By Tim Crowley
In 2015, as a CPE student at a local senior living community, I and hundreds of other healthcare professionals were trained to become certified advance care planning facilitators. Hospice of Cincinnati offered the project, using the Respecting Choices advance care planning program from Gundersen Medical Center of La Crosse, WI.
During my CPE training, I was privileged to spend time discussing advance care directives with more than 40 residents and families across all levels of care: independent living, assisted living, memory care, skilled nursing, and rehabilitation. I quickly learned that a chaplain, or chaplaincy student, is uniquely qualified to assist residents and families through what can be time-consuming and complex conversations. Almost none of these conversations was done quickly, and many extended over weeks or months, as people need time to process and pray about their decisions.
Our goals were to have each resident consider how they wanted the final chapter of their life to be written and to help them write that chapter. Additionally, we wanted their families to agree with the resident’s wishes. On occasion, the resident was no longer able to make these decisions, and helping the family through the process became the goal. Commonly, we would end up with a living will, durable healthcare power of attorney, a DNR form (if appropriate), and a medical order for life-sustaining treatment form (if appropriate). Other legal documents and arrangements, such as a will, a financial power of attorney, funeral arrangements, and burial site, were often discussed but were not the focus of this effort.
One resident we’ll call Mary said she had her advance care planning documents complete but wanted to review them. I volunteered to meet with her. Mary was approaching her 90th birthday. She had never married and had no children. A nephew was her durable healthcare power of attorney, and on her living will, she had herself listed as a full code and wanted artificial nutrition and hydration. I wasn’t very familiar with her medical history but knew that she had been hospitalized a few months before. I made several attempts to meet with her, but she continued to delay. Her anxiety was palpable. Finally, one day she said she’d like to meet.
I pulled the living will and healthcare POA that she had on file and brought them to the meeting. When I arrived, her nephew, whom we’ll call Mike, was there, as were Mary’s older brother and his wife, whom we’ll call Bob and Carol. I framed the conversation as a chance to review Mary’s wishes about how she wanted things to progress, should her health begin to fail. I explained the meaning of each of the documents, and that they could be changed if they no longer clearly articulated Mary’s wishes. Our first surprise was that Mike was not aware that he was designated as his aunt’s healthcare POA. This led to a long conversation about that role, but he agreed to serve. We agreed that he needed a backup, and his wife was chosen.
Mary then disclosed that she was living with a serious health issue, which could prove fatal. When we got into a detailed conversation, she quickly acknowledged that she was not interested in having CPR, and that brief trials of mechanical ventilation, artificial nutrition, and hydration were the most she wanted. We prepared a list of items that she would discuss with her physician on her next visit, as she wanted to have a DNR completed by her physician, and wanted to engage in a MOLST conversation with him. The detailed resources that Respecting Choices provides to assist in these conversations were invaluable.
Then the next surprise came. Bob and Carol looked at me and said, “We haven’t done any of this, and probably should. Can you help us?” Bob was in a wheelchair, on oxygen, and in apparently poor health. Carol was near tears. I realized that Mary had invited Carol and Bob, not to support her, but for their own education. I entered the room that day thinking that I would help one resident but ended up affecting three lives. I subsequently helped Bob and Carol through their own advance care planning.
Medicare now reimburses physicians for having end-of-life conversations with patients. I can assure you that a physician, during a 30-minute office visit, cannot go into the depths that a chaplain can. But Mary, at the end of our session that day, was prepared to spend 30 minutes with her physician to cover those items that only he could handle.
Tim Crowley is a part-time chaplain with the Twin Lakes Senior Living Community in Montgomery, OH.