AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger is joined by Dan Morhaim, MD, an emergency medicine physician in Maryland and author of the book "Preparing for A Better End", to discuss advance directives (also known as living wills) in preparation for National Healthcare Decision Day #NHDD on April 16.
Visit thebetterend.com, for more information on Dr. Morhaim's book "Preparing for A Better End: Expert Lessons on Death and Dying for You and Your Loved Ones."
- Dan Morhaim, MD, an emergency medicine physician; author of the book "Preparing for A Better End"
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're joined by Dr. Dan Morhaim, an emergency medicine physician in Maryland and author of the book "Preparing For A Better End." We'll discuss advance directives, which are also known as living wills, in preparation for National Healthcare Decision Day on April 16. Dr. Morhaim is also an AMA Senior Physicians Section liaison. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Morhaim, thanks so much for joining us. When I looked ahead and started thinking about what we're talking about, this issue of updating your advance directives, I thought back to the beginning of that pandemic and this is one of the first things that crossed my mind is I need to update that, which I think the last time was when I had small children. So, the pandemic made me think about that. Is that something that occurred with other people as well or am I alone in that?
Dr. Morhaim: You're not alone but still, not enough people have completed these free legal documents available in every state that directs care when you can't make health care decisions for yourself. The pandemic highlighted it, especially because families which we usually rely on, although sometimes it's conflict when families there but families weren't at the bedside, the usual source of information about what a patient might want when they can't communicate.
Unger: You've had four decades of experience as an emergency physician. And over that time, I'm sure you've been able to witness firsthand. What happens when either there isn't an advance directive in a patient that's in a critical situation? Tell us a little bit more about how that plays out.
Dr. Morhaim: Well, I got interested in this topic because I found myself doing full codes on patients that I knew in my head and my heart wasn't the right thing to do. But since I didn't know what the patient wanted, I had to make decisions but I'd rather known what the patient would've desired. So we don't see enough advance directors in the emergency room or the intensive care unit. But what I did observe was this. When people didn't have them, chaos ensued. Clinicians didn't know what they wanted. Families got into conflict, all kinds of emotional disruptions took place.
And sometimes when they did, however, it took the burden off the family making decisions and it was clear to the clinician and then I was able to explain to the family what the patient wanted and they could accept it because the burden of sometimes very difficult decisions was removed from them. So really an advance directive, although we're a very "me" oriented culture, it's all about me, when it becomes operative, you're not making the call. So it's really a gift to your family that you've indicated to them what you want. So they aren't in conflict about your care.
Unger: That is definitely something you don't want, which is chaos and that kind of burden on your loved ones. So much better, obviously, to be explicit about it. What kind of scenarios are covered by advance directives?
Dr. Morhaim: Well, it's basically two key parts is what kind of care do you want in general terms? Although there are further iterations of that possible when you can't make decisions for yourself. And at times the full court press is appropriate and other times comfort care on the other end of the spectrum's appropriate. Most of us tend to choose the middle path as long as I'm functioning and aware and pain free and going along okay, keep me going. And if a minor illness comes, treat me but if a really serious thing comes and it's the end, then let me die in comfort. And my family in a holistic situation. I want the best of modern medical care for sure. If I get chest pain during this call, please call 911.
But I don't want to end up in intensive care unit long past any hope of recovery, tied to tubes and monitors with family down the hall. And nobody really wants that. So this enables people to get the right balance, the best of modern medicine but also when modern medicine has to shift to hospice care, palliative care, comfort care and supportive care, that you can get that too. But what most people fear is pain, isolation and dependency. And those things can all be managed if we take advantage of the tools that are available right now, essentially all for free.
Unger: Well, I know what April 15 is, I think, this year but April 16 is National Healthcare Decision Day. What's the significance of that date and what's it mean?
Dr. Morhaim: Well, whoever thought it up decided to link death and taxes. So that's how April 16 came about.
Unger: Oh, very funny.
