State Alzheimer's Alliance right here in Texarkana, and it's local. All the funds stay here local, and provides a great support. Particularly, those funds help keep the Our Place Day Respite Centre running.

Annette

Am I? I thought I was just her as a sidekick.

John

Yeah, just somebody...

Annette

Just hanging out.

John

Just somebody for me to have in the studio with me today. So what's your background here? You're a nurse, right?

Annette

I'm a nurse, I've been a nurse for... You know, do I really need to say how long? It's been a long time I've been a nurse.

John

Let's just say that you've done it long enough to be somewhat of an expert in the field.

Annette

Right. In some areas you could say I've been grandfathered in. I've been doing it that long.

John

There you go.

Annette

And then I've got over 15 years of experience strictly in hospice.

John

All right, so definitely know what you doing out there, and of course, you work for Dierksen Hospice.

Annette

I do work for Dierksen.

John

Is it Dierken or Dierksen?

Annette

It's Dierksen.

John

Dierksen?

John

: Yeah.

John

: Everybody mispronounces that.

Annette

Yes, well because there's Derek's Arkansas and so it's Dierksen. And sometimes it's spelt with an e, sometimes its spelt with an o, sometimes it's Diorksen. I mean…

John

Well, of course, everything in Arkansas is mispronounced too.

Annette

I don't care how you say it as long as you call us.

John

That's right, all right. So, fair enough. All right, so I was reading an article this morning and this was in "The Washington Post," and it was talking about how living wills, DNRs, things like that are misinterpreted often by medical staff. And anybody who's listening to the show before has heard Lisa and I say over, and over, and over that there are four things everybody walking around over 18 in the United States should have in place. That would be a financial power of attorney, a medical power of attorney, a HIPAA release, and a living will.

Annette

That's right.

John

And what happens if that adult person becomes incapacitated. What if they get in a car wreck down there in Waco? And I've had many parents find out the hard way that just because they're the parent, doesn't mean they have any say so whatsoever on that adult person.

Annette

That's correct.

John

So we talk about all of those things, and the last one of those being the living will. And I mentioned I was speaking in Marshall, and my topic in Marshall was actually related to how to save a house from Medicaid. But as it always happens, I get folks asking questions at the end, and somebody in there said something about a DNR. And I said... Well, I think they asked about you know, any documents. I said, yeah you know, medical power of attorney, financial power of attorney, HIPPA release, living will, and they were like, "Yeah, living will, same thing as that DNR, right?"

Annette

No.

John

No. Right. Unfortunately, as common as that misconception is in the general population, what's really concerning is if that same misconception is in the medical community. And I have found that to be the case in some situations.

Annette

It absolutely is. And the other thing that's really confusing to the medical community is we are very unique in being in this Tri-State area. And with each state, the law changes a little. So some of our physicians that are from Texarkana may have trained in Arkansas, and then they come and practice in Texas and vice versa. Some of them go to LSU and then they come up to Texarkana, and all of the regulations regarding the state change.

John

Right, because all of these rules are state-based rules. There's no federal rules related to these documents, other than the HIPPA, I guess. But when we're talking about these end-of-life type decisions, yeah, it's all based on state law, and the interpretations are based on state law, and they can get really complicated. There's a whole semester-long course in law school that's called, "Conflicts of Law," and it's a whole class in law school on what do you do when you've got different states doing different things and... So if I'm a Texas resident but I'm in a hospital in Arkansas, then which a law applies? Is it Texas law or is it Arkansas law?

Annette

Exactly.

John

And there's a whole… Like I said, there's a whole complicated semester on this in law school, which kills many law students because it's so complicated. So even the people that are trained in legal stuff have a hard time with this issue. So you certainly get with the medical. But anyway, so this Washington Post article had had this...it opened...the thing opened with this scene from a hospital. And they've got this person in, they're unconscious, they're maybe having a heart attack or whatever it is. And the nurse yells over at the doctor and says, "Don't resuscitate. They've got a living will in place." And you're laughing because to us, that's funny because it's so wrong.

Annette

It's bad wrong.

