Q&A with Dr. K
Do you have questions about your health? Need help navigating the health care system or understanding certain conditions, medications or other treatments? With decades of health care experience, Mountain Pacific Chief Medical Officer Dr. Doug Kuntzweiler (Dr. K) has the answers. And on Q&A with Dr. K, the doctor is always in.
Q&A with Dr. K
What Is a Power of Attorney, and Why Is Having One So Important?
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Talking about death or life-threatening illnesses or injuries is not easy. However, planning for these events makes sure you get the health care you want and offers you and your loved ones peace of mind, helping eliminate difficult decisions in the midst of extreme emotions, confusion and pain. Dr. K and special guest Ramon Mercado discuss important end-of-life planning tools, including advance directives and a health care power of attorney.
Additional resources for this episode:
National Institute on Aging: https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care
Mayo Clinic: https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/living-wills/art-20046303
Johns Hopkins: https://www.hopkinsmedicine.org/patient-care/patients-visitors/advance-directives
If you have a question for Dr. K, email QandAwithDrK@mpqhf.org. Your question will remain anonymous.
Welcome to Q&A with Dr. K, a podcast by Mountain Pacific Quality Health, where we sit down with Dr. Doug Kuntzweiler and get your health questions answered. Because on Q&A with Dr. K, the doctor is always in. Hello, everyone, this is Beth Brown, your host and I'm here, as always, with our very good friend Dr. Doug
Dr. Doug Kuntzweiler:Thank you.
Ramon Mercado:Thank you. Okay, so today's question actually does not come from a Kuntzweiler, Mountain Pacific chief medical officer. But today patient. We might be cheating a little bit. But I did get an is a little bit different, because we also have a special guest joining us. For our topic today is also Mountain Pacific email from one of our colleagues at Mountain Pacific who often staff attorney, Ramon Mercado. So thanks so much for joining us works directly with patients and raised this topic as a concern. both Dr. K and Ramon.
So this is what her email said:"I have spoken to multiple folks that either don't know or don't understand the importance of power of attorney and advance directives. There is a lot of uncertainty and fear regarding both. Maybe this could be addressed on Q&A with Dr. K at some point." And of course, I said, of course it can. And so here we are. And so let's start as we usually do, Dr. K, with defining what we're talking about. So let's start with the term advance directives. So people might hear that term, either advance directives or advanced care planning. Are those one in the same? What are we talking about here?
Dr. Doug Kuntzweiler:Well, some of this is semantics. If you're talking about advanced care planning, that's sort of an umbrella term that talks to any conversation you have with somebody about what you would like to have happen, you know, in the event that you can't make decisions for yourself, but generally, when people are talking about advance directives, they're talking about a legal document that specifies what sort of care they want, or just as importantly, what sort of care they don't want in the event that they can't make those decisions for themselves. And people think, well, you know, I'm 30 years old, I can always make decisions for myself. But if you're in a motorcycle accident, and you're unconscious, for instance, now, you can't really, you know, if if you have a severe illness, you might not be able to think straight in might not be able to make decisions for yourself. If you're old, like me, you might get dementia, and you're not competent to make decisions. Or you may have a mental illness that can flare up and make you make it so that you're not able to make decisions for yourself. So these are legal documents that you can fill out and, and they specify what sort of care you would like at the end of life or in the event that you are not able to make decisions for yourself now.
Beth Brown:We don't want to talk about these sorts of topics. They make us uncomfortable, especially when we're younger. We're cocky about it. We think we're gonna live forever, we don't need these kinds of things. And so the message is planning is better than not planning no matter what your age. Yeah, none of us are getting out of this alive. And it's you know, it's it's unpleasant to think about. But on the other hand, unpleasant things can happen if you don't think about it. So I encourage everybody, no matter what your age is, it just will save you and your family some grief in the long run. And you mentioned these being legal documents or legal documentation that people can have. And that's why we have Ramon on here with us today. But before we dive too deeply into the legality of some of these, let's talk about all the different types of advance directives that exist, what kind of planning people can be doing for the unpleasant or the unforeseen. So let's start with the living will. And we also want to talk about a durable power of attorney for health care, there are different powers of attorney. So let's start with what is a living will?