Dr. Morhaim: That was not me. That was other folks all together but it is a reminder that when you do this one thing that most of us have to do every year, take care of our taxes, April 15. It should be a reminder the following day, take care of this other piece of business, which we're all adults, have to confront. So it's really a reminder and it's an opportunity to bring the topic up and discuss it. And if you've completed your advance directive, it's time to review it because things may have changed in your life or your health or your values or your relationships. And if you haven't done it, then you should complete it. And then you should also bring it up to others because we know that only about 40% of Americans have completed advance directives. And it's a minority health equity issue too. I did the study on this part and only about 20% of minorities and people of color complete advance directs. So that's another equity issue that we got to take care of.
Unger: Two questions there. One, I thought I was done with my advance directive for a while. Is this something I should be reviewing every year?
Dr. Morhaim: I think you should review it every year, every few years. But as your situation change. If your health changes, relationships change, spiritual values change but it's not just for old people. I mean, for those of us who the path of life ahead is shorter than the path behind, you naturally start thinking about those things. But the three most famous cases in American medical legal history were all women under 30. And as an ER doctor, what I often saw was that when we're young, we think we're immortal and going to go on forever. Young people tend to get in trouble catastrophically and no one's prepared. So when my kids turned 18, the challenge of living with the daddy who's into advance directives is I gave them all advance directives to complete. And they did. And one of them said, "Gee, dad, when I got my driver's license, I checked organ donation."
So it wasn't that remote. Later, as they grew older and got married and other things, then they made adjustments. So every adult should have this. We don't know what's going to happen to any of us in this crazy world, in this crazy life that we lead. So this is like wearing a seatbelt really, is how I think of it. And you wear your seatbelt, if you didn't wear it, you probably would be okay but it's a safety tool. And if you got in a minor car accident will protect you from something more serious.
If you got in a major car accident, it might save your life. A car was utterly demolished, it might not make a difference but advance directive is about shifting the likelihood from one set of outcomes that are more or less out of your control or will be decided by others who don't know you, to shifting it to what you would want under various circumstances. And the second part of advance directive is who will speak for you if you can't. And obviously, most people choose their spouse, adult children, siblings, close friends. By the way, you can also, if you have an annoying relative, you can say please don't let person in the room when my medical care is being discussed.
Unger: But I am adding to my list, get my adult children advance directives. So I imagine in the scheme of things, many conversations that physicians have with their patients, this may not be top of mind necessarily but at relevant times, having that conversation would be really important. I also imagine pretty challenging. Do you have any advice on how physicians should approach this topic and make it easy for patients to act on it?
Dr. Morhaim: Well, that's a great question. I think there's several levels of answer to that. First in the study that I did, a peer review published study, we asked people if they didn't have an advance directives, would they want one? Overwhelmingly, they said yes. And who would you want to get the information from? And they said their physicians. So they're looking to physicians. And if they don't bring the topic up, if we don't bring the topic up, patients are often very hesitant to start talking about this. So you have to bring it up and you have to bring it up several different times. Most people don't, including me. I didn't absorb this all at one sitting one time in 10 minutes, it's a big topic. Although it only takes a few minutes to complete the forms. So I think it's sub persistence and having information available wherever you practice and just spreading the word more and more so it becomes more normative rather than an outlier event.
There's also significant financial implications for the health care system. Medicare is about $900 billion. About 25% is end of life care. And for every hospital death that doesn't occur in an ICU but occurs in the hospital or doesn't occur in the hospital but it happens in a hospice or at home, significant costs are achieved, not by the usual hard ways we try to reduce costs but by respecting people's rights. And if that doesn't motivate physicians, let me throw one new one out there. There are now things called wrongful life lawsuits ... of wrongful death. Somebody goes to the hospital and something unexpected happens and negligence is alleged. You're in court. Wrongful life, they're now a whole series of lawsuits where typically a person came to the hospital for something not so serious. Said, "I don't want full resuscitation," and was done. One case a 91-year-old woman and spent two weeks in a coma in the ICU before she died, her family sued and won a million dollars.