John

It's so wrong. So we're gonna talk about a lot of the sort of things today, and just kind of the differences between the two, and maybe some things that y'all can do out there. So let's start with the living will, right? So in your... I can talk about it from what it is as a legal document, but tell me in your medical opinion, what is a living will?

Annette

A living will is what the patient themselves execute, that just kinda has what they would like to have done at the end-of-life, okay. So there's a will like you would deal with every single day, "When I die, I want so and so to have this."

John

Yeah. "Little Timmy gets the car."

Annette

That's exactly right, but a living will is exactly what it says it is, it's what is your wish while you're alive? But unless it's been executed into a formal document, and the power of attorney is there, and then you have DNRs, and all of these other things that have to roll along with it, it really isn't substantial. And let me just give you a word of advice when it comes to physicians and nurses and all the people who are actually putting hands on them. And I know this is terrible. But we're in a very...our society is to a point now where we'll sue each other because we dropped coffee. And it's our fault but you were there and you laughed and so now I'm gonna sue you because you humiliated me.

John

That's right.

Annette

So people who are no longer alive can no longer sue you, but family members absolutely can. And even if they knew that was the wish of the patient, they're gonna sue you just because they're in mourning and you're liable.

John

Yeah, and the doctors know this, the hospital's know this.

Annette

Yes.

John

The rest of the medical professionals know this. So yeah, you know, from the legal standpoint, that living will is you saying, "Here's what I either want or do not want once I have gotten into a certain particular situation." And that certain particular situation is that you have an irreversible or incurable condition that will cause death without continuing medical intervention. Or you are in a persistent vegetative state.

Annette

Yeah, seems simple

John

It's seems simple. And I think, you know, a lot of times people say...at least when I'm talking to them, they often say, "Yeah, John, just pull the plug. You know, if I get in that spot, I'll just pull the plug."

Annette

Yeah, and I mean I have this conversation, I have this conversation daily with patients and families, and I have this conversation pretty frequently with my spouse, my children, and my family. And we as people tend to say, "Do we want it?" and actually there's a lot of studies out there that have been done that says you know, when we went out and we did a perception survey, how many people said, "Do you wanna live in a constant vegetative state?" Well, almost 100% of them said, "Absolutely not." But then they ask, "What have you done? What have you put in place to prevent that from happening?" And almost 100% of them said "Nothing."

John

Yeah, and that's pretty much right. All right, we're gonna take our first break of the day. So stick around until after this. We're gonna get into a lot of the other details: the differences between the living will and DNR, and some things like that. So lots of good information today.Stick around, we'll be back.

Annette

I'm gonna stand up and let the...

John

Let the blood.

Annette

Blood come back to my legs. You all are gonna get to see what happens whenever I choose to stand.

John

Yeah. So just disappear below the...

Annette

Yeah

John

There is a height difference between Annette and I, slightly.

Annette

There's kind of a height difference between me and everybody.

John

Slight height difference between the two of us. All right. Here you go, pop quiz, right? So you're at the hospital, right, you're in the ER, they have brought in this unconscious person that is, as you and the hospital people like to say, actively dying, right, which to me is the weirdest phrase ever.

Annette

There's more phases than just active even, there's transitional, there's...sometimes it's even circling the drain.

John

So we got this person that's actively dying, you got them in there, you pull their shirt off and this is what you see.

Annette

What am I looking at?

Annette

Oh that's cute. It's not effective.

John

Very good. This is true. That is not effective. This was actually... This is a real picture from a homeless person that was picked up off the streets in Chicago who...

John

A tattoo across the chest that says, "Do Not Resuscitate."

Annette

Is a great idea, and I wish it were. I wish it were a legal document. I mean, I can't imagine anything more permanent than taking the time to ink it on yourself. That's exactly how, you know, you think you can...when I can't talk, you can still read me.

John

Right, see here.

Annette

That's exactly right, but it's absolutely not effective.

John

Yeah, so the hospital in Chicago, they did go ahead and administer life-saving procedures and saved the guy. And there was some discussion as to whether or not they had done the right thing. I actually say that they did the wrong thing for the right reasons.