Dr. Doug Kuntzweiler:So I'm gonna give you a little thumbnail history of living wills. Up until the 1950s or so, And so some of the different directives go into that living this wasn't an issue, because pretty much medical care wasn't very good. We didn't have a lot of resuscitative measures. We weren't prolonging people's lives, you know, by putting them on ventilators or treating their heart attacks and their strokes aggressively. We just simply didn't have the technology. So you either lived or died. It wasn't, wasn't a big issue. But in the 1960s as medical care got a lot more sophisticated, and we started putting people who were in comas on breathing machines, and we started treating them aggressively with all kinds of medications and new surgical procedures, and we started putting stents in their plugged coronary arteries and saving them from heart attacks, and so suddenly, it became an issue because it's not always clear exactly what what we shouldn't be doing. And so that's when living wills, late 60s, that term sort of came into vogue. And, and the idea was that, just like you write out a will that directs what you would like to have done with your estate when you died, the living will was designed to direct the sort of care that you wanted, or the sort of care that you didn't want. And so it was written up just like a will. will? Yeah, and, and a lot of people when they when they did that, they just said sort of general things like in the event that there's not hope for a meaningful recovery, I want all care stopped, you know, kind of general things like that. But it's a lot more complicated than that. And things got a lot more sophisticated as time went on. We'll we'll talk about that the durable power of attorney, and Ramon, you can you can talk about this, maybe but as I understand it, that is basically a legal surrogate.
Ramon Mercado:Yeah, durable power of attorney, it's it's a document where it's, it's an advance directive on its own. But also, it's a document where you designate an agent to act on your behalf, let's say if you become incapacitated, or you are unable to make decisions for yourself regarding your health care, then that agent steps into into the patient's role and has the authority to make, to make every every medical decisions, basically, they're treated the same as the patient would for terms, in terms of HIPAA privacy and everything. So they do have quite a bit of power here.
Beth Brown:And people can put different people in different roles of a power of attorney, correct, Ramon? This is specific to a power of attorney of health care, but you can have a power of attorney for different aspects of what's happening with your life.
Ramon Mercado:Yeah, you can have different power powers of attorney. You can have, and you can have one for medical purposes. And then you can have one for, let's say, handling your finances or making decisions outside of the health care realm.
Beth Brown:Can anyone be my power of attorney for health care? Or do they have certain skills or knowledge?
Ramon Mercado:I wouldn't say that they need certain skills or knowledge. The only requirements that they are of legal age to enter enter into the agreements, because this is basically an agreement between you and the agent. Also, that they that they're willing and able to do what it's requiring them to do, you can't you can't just designate someone as your agent who doesn't know about it, or is not willing to make those decisions whenever, whenever the time comes. Usually someone that lives close, close to you where you are, you don't want to be in Montana and have somebody on the other side of the world making these decisions for you. That's usually a good idea. Most importantly, someone that you trust that they're going to be looking out for your best intents, intentions when, when the time comes.
Beth Brown:We're going to talk about some of the different types of advance directives or advanced care planning people can put into place. But let's go back to a high level spot, Dr. K. What happens if someone does not have advance directives in place, and they're in a situation in a hospital where they cannot make decisions for themselves?
