I distinctly remember the day I decided NOT to go into internal medicine was when multiple “influential” family members of this patient I was taking care of swooped into the hospital one day to take control of his medical planning - he was dying of pancreatic cancer, and was a drug-addict to boot, and I think his care ultimately suffered because none of the family members could agree with each other what was best for him, and he certainly couldn’t advocate for himself because he was so snowed with opiates all the time. Of course, I’ve witnessed similar scenarios in pediatrics, so what I’ve come to learn is that (1) death is unavoidable in all settings, no duh, and (2) horrible deaths can occur in all settings.

Joe and I talk about advanced directives all the time, I think, partially because of my horror over how horrible many deaths are, and I think it is never too soon to talk this.  I also think that too few people know what needs to be discussed when talking about advanced directives, partially because our medical system really sucks at this, but also partially because people are afraid to talk about it.  This article got me thinking about how a discussion about advanced directives should occur.  In my dreamiest of dreams:

1) The patient, along with a family member who will likely be the primary medical decision maker, will meet with the patient’s doctor over a series of 1-3 meetings to discuss advanced planning.

2) They will talk about the patient’s health and what kind of things could happen at end-of-life care.

3) They will talk about respirators and cardiopulmonary resuscitation.

4) They will talk about tube-feeding and other matters around prolongation of life.

5) They will talk about pain management.

6) They will talk about the settings in which all this may occur - in the hospital, in a palliative care suite, in a hospice care setting, at home; hopefully, not in an ICU.

7) This will all be documented in writing with the caveat that nothing is binding.

I think about this stuff because ever since getting knocked up, I’ve been seen as a patient more frequently, and worry that if anything ever goes wrong, I have no idea how comfortable Joe will be with managing the medical system.  (I worry about a lot of other ridiculous stuff, too…polymicrogyria! What if my kid has polymicrogyria?!)  And even though my parents are quite healthy right now, I wonder how I’m ever going to broach the topic with them.  When my dad underwent some minor eye surgery last year, I wanted to talk to him about advanced planning, not that I had fear that things would come to that from a little laser debridement of his eyeball and some conscious sedation, but he brushed it off.  It’s certainly not a comfortable subject, but it’s so important. Of course, there’s lots of stuff that he likes talking about that I hate talking about, too, like traffic, or pharmacodynamics, and Costco deals on ham.