Annette

Well, I started to say, the question isn't really did they do the right thing? It's like, did they do the right thing, or did they do the legal thing? And sadly, that's what it's come down to, and you can hear me say that over and over and revert back to legal things. Look at malpractice insurance nowadays, and it will exactly explain why I put so much focus on it. It's not the right thing in any way. It is, however, unfortunately, the legal thing.

John

Yeah, the interesting thing on that would have been what if he would have had two witnesses, and his treating physician also tattoo their signatures onto his chest?

Annette

Now, that would have been okay.

John

I think it might have been.

John

: Annette: I think it would have worked actually.

John

: John: It just might have been.

Annette

Nobody said the paper or the parchment had to be of any particular matter. It just said you had to have those things.

John

Yeah, you just have to have those basic things. Anyway, I just always thought that was interesting. I did a whole show on just that one a while back.

Annette

Yeah, you're gonna get to watch me climb up. It's like a ladder.

John

All right, we are going back to live in four seconds.

Annette

I'll take the earphones off.

John

What?

Annette

I have to take the earphones off with the short in it.

John

Okay.

John

All right, here we go. Welcome back to "Aging Insight" everybody, this is your host John Ross here Live in the studio today with Annette Mugno. I have to... Mugno.

Annette

Okay, I'm gonna have to say.

John

I have to... Every time I say it, because I've known you for so long that I have to remember that you have a different last name.

Annette

I do.

John

So that I stumble every time because I don't wanna mess it up and I mess it up anyway.

Annette

Everybody messes it.

John

Yes, so today we're talking about living wills, DNRs, and this sort of stuff. So we were been talking about the living will, which is you saying what you want there at the end-of-life or don't want there at the end-of-life. And I think one of the things that a lot of people don't necessarily understand is, what exactly is a life-continuing procedure?

Annette

That really varies. I mean...and there are documents that can break it down into very, very, very specific things, and that's where we get into some issues. Is because the average Joe on the street doesn't know what constitutes a life-sustaining device. And then some life-sustaining devices can be used strictly for comfort. An IV could be considered a life-sustaining device, even if it's just putting fluid in because if we don't have fluid we die.

Annette

: John: Exactly.

Annette

You can't go more than about three days without hydration. So in that circumstance, absolutely is considered a life-sustaining device. Oxygen absolutely a life-sustaining device, although if you are actively dying and you are truly terminal neither of those will save you independently.

John

Okay, yeah, and others that are...something as common as antibiotics.

Annette

Absolutely, absolutely, and lay people tend to think of what is a life-sustaining device, we wanna get really technical and go those are things like ventilators, and being intubated, and CPR, and they are. Those are a more aggressive life-sustaining devices, but there are lesser aggressive life-sustaining devices as well.

John

Yeah, and I think this is where a lot of people...again, they don't necessarily know, and I have...although I will say that the vast majority of people once I explain to them where they would be at this point, right, how far down the road of bad health they are, before this becomes an issue.

Annette

Actually yeah. The question for most people, the way I tend to put it, and I wrote it down so I get it right because, you know, this is what happens, is do you want a long lifespan or a long health span? And those aren't necessarily the same. We all tend to think, "Yeah, I'd love to be 110," would you though? What if you couldn't communicate? What if you were in a vegetative state? If you were in a bed, contracted, and you were in constant need of all of your ideals or activities of daily living. You had to be fed by a tube, you had to be changed by someone else for your incontinent care, is that a life that you want? So in that case, do you wanna be 105, or do you want to be whatever age that you stop sustaining yourself with quality to yourself, what you consider quality?

John

Exactly, and then the other thing that I think a lot of people have some misconceptions on beyond just that, you know, one they don't know where they're gonna be in this position. And once it's explained, look...like you said, you know, you're gone basically, right? Your body's there but all the other things are gone, and then now would you still want these things? The other thing I see a lot is people have a misunderstanding of essentially how death works. And so, for example, I had somebody just the other day that... They had a big issue with artificial hydration, right? They said, "I want the living will, no artificial means whatsoever except artificial hydration."