Dr. Doug Kuntzweiler:Well, I can tell you that I've been there and done that in the emergency department, which is why I'm fairly passionate about this whole topic. Because in that event, all bets are off as to what's going to happen. People would come into the emergency department by ambulance, maybe CPR had been started out in the field by the medics, and if you don't know them, and if there's nobody coming forward and saying I have durable power of attorney, and there's no obvious living will anywhere, then you have to try and make a judgement on your own. You try and get as much information about the patient as you can, for instance, do they have terminal cancer, and and we probably shouldn't do anything to resuscitate them. You know, their age plays into it, whatever you can learn about their past health care, their medical condition plays into it. And I would always just sort of think, well, if I were in this situation or if this were a family member, what what would I want done? What do I think would be the best thing to do? And so that's, that's all you can do. Sometimes you could try and make phone calls, you could try and call their their physician or their primary caregiver, or if they have a spouse, you could try and contact their spouse because it's oftentimes they didn't, you know, the spouse or next of kin wouldn't come in with the ambulance, and sometimes there was no next of kin. Sometimes it was the neighbor, you know, and the neighbors would kind of shuffle their feet and say, Well, I don't really know him that well, but we say hi in the morning to each other and, you know, and so you wind up just doing what you think is best, which is an uncomfortable feeling for everybody. And I never got sued over this, but I had people who thought about it, because either I resuscitated somebody that they thought shouldn't have been, or vice versa. I didn't resuscitate somebody who they thought should have been resuscitated. You know, it puts the primary caregiver in a really awkward position, because you have to just try and do the best thing, you know that you think at the time. And that's all you can really do. So if you have something bad happen, and you don't have a living will, or you don't have a durable power of attorney, it's a crapshoot as to what's going to happen.
Beth Brown:You're sort of at the mercy of someone's most educated best guess. On the flip side of that, then, if you do have a living will or advance directives in place or a power of attorney, does that guarantee that your wishes are going to be carried out by a doctor who is making those decisions?
Dr. Doug Kuntzweiler:Oh, in your dreams. Yeah, I wish, I wish I could say that was that was true, but there are no guarantees. And there certainly are no guarantees in medicine, because a lot can go wrong. If, if it happens, let's say you're in an automobile accident out on the road, and you come in by ambulance, and and we don't even know who you are, at that point, you know, you go through their ID, and maybe you can figure out their name, but you don't know who the contact people are. And, you know, there's all sorts of situations come up, where even though they had advance directives, you might not know that or you might not be able to access them in time to make a decision. And from the ER perspective, is it often you know, we didn't have much time to make a decision, those are usually critical situations. But there are there are less dire circumstances where, cancer is the one that comes to mind, where somebody has a cancer and it's been treated. And maybe it's been in remission for a while, and then it comes back. And you know, it's resistant to the next line of treatments. But at any rate, you have some time, you have weeks, maybe a month or two, to think about that and to talk and make sure that everybody that's important in your life knows what your wishes are, and that you make one of these legal documents so that your wishes will be respected. Then you have a much better chance of that happening. But even in that situation, I've I've seen people who do all of that, and then there is typically some remote relative who calls and thinks that they should be treated aggressively, or vice versa. And so the family sometimes has an inner turmoil. And we would sometimes get stuck in that situation in the ER that the person had a very well documented desire. And we would try and follow that in the ER and a family member would say, No, no, no, no, I want you to do everything to everything. And so you would have to sit down and say, Well, I understand how you feel. But it's quite clear that your loved one did not want that this is what they said they want it and we're going to honor that. And sometimes that was could get pretty uncomfortable too. But you try and do what people want.
Beth Brown:So it sounds like communication is a big part there, too, once you do get those advance directives in place. So from that health perspective, you know, where it's uncomfortable when you don't have them in place, it can be tricky when you do have them in place. Ramon, from that legal perspective. Why do you think - you know, Dr. K has said that he's passionate that people should have advance directives in place. From your perspective, why do you think it's important for people to have advanced directives in place?
Ramon Mercado:Dr. K covered most of them, and the legal reasons are right, right in line with what he mentioned there. I was gonna mention another thing when you file an advance directive you need to have a two witnesses, at least in Montana, two witnesses, sign the advance directive. And also going back to what Dr. K was saying about the the accessibility of some of these forms, that Montana has what's called the Montana End of Life Registry. And Dr. K, you can shed some some light on this. I don't know if doctors have this available to them right on the spot, but medical providers and people with the patient's information can can access it, and you file you can file your medical directives into the Montana and a flat registry. That's a good database the state has.