And so clinicians are going to have to understand this better than we have. Our tendency has always been to do more but there are times when that's appropriate, but now we should do the right thing. And I think institution and clinicians, especially those on the front lines, better be aware of wrongful life lawsuits. The plaintiff's attorneys have found a new area to explore. And for my 24 years in the Maryland general assembly, I'm very familiar with how sophisticated that they are, and they will pursue it. But if you haven't heard about it, just search online wrongful life lawsuits. You don't want to be in that situation. And if you know what an advance directive is as a clinician, you should learn to honor them.
Unger: Hopefully not sound like completely uninformed, but if you're in a catastrophic accident, you're taken into an emergency room. How do they even know you have an advance directive?
Dr. Morhaim: That's a part of the whole system that's not entirely together. So I would say answer it this way. Obviously the first step is one is to complete it. And number two is to be sure it's distributed. This should not be something that's in a filing cabinet or a safety deposit box. So I use something called mydirectives.com, which is free and online. And I get a little print out, a little QR code. It's in the glove compartment of my car, it's in my wallet. And then I take it with me when I go jogging.
And if I happen to be someplace out of state, whatever or at home on the street near my neighborhood, they can QR code that thing and not only who to contact, my advance directive but also health information and other relevant materials. So that's not all worked out as well as it should be. And there's challenges if you're in the different state. You're driving to some other state and something happens there. And then what? But in the emergency room, if somebody came in from out of state and we had a lot of patients because that was on a major hospital, a major corridor, we would respect that.
Unger: I'm adding that to my list also. Get advance directive out of safe because that's really important. You mentioned this is freely available and easy to do. Where would someone go to get an advance directive put together?
Dr. Morhaim: Well, there are many sources. AARP, hospitals, most state health departments and local health departments. I happen to like mydirectives.com because it's free and it's easy and it's very simple way to go through it. There's five wishes. There's a thing called Cake, which is another one. And if you're very involved in your faith, there are faith-based ones according to different faiths. So there are many different sources. You can also just, you don't need the form. You can actually just type it out on a piece of paper and just say here's the three components. One, what kind of care do I want if I can't make decisions. Two, who makes decisions for me and put a sequence of people, and three has to do with organ donation and disposition of body at the end.
Unger: Any other final thoughts on your advice to physicians in this particular arena?
Dr. Morhaim: I would say to physicians and everybody, look, I get it. It's a tough topic to go out and talk about death and dying. Look, I was running for office and got elected six times and I was in community meetings and people would say, "Morhaim, what are you working on?" And I would go through the usual list of issues. And then I would say, "I'd like to talk about your death, the death of everybody you know and don't forget to vote for me in the next election."
Unger: It's very depressing.
Dr. Morhaim: Are you politically crazy? Because you know, we like to be at groundbreakings and ribbon cuttings and graduations and happy things. But what I found was that people really appreciated that somebody was willing to break the ice and talk about it. Just like women who came forth like Betty Ford talk about breast cancer or people would talk about a kid with autism or a birth defect or even substance abuse. This is happening to everybody. And we're the first generation in human history that likely has some say about how we die. And that's a powerful concept. And when you go through the process of completing the advance directive form, it also makes you think about your values and what's important to you and really ends up being about appreciating your life and the people you're with.
Unger: So much of being in control of that decision and not leaving that for someone else to have to make for you. Really helpful. And I learned a lot, and I really appreciate you Dr. Morhaim, being on today's episode. Thanks so much for all your work.
Dr. Morhaim: Go into details in my book "Preparing For A Better End," www.thebetterend.com or Johns Hopkins Press. And there's a lot of other information, very practical guide in there and endorsements by a lot of prominent people.
Unger: Well check out thebetterend.com for Dr. Morhaim's book and more advice there. Thanks so much for being here today and for all of your work on AMA's Senior Physicians Section. Shout out to all the folks in that section. We'll be back soon with another Moving Medicine video and podcast. In the meantime, don't miss these episodes because they're great. Hit subscribe on our YouTube channel, Spotify, Apple, wherever you listen to your podcasts or find them at ama-assn.org/podcasts. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.