Annette

Right, and so then it comes down to semantics, and really a lot of study. And this, honestly guys, is still a real controversial thing even in the healthcare industry. Because I know some healthcare professionals who've said, "I've been really, really, really sick and I was thirsty and I wanted hydration." Yeah, but it's hard to know what happens when you're actively dying, or you're terminally ill. Without getting too religious, I always say there's a way we were made to come in this world, and there's a way we are made to go out of this world.

John

Good stuff. We'll be right back after this break. Sorry.

Annette

Sorry. I was like, "What are you doing with your fingers, man?"

John

I was trying to count you down.

Annette

You're used to playing with Lisa and you all know this thing, I'm just like.

John

Yeah, I forgot to warn you our bottom of the hour, we have to take a news break, Fox News starts…

Annette

The things you should tell me to begin with.

John

Fox News starts at 12:30 whether you're still talking or not, so all right...

Annette

All right, so we learn or I learn, who knows.

John

Well, Arwen did give you a thumbs up.

Annette

Sweet. I love Arwen.

John

So there you go. You know, I had a...and I may mention this, but I had a case years ago where a gentleman was at that point, had two daughters and he was a silent aspirator.

Annette

Yes/ Does everybody know what that is?

Annette

:John: Meh, probably not.

Annette

So sometimes...and I always wanna make sure I'm not talking over anybody, and I'm also not wanting to offend anybody by you know, making...or assuming that you don't know what we're talking about. But a silent aspirator is a person who when they drink or eat food, rather than swallowing it down their digestive tract as they should, part of that goes into their lungs. And they will develop what is called an aspiration pneumonia where the fluid collects in the lungs.

John

Right. But they're so paralyzed that they don't cough or choke?

Annette

Right.

John

They...

Annette

And sometimes even if they do choke or cough, it doesn't matter, it's too late. I mean, I've literally looked at X-rays with patients that had bacon and eggs in their chest, yeah.

John

Okay. That's nasty.

Annette

It is, but again it is 100% accurate. And so one of the things that I was talking to my husband about this morning, I said you know, I just want people...the reason why we do these shows are to make people understand what you see on television isn't accurate. A lot of what you hear is people who are semi-educated on it and a lot of times isn't accurate. And so I just wanna break it down into a regular conversation to where we're putting accurate information out there. So when you make these informed decisions, they're informed based off of something that's actually accurate.

John

Right, well, and of course, this was one of those situations where we had two daughters, they did not like each other. And so you can imagine that they had a difference of opinion when it came to the care. And the doctors had said, "This is a done deal, this is permanent. There's no going back from here." So it's either feeding tube or not, and my client said, "Dad wouldn't wanna live like that, let him go." The other daughter said, "This is cruel because you're starving him to death," is that starving him to death? No.

Annette

No, again back to what...

John

And so explain it, so why isn't it?

Annette

Well, okay. First of all, can we withhold nutrition? Absolutely. Should we withhold nutrition? That's up to the person that we're withholding nutrition from, okay. So it's their perception as to what they wanna do as to what you really consider it. So is it keeping them comfortable or is it forcing nutrition on them? Because it's just as wrong to force something on someone who doesn't want it. And like I said before, a lot of times when you're in a terminal state, you aren't hungry. So you will offer food and they will often times tell you no.

John

Well, and in this particular case, one thing we did have was he did have a living will in place and it specifically mentioned no artificial nutrition. Whether or not he really had thought all of that through, or whether or not he had just signed something that somebody had put in front of him, I don't know. But what we did have was we had what was on paper which was no artificial nutrition. Unfortunately, we had to go and have a judge confirm that, and then get an order sent back to the hospital and everything.

Annette

For them to not give him artificial nutrition.

John

For them to not do it.

Annette

And that's exactly right.

John

All right. Going back live. Welcome back to "Aging Insight" everybody, this is your host John Ross here in the studio with Annette Mugno of Dierksen Hospice. Is it Dierksen Hospice, Dierksen Memorial Hospice or…?

Annette

We'll just call it Dierksen Hospice.

John

Dierksen. I still messed up, didn't I?

Annette

It's okay.

John

That's fine.

Annette

Actually, just so we put it out there, it is actually a long name. It is Lester Dierksen Memorial Hospice because that's exactly what it is. It's a memorial hospice based off of Mr. Lester Dierksen.