Dr. Doug Kuntzweiler:Yeah, and that gets back to what I was talking about that sometimes you've made one of these documents, but it isn't really accessible. So it's important to make the document, but it's also important then to talk to the family or your friends or whoever you expect is going to be around, certainly to your durable power of attorney, if you execute a durable power of attorney. Sit down and talk with them and make sure they understand exactly what you want and then make sure that those documents, people know where those documents are so that when the ambulance shows up, they can be produced and then then you know what to do. But I think it's it's important to talk about these things. What do you really want. As you get older, and if you have, you know, an incurable illness or what looks to be a terminal illness, typically you have time. And people often do sit down and talk with their family about what they really want done. And that that's the best case scenario. But even young people really should have some idea of what they would like to have done. And you can't just end it there. You can't write out a will, get it notarized and stick it in a box somewhere and nobody knows where it's at. You need to have somebody who knows what your wishes were and knows where to find the documents that you've executed.
Ramon Mercado:Well and also, there's the, what they call the POLST, that there that's acronym for physician orders for life-sustaining treatments, that's actually a physician's order. And it becomes the first page of your medical record. Is that right?
Dr. Doug Kuntzweiler:That's absolutely correct. And there is a national POLST form. And it's pretty cool. I understand that some states have their own, so there's some variations, and you can get them in foreign languages and all sorts of things. But it goes through in very great detail. It's a checkbox sort of thing and places where you can fill in the blank, but, but it goes in great detail and exactly what your wishes are. People say things like, Well, I'm going to have DNR tattooed on my chest, do not resuscitate. So nobody will be pumping on my chest when I drop over. It's a lot more complicated than that. It's if I have a terminal illness, and I'm kind of failing and people can't take care of me at home, and I go to the hospital. Okay, well, do you want IV fluids? Some people do. Some people don't. Some people say, well, that's like offering a sip of water to a dying person. That's a care comfort. Okay, but some people say no, that's too aggressive. I don't want to be kept alive by any artificial means. And some people say, Okay, if you have a pneumonia on top of whatever else was going on, do you want us to give you antibiotics to treat that? Or if you have, you know, a urinary tract infection as part of your whole medical complex thing? Some people say, Yeah, sure. Because that's a simple thing to do. And that might make me more comfortable, and other people say no, I don't want you to interfere with nature, let it take its course. These are things that people don't really often think about, or that it doesn't occur to them that yeah, can get pretty complicated. What exactly do you want? Do you want a feeding tube in the event that you can't eat like you normally do? Then even in pain, you say, well, I don't want to suffer. Okay, well, what level of pain control do you want? Do you want to be unconscious? And that's, that's the old joke that, you know, I don't mind dying. I just don't want to be there when it happens, you know, and so some people say, just knock me out, okay, when other people say, No, I want to be able to talk to family and friends. And you know, it can get pretty detailed. And the only way that's going to happen, is if you think about it ahead of time, and you convey it to someone and the POLST, I agree with Ramon. It's a physician's order. So it pretty much has to be honored. As long as you know, it's signed by everybody. And that's the closest you're gonna get to a guarantee, I would say.
Ramon Mercado:Yeah, I agree with that.
Beth Brown:So it's so objective. There's so many shades of gray depending on what an individual wants, and you touched on so many different things. So I don't want to lose track because you mentioned a DNR. So for those folks who don't know, that's probably one of the most common that I know of the ones we're going to talk about today. But what is a DNR and when might a DNR come into play?
Dr. Doug Kuntzweiler:The DNR stands for do not resuscitate. And typically, if somebody has a terminal illness terminal condition, they execute a DNR and they get it notarized and signed and somebody can speak for them. So yeah, they didn't want to be resuscitated. Again, that's still sort of what it means to me in the ER is I'm not going to put a tube in their windpipe and artificially breathe for them, put them on a ventilator, a breathing machine, I'm not going to do that. If their heart stops, I'm not going to do anything to try and restart it. I'm not going to get the electricity paddles out and be, you know, shocking their heart. Sometimes I leaned towards IV fluids are a comfort measure, you would you would offer a dying person a sip of water. And so I often would start an IV and I didn't think that was too aggressive. And if it seemed like they were uncomfortable or seemed like they were in pain, and if they couldn't speak and if you don't have any advanced directives, I would usually give them a little bit of pain medication or a little bit of sedation. You know, just try and do common sense sorts of things. But it does get pretty complicated. Anyway Do Not Resuscitate doesn't tell you very much. It means don't pump on their chest. Don't shock them; don't put a tube in their trachea, but then there's a lot of other stuff that is that really resuscitation or is that offering comfort.
Beth Brown:Lesser known ones maybe are DNIs and DNHs. DNI stands for do not intubate and DNH stands for do not hospitalize, so someone doesn't even want to go to the hospital in the first place. So when should people put these types of orders in place?
Dr. Doug Kuntzweiler:Well, I think they should put them in place if that's really how they feel about things. And sometimes you I mean, if I'm young, yeah, and I'm, I have, let's say, a motor vehicle accident, I want to go to the hospital, because I don't know, maybe I maybe I'm gonna recover from all of this, you know, or maybe I will have meaningful life after. So you just don't know. But if you are, let's say you're in a long-term care facility. And you know, you're sort of winding things down, you're comfortable, that is your home at that point, you're comfortable there. You don't want to be taken by ambulance to a noisy ER, and then sit around in the ER for 12 hours, and then eventually get admitted to the hospital where you got a bunch of doctors who you don't know, and you know, it's not very comfortable. And so some people would just assume not be hospitalized, whatever's going to happen is going to happen anyway. And they would say, just leave me in my home or leave me at my daughter's house or leave me in the long-term care facility. These are do nots, and they are specific: do not intubate, don't put me on a breathing machine, do not shock my heart do not hospitalize me, or some people say, yeah, you hospitalize me, but I was in intensive care before and it was a nightmare, and I don't ever want to go back to intensive care and say, Well, okay, then there's certain things we can't do in a regular hospital bed. And you know, as long as they understand that, that's fine.
Beth Brown:And you both talked about POLST and how helpful that part can be. I also know there's a MOLST, which stands for medical orders for life sustaining treatment. Are those the same?
Ramon Mercado:I think those are terms are used interchangeably.
Dr. Doug Kuntzweiler:Yeah, I agree.
Beth Brown:Okay, great. So we've talked about living wills, we've talked about power of attorney and DNRs and DNIs and DNHs and the POLST. Where does someone get started? And Ramon, maybe you can kind of give some direction here. What should someone do to start with some advanced care planning and get getting some of these orders and these directives in place?
Ramon Mercado:The first step will be to talk to everybody that's going to be involved with this in this process. The more people you talk about it, the better. That's how I would approach it both professionally and personally. The then the next step, once you have everything in order, and you're you know exactly what you want. There's there's a lot of forms online that people can find on how to do estate planning and advance directives. I know that Montana for Montana DPHHS, Department of Public Health and Human Services has, uh, has all these forms available on their website. Also, in Montana, a good resource to that we have is the Montana State University Extension program, they have a very comprehensive estate planning section, that mean they have every single form that you can possibly imagine. And they keep coming up with new stuff almost every year. So you can download forms for powers of So a lawyer isn't necessary but could be helpful if needed could attorney. I have used some of those myself for some clients before. And it's it's very useful. So Montana does have a lot of resources. I don't know about other jurisdictions. But let's say you do all the research, you find a bunch of forms online, they all kind of do look a little different. If you find yourself in a spot where you don't really know what you're doing, or you feel like there's something wrong, just talking to an estate planning attorney is probably a good idea. Most times, it won't get to that point because some of these forms are pretty self explanatory. And most of the forms have a package that out that describes, you know, line one means this, line two means that you know, it's, that's that's how I would approach it. be helpful. Yeah.
Beth Brown:Okay. And for those listeners who are not in Montana, their State Department of Health is probably a good place to go at least initially.
Ramon Mercado:Most likely. Yeah.
Dr. Doug Kuntzweiler:I would add that I think most primary care physicians or primary care people will have dealt with this know in their practice and so they should have some knowledge about where you can acquire their forms and you probably should sit down and talk with him anyway and make clear that if you have a primary care giver make make it clear that they understand what your wishes are.