John

Got you.

Annette

But for that for all of us out there, it's just Dierksen.

John

All right, if you're listening to the radio, you can also login to Facebook, as we've been doing for about a year now. We're doing all the radio shows on Facebook Live. So if you'd like to see how to spell Dierksen, I have put it on the Facebook, so that you can see it. And you can also get on Facebook and see the height difference between John Ross and Annette.

Annette

This is on an elevated stool.

Annette

John this is on an elevated stool. All right, so we're obviously... You know, the thing is, you know, you're in the hospice business, so you get to talk to people about...

Annette

Death and dying, absolutely.

John

Death and dying on a daily basis. I'm in the estate planning business, which means I get to talk to people about getting old, getting sick, then dying on a daily basis. And so people that are listening may seem...maybe it seems a little squeamish to them that you and I are laughing and joking, while at the same time having this conversation. But that's the way it should be, right?

Annette

Right, and that's what I was laughing about this morning. I said, "This outfit isn't..." because John gave me an hour's notice that, "Hey, I could use you to come in here and sit with me if you want." I'm gonna say this was done intentionally to take on a comfort level because that's the level we should present it at any time we have that conversation. I really wish people wouldn't wait until the last minute, until someone is actively dying or very sick, terminally ill, before they have that conversation. Have that conversation over coffee, just sit down and start talking about it one day.

John

Yeah, and again, you confront this stuff head on. At least that's my personal philosophy. I have a friend of mine that was in my Marine unit, he's actually I think a year younger than me, and he has pancreatic cancer.

Annette

There you go.

John

And I found out a couple months ago, and when I found out I gave him a call and I said, "Hey man, I hear you're doomed."

Annette

Exactly.

John

And you know what, that immediately broke the ice, it got us past the big elephant, and then we could go on and have a two-hour long phone conversation about old times, and it was great. You know, so yeah, so we do, we joke about it but it's serious stuff but you gotta just face it, and go head on.

Annette

It happens and sometimes people… Nobody knows better than a terminally ill person that they're terminally ill, and they get accustomed to people. Everybody that comes in and talks to them about being sick. Please don't ever forget that they're still human, they're still the same person who you knew six months ago, or a year ago, or two years ago, that wanna have companionship last time with someone who wants to talk to them something about other than being sick. And if you do talk about being sick, make it funny. One of my really good friends that passed away, she had liver cancer, her eyes turned very, very yellow, and so when she took her sunglasses off one day, I looked at her. I said, "Oh my God. Is there a superpower that comes with those?" you know, "Do you have x-ray vision? I just need to know."

Annette

: John: Exactly, that's exactly right.

Annette

So try to make light of a difficult situation if you can.

John

So we were talking about the living will which again, the living will kicks in once you...you know, this is you while you're alive and competent and thinking down the road, and saying, "Okay, if I've gotten to this end-of-life point, what kind of procedures would I want, would I not what?" One of the most common misconceptions is that the living will, which is also called a directive to physicians if you live in Texas. Because apparently, the Texas legislators had to give it a brand new name when everybody already knew what it was called.

Annette

And we can really confuse them with Texas.

John

So living will/directive to physicians, same document, different names, but people often confuse that with the Do Not Resuscitate order or DNR. These are not the same things, right?

Annette

I wanna watch a professional get stumbled up by this. I really do, because this is really difficult for everybody. So I'm just watching you trying to sort this out, if you can make it sound better than me.

John

So here's my DNR. The DNR is Do Not Resuscitate which basically, the way I often describe it is if the death process starts, don't stop it.

Annette

Pretty much, yeah.

John

That's how I describe it.

Annette

Okay. And, let me just also add, in the lovely side of Texas, there are two separate DNRs. And why this is, I'm not aware. So don't look at me. It's not my fault. I didn't do it. I'm just making sure you know ahead of time. You're gonna need two, if you find out you're dying in the hospital, there is a in-hospital Do Not Resuscitate. And then if you decide you wanna go home, and continue your dying process at home surrounded by people that love you in a comfortable environment, then you have to have another one that is an out-of-hospital Do Not Resuscitate.

John

This is also correct.

Annette

Yes, and you have to have it before you leave the hospital because if you only have the in-hospital, and you get on an ambulance and you get around the corner and you start dying, they're gonna code you and send you back to the hospital.

John

Right, so yeah. You do have... So yeah, in-hospital DNR, out-of-hospital DNR. They're basically, you know, from a medical standpoint, they're basically still the same thing.

Annette

They are.

Annette

So why do we need two?

John

There's no reason.

Annette

Go change that.

John

Unfortunately, I've got…well, I was gonna say something nasty about the Texas legislature. But since I'm live broadcasting on multimedia, I'll...

Annette

I've been thinking about saying something nasty about Texas legislature.

John

I'll just keep my mouth shut for a moment on that issue. So I got a call...actually, I think it was an email, but I got a call, email something. It might've even been a comment on Facebook at one point. But this was from a hospital nurse and they had a person in hospital with an in-hospital DNR, and they were they were feeding the person who basically choked on it. And the question was basically, you know, doing any sort of intubation or anything to clear that blocked passage, is that appropriate with the DNR or not? That's a tough one, isn't it?

Annette

Yes, so I wouldn't consider a finger sweep, if you were choking, to be resuscitative measures. Because...let me just throw this in there. For what we do on a daily basis, if a patient is on hospice and they have a Do Not Resuscitate order, I still give them antibiotics. I mean, we've already talked about it. Antibiotics could be life-sustaining in certain circumstances.

John

But it's not a DNR issue. That's a living will issue.

Annette

Right, so a finger sweep is not considered really a resuscitative measure in and of itself. Now, if the easiest modes of transportation in getting that out were not effective, then what would you do?

John

Right, and that was basically...that was my position on it, was essentially if a tool is involved. I mean basically...

Annette

Well I mean if you...because it's a hospital. So the patient has got a DNR, yadi-yada, so you're gonna have suction. Now, oral suction versus endotracheal suction down in your chest, there's even a difference in that. If I were to suction out your mouth, you do that at the dentist office. That's not really considered...

John

That's no big deal.

Annette

…life-sustaining. And I would do that if that could. You could see it. If you can see if you can visualize it, yes. But then if you're gonna start something super aggressive, is that what you wanna do? Is that what they want you to do is actually the question.

John

And the main thing I think people, the general population, particularly needs to understand is that there is a big difference between that living will and that DNR. I've had some folks that were very hesitant to take my recommendation of doing a living will because they had the impression that if they signed that document, and then had a heart attack, that everybody was gonna sit around and drink tea while they died.

Annette

Right. And that is a very common misconception.

John

And it's just plain wrong.

Annette

That is absolutely wrong.

John

And we cannot say that enough. And just like when we were talking opening, that same misconception does even get into the medical community. In the news article that I was reading where, you know, the nurse says, "Hey, don't do CPR, this person has a living will in place." And you and I both started laughing because that's just wrong. Those are two completely different things. All right, we're gonna take one more break. When we come back, we'll finish talking about this. Yeah, no there's no timeline now. So I can just... So there's no...

Annette

I'm just giving you completely irrational finger movements because that's what I thought I was getting earlier.

John

No. There's no risk of you talking over the Fox News announcers this time. All right, we'll be back here in just a second. Stick around. All right, of course, we're still live on Facebook.

Annette

Yeah, also, I mean, we'll just continue that conversation. I've actually had patients who had DNRs who were on-hospice. The family had come in, specifically said, "You know, they are silent aspirators, they have a feeding tube, we put a feeding tube in years ago because we thought that it would just bring them back to health." And so many people find out that's not accurate at all, and they were in a long-term care facility, and after three days, we kind of thought, "Well, if they're not getting any hydration, then they should start to pass," okay. Nothing happened, no change. There was an order in place. Nothing by mouth, no feeding tube. Now I think its gonna get real controversial here. Thirty days into it, this patient is still alive [inaudible 40:28] what is going on?

John

So no food…

Annette

No documented…

John

No documented…

Annette

…food or water.

John

And it's been 30 days?