Beth Brown:Perfect. Okay, so that's another great resource - your primary care maybe or Department of Health. So once I have my documents that I think they're complete, I'm I'm ready. You talked about sharing those or having that communication. Sounds like primary care provider is definitely someone you want to talk to. Who else should have these forms either on file or saved somewhere so that they're accessible and ready to reference should an emergency or something happen?
Ramon Mercado:If you are designating an an agent to be a power of attorney, that person, that person should have all these documents. One thing I would not ever recommend would be putting these things in a safe or a safety deposit box. It's just not a good idea just to same with a will, getting it get into it when you're incapacitated is is just a nightmare. So most people keep them on their fridge or on the on, like behind their door in their bedroom. I mean, I've, I've heard many spaces where people who are accessible, I would just let the people that are involved in this whole process know. Everybody who was involved.
Dr. Doug Kuntzweiler:Yeah, if there's somebody else in in your home with you, you know, make sure that they know where the documents are. If you're in a long-term care facility, you know, the nurses should have access to that. It should be in your chart. If you waited till you got in the hospital, it's going to be in your chart, the typically a hospice nurse or somebody like that will come and sit down and talk with you and help you fill out the documents. And then it'll be on your chart, but but you have to make sure that there's somebody who's likely to be around. If it's not somebody that lives with you, maybe a neighbor or a friend or somebody, much like you would do with an emergency number to call, you know, people ask you that all the time, in case of an emergency, who should we call, and you tell them oh, call my daughter, call this person or that first of all, those people should probably have a copy or have access to it or at least know where it's at.
Beth Brown:Good advice. Can you think of a time when someone might need to change their advance directives, or they would want to edit their forms for any reason?
Dr. Doug Kuntzweiler:Oh, yeah, sometimes a medical condition changes. Yeah. Sometimes things look better. Sometimes they look worse. Sometimes they're grim. But yeah, so sometimes a change in your medical condition may may change your thoughts on what
Ramon Mercado:Yeah. Also, same thing goes with power of you want done. attorney if, let's say the person moved out of the area, or you are no longer in good terms with that person, I mean, things happen. And you might want to switch your power of attorney, you know, a couple years from now.
Beth Brown:Okay, so let's close like we always do with some good resources for folks. I think we've provided some with the Department of Health and talking to your primary care doctor. Are there other places where people might want to go online to learn more about these advance directives, or maybe find some examples of the forms that they want to fill out?
Dr. Doug Kuntzweiler:The National Institute on Aging and their website, that they have some good information, places like Mayo Clinic, Johns Hopkins, Cleveland Clinic, they they all will have some information on their websites.
Beth Brown:Any final message before we wrap up for today?
Dr. Doug Kuntzweiler:Well, I've already written my own obituary, so I'm not pressing anything to anybody else. So if you feel strongly about what happens to you, as as you near the end of your life, whether that comes suddenly or coming slowly, I think you would do yourself a big favor to put a little advanced planning and and it's not just that, then your wishes are followed. It also makes it so much better for the family. Because if the family if you've never said anything about I don't want to be on a ventilator, if you've never said anything like that, and it comes to that, then the family sometimes doesn't know what to do. And they it's very stressful for them. And if on the other hand, you have told them in no uncertain terms, I don't want to be intubated. I don't care. If that's the end, that's the end. I don't want to be kept alive artificially. And a lot of people feel that way. And if you let the family know that then they feel comfortable saying no, they did not want to be intubated.
Beth Brown:Ramon, anything to add to that.
Ramon Mercado:I forgot to do the standard disclosure that this is not legal advice. And if you have any legal questions, please go to your attorney,
Dr. Doug Kuntzweiler:I was giving medical advice, and I stand by it.
Beth Brown:All right, thank you, both. And thank you to our listeners for tuning in. We're going to put some of these resources that both Dr. K and Roman have provided with this episode so that you can access them. And if you have a question for Dr. K or for any other expert that we can trick into coming onto this program, please email us at Q&AwithDrK@mpqhf.org. And that email address will be provided with this episode as well.
Dr. Doug Kuntzweiler:Thank you, Ramon. Thank you, Beth.
Ramon Mercado:Thank you.
Beth Brown:Yes, thank you, both!