Annette

Because the patient had a DNR, the family had clamped off the feeding tube or given an order to clamp off it off. You don't have to have them taken out. Let me just dispel that rumor right away. You don't have to take it out, then you just clamp them off and not access them. The patient was still continuing to live which is very, very, very unusual. So you know, I mean you can only figure what's happening. And there is another issue you run into in long-term care facilities is you put in so many people with so many different philosophies on what is right, and what is wrong. There were staff in the facility who were giving this patient food and water.

John

Yeah, I guess so.

Annette

They did not...they were not in agreement with the family, and they were continuing to do those things. Now, was the patient still developing Pneumonia, [inaudible 00:15:13] yes, there were other things. That's the reason the patient had a feeding tube is because they couldn't effectively swallow food and water.

John

Fine.

Annette

I know, you never know.

John

But yeah, I mean you do get lots of different philosophies on it. And that's really what it comes down to a lot of time. It's just philosophies.

Annette

Absolutely, and that philosophy is what's led into a lot of confusion is why there's living wills, and DMPOA, and DNRs, and now there's five wishes, and there's... I mean there's POLST as we've talked about. Do we really need this many terms for essentially the same thing?

John

Right, basically yeah. You really could cover all of this in essentially one document.

Annette

Right, absolutely.

John

You know, here's what I want, here's what I don't want.

Annette

That's why we send you to professionals.

John

Yeah, unfortunately even us professionals are still bound by, [inaudible 42:37] some of the other stupidness that's out there.

Annette

And what state you live in.

John

And what state you live in, that's right.

Annette

Depending on what state it is, the stupidness can be elevated to a next level.

John

It can, especially if it's Louisiana.

Annette

Do not die in Louisiana. That's my professional advice.

John

Always cool advice.

Annette

Just crawl across the line if you can.

John

Welcome back to "Aging Insight" everybody, this is the last segment today. We did have a caller earlier but it was right before the break and so we couldn't take it. But if you do have a question you can give us a call, the phone number is 903-793-1071, we'll be happy to see if we can answer...

Annette

And apparently, we will and will not answer.

John

Yeah, we may or may not.

Annette

We may or may not.

John

So you know, we've talked about the difference between the DNR, the living will. A common question that I get is okay, well, "You know, John, we've signed on this stuff, what we do with it?"

Annette

Yeah, what do you do with it?

John

That's a good question. I mean...

Annette

Apparently, you tattoo it to your chest and it's ineffective.

John

Yes, don't tattoo it to your chest. We did do a previous show on that and no. That does not work. It's a bad idea. Oh, and here is our caller. So we'll see what caller has. Let's see…oops. It's gonna take me just a second.

Annette

May or may not answer it.

John

All right, caller. You're on "Aging Insight," what can we do for you?

John

: Caller: [Inaudible 44:09].

John

Right, so good question, I'm gonna go ahead and cut you off so I can answer the question. But yeah, so the question is basically, has there been any effort...oops. Has there been any effort kind of nationally to create maybe a standardized version of all of this? And I would say, the closest there has...and this is the one thing that we haven't really talked about on the show here is the POLST.

Annette

Yeah, that's what we're talking about during the break.

John

Right, and so the POLST is the Physicians Orders for Life-Sustaining Treatment, and this is kind of a national movement. And basically, what this is, is, and again I'll give my, frankly, layman opinion of it at this point. But the doctor in consultation with the patient or patient's family based on patient's wishes, the doctor actually signs some medical orders and says, "This person is a DNR. This person is a living will person, whatever it is. And here's what to do and here's what not to do." And the idea is that since those are doctor orders, they're gonna follow the patient wherever the patient goes

Annette

Correct.

John

And kind of as we were talking about earlier where, you know, like in Texas you've got an in-hospital DNR, an out-of-hospital DNR, whereas with this Physician's Orders for Life-Sustaining Treatment, the idea would be those doctor's orders would follow that person from the hospital to the nursing home, or follow from home back to the hospital, or from hospital back to home or whatever it is. Where are we on that? I looked at a map earlier this morning on this and it had states that are doing this very well, states that are kind of doing it, and states that aren't doing anything with it at all. And it looked like Texas was one of the kind of doing it, and Arkansas it was a not doing it at all.

Annette

Right. And again, during the break we were talking about POLST and Five Wishes, I think what happens is there's an initiative that gets started, and then it gets to another state and that state is like, "Oh, we already do this. Ours is called this." And so as far as a federal regulation that has been set down and mandated to say, "This is the rule we're going to follow. This is the form we're going to utilize," the cut-and-dried answer to that is that has not been done.

John

Right, it just hasn't.

Annette

Does it need to be done? Absolutely, should have been done a long time ago. One of the reasons Arkansas is not utilizing the POLST is because they utilize Five Wishes and they think that it's essentially the same.

John

Yeah and so you've got this...the other thing is, you know, again from a federal law standpoint, it's very difficult for the federal government to do something that involves what are essentially a states' rights issue. I mean this sort of conflict goes all the way back to the Civil War, and the Federalist Papers and things like that, this conflict of who should be making up these rules. The other thing is the politics that you get behind this occasionally. Sometimes it happens.

Annette

I can't even imagine.

John

You know, a couple of years ago, there was this big uproar of the death panels. And all of that basically stemmed from the idea that there should be a Medicare reimbursement code for doctors to have a conversation about what we are talking about right now.

Annette

So just to add to it, specifically what those panels...and they were not death panels guys, they're just people wanting to have conversations and inform the community and the public as to what reality is. It was based off of what's considered futile care. So if you are a...for instance, and I'll use cancer patients just because it's more of a cut-and-dried type deal. If you are a patient, a hospice patient or a not hospice patient, regardless of what your perception is, and what your level of care is, if you're going in for a treatment that you know essential is not going to work, it was giving you a support system, and a sounding board to go in and get different opinions on what is the reality of the effectiveness of this treatment.

John

And I know this same friend of mine that I mentioned earlier, again, when we were on the break. I have a friend that has cancer, and it's terminal cancer. And he just recently was posting a few videos on Facebook of some documentaries and stuff that kind of go into, essentially, pointless treatment. He personally has foregone virtually all of the treatment options that have been presented to him, because he sees very little point in them as he has gotten in and actually investigated them.

Annette

Right. And I'm gonna tell you, your physician has a lot to do with that. And physicians get a lot of bad raps in many circumstances because most people say, "They're in it for the money. They're just doing more treatment because they want more money." And that's not it. I know an oncologist who loves his patient to the point of on his downtime, he's constantly searching for experimental therapies to see if he can find something else for this patient. Because he wants at the end of the day, to know he did everything he possibly could for this person. And so it wasn't that he's doing it to get money, he doesn't make a dime off of those experimental therapies, he's...you know, we can further research and maybe help somebody later on but also to know that every option was exhausted.

John

Yeah, so at that point, you just basically...?

Annette

So what are you doing? What's your quality of life? Back to what we were saying earlier, what is your quality of life? Do you wanna stay sick? Is it...what are the side effects? You gotta look at that versus, "Hey, is this [inaudible 00:51:23] I wanna kick in my bucket list philosophy?"

John

Right, yeah, and actually go do some stuff and be...

Annette

And while you got it.

John

And not be so wiped out from chemotherapy…

Annette

Absolutely.

John

…or whatever else it is, that you can actually enjoy, you know, that last tee-ball game or whatever it is.

Annette

Whatever it is. I called a patient across the state of Texas to take him to a Willie Nelson concert and drink a beer one more time. I mean everybody's bucket list is unique to them.

John

No, that's exactly right. I did have a gentleman one time. We were in the office. It was husband and wife, and we were talking about the powers of attorney and we were kind of going over the living will and different forms of life support. And I was just kind of explaining some of that, and again in my layman's terms. And the husband, he says, "Look, I don't want any of that stuff. You know, if I'm in that spot, you don't do anything that's gonna prolong my life. You just let me go. I don't care what it is. You just pull the plug." He said, "But I do have a question. Can you put in there that they'll go get the prettiest girl in the hospital and make her pull the plug?"

Annette

Maybe a taller co-host.

John

That's right. All right, so thanks again. We'll see y'all later. Bye-bye.

Annette

Bye-bye.

John

And goodbye to all of our Facebook people.

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