Improving Dying & Preparing for A Better End with Dan Morhaim, M.D.,

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[upbeat music] Welcome to the Pro Aging Podcast. I'm Steve Gurney, founder of the Positive Aging Community.
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We're thrilled to have you join us for our interactive discussions with pioneers and thought leaders on a wide variety of topics related to aging and longevity.
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Visit proaging.com to connect with them and discover hundreds of valuable other resources. We're excited to have you with us today, so let's jump in to an engaging, positive aging live and interactive discussion.
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[upbeat music] button and bring in our l- live stream audience. And now I am going to welcome
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our presenter today, our guest today, which is, uh, Dan Morhaim. And, uh, Dan, r- really excited to have you.
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This is our, our second time, uh, that we've had you, uh, spotlighted on the discussion. And, um,
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so Dan, before we dive into the topic of, um, end of life, uh, let's get to know you a little bit better. Uh, share with us a little bit about your background and what led to you being a thought leader in this space.
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Well, thank you, and, uh, good afternoon or morning wherever you are. Everybody that's listening, it's great to be with you. Steve, you can hear me okay? I can, and I'm just, uh- Good...
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kind of playing around with my camera here. Yeah. All right. So, um, I got into this, uh, because, uh, I became an emergency medicine physician.
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Uh, so that was many years ago, and I found myself in the position of doing codes, that is that full court press that you see on TV, uh, that almost always works out on TV, but is a lot messier and less successful in real life.
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And back then, in the 19 s- late '70s, '80s and '90s, you know, w- we were doing all these procedures, and I'll be just pretty graphic in some of my conversation here, on, you know, people 99 years old who, you know, long demented, contractures, feeding tubes, and I'm wondering, "Why exactly am I doing this?"
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And in the ER, we don't know our patients, they don't know us, so there were a lot of times situations came up.
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That's an extreme, but there are others, and if I knew what the patient wanted or if I knew who I could speak to if the patient couldn't speak for themselves, it would expedite care, make it more centered.
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Um, but I, you know, I was the one jamming tubes into windpipes and putting big needles in to start central lines and ask myself, "Why am I doing this?"
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If I knew what this person wanted, or if I knew what their agent and they had worked out, then, then I would feel much more comfortable ethically, and it's actually better medicine, better for the family.
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And so that's how I got into it. Um,
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I started looking at the issue of advanced directives and, uh, asked, uh, one of my wonderful, uh, volunteer staff from Johns Hopkins, Keisha Pollock, now Keisha Pollock Porter, "How many people complete advanced directives?"
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A very simple question. I mean, as a clinician, you can look, uh, you'll have psoriasis or sickle cell anemia or broken hips or whatever.
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And that question had never really been studied properly, which told me that the taboo about talking about death and dying was so profound that even the public health 101 question, how many people have X, had never been done across a population.
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We made a... We got a grant, we did the study, and, uh, Keisha is now, uh, she was a grad student, now she's Dean of, uh, Public Health at Johns Hopkins, so talk about greatness early on.
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Uh, but we did this peer review published study. We found that only about 30% of Americans had completed, 35% completed advanced directives. We were the first to formally identify it as a minority health disparity.
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And we asked people two other questions, "If you don't have one, would you want one?" when it was explained. And this is all peer review published study, by the way, with graphs and stuff, so I'm simplifying it here.
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And they said overwhelmingly, yes. So, like 90% of people said yes, so 90% of the 60% or so that didn't have them, that's 54%, right, of the population. And we also asked, "Where would you like to get the information?"
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We gave them a whole range of choices from internet, friends, family, uh, faith. Uh, but overwhelmingly they wanted to have that conversation with a clinician.
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So that launched me on this crusade, in effect, to get people to complete advanced directives, and I've been working on that ever since.
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And as we talk today, I'll tell you how I approach it, but you know, I'm always refining my presentation, and if folks have other, uh, ways that they try to make that point, please do.
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And I'll close this section with one question that we all face, which is the end of... Let's take a moment. I mean, who wants to talk about death and dying?
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Uh, by the way, besides being an ER doctor, I also got elected to the Maryland State Legislature for 24 years, so I had that career simultaneously and did some other stuff.
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But when the end comes, five-second exercise, where would you like to be? Who's around you? What's going on? Um, let's...
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Folks, this is a great thing to, if you're brave enough and you l- and you're okay sharing, I'd love to see what your, um, what, what you, you would like. Uh, use chat and, and share that.
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Uh, Dan, while we're waiting for folks to share that, I, I, I jokingly tell people, but I'm not really joking, that I hope that on my 85th birthday, I go to sleep and I just don't wake up.
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Well, let me, let me jump into what Renee writes. Um, at home with family and friends. Everybody says some version of that. Mm-hmm. I've done hundreds of thousands of these talks, live audiences, podcasts.
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No one ever raised their hand and says, um, uh, uh, "I wanna be killed in a fiery car crash."
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You know, I'll have some version, maybe it's in some privacy, in a hospice, some walking in the forest, but it's usually some family-centered thing.
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Now, what a lot of people end up getting is, a- and nobody also raised their hand and said, "I'm gonna die of a, you know, hopeless disease in an intensive care unit," [laughs] "...
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uh, in a coma for weeks, long past any hope of recovery, with my family, you know, kept down the hall." Nobody says that either, but a lot of those deaths take place.
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Now, don't get me wrong, I want the best of modern healthcare, you know? I love modern medicine, and if I get chest pain during this call, figure out how to call 911, you know, and, and give me that care.
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But if I have advanced pancreatic cancer, um, you know, I've been through chemo, radiation, everything, I don't want a horrible septic shock death in a, you know, hemorrhaging in a, in a hospital.
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I wanna be dying quietly at home with family and friends around. And this is about shifting the likelihood to those kinds of things. It's not a guarantee.
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Completing advanced directive forms, um, advanced care planning, using hospice and palliative care early takes something that we all fear and worry about, and we're not gonna avoid death, but the things that we fear, when you really break it down, is pain, isolation, and dependency.
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And all those things, let me say it again, pain, isolation, and dependency, and all those things can be managed
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by filling out free paperwork and taking advantage of readily available services like palliative care and hospice care. The real question is, why don't we do that? Why don't we do that? So, um, uh, a- a- and
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hopefully someday we'll know the answer to that question so that we can better address and get more people to do that. But let's, let's dive in.
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I, I wanna, I wanna spotlight the two books that you've authored and co-authored, but I also wanna remind everybody, folks, you got questions on this topic, anything that you'd like us to talk about, just use chat and Q&A, okay?
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Um, but, but Dan, could you g- I love that you share an emergency room physician's perspective on this matter. So in a perfect world, somebody comes into the emergency room,
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what documents should we have? Where should they be? How can we make your job easier? And, and, and my... Yeah, let me just stop there. So it's a really a three-part process,
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and, uh, part one is you have to complete the documents. Only you can complete yours, not your best friend, spouse, faith leader, congressman, next-door neighbor, whatever. Only you. Look in the mirror.
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That's the person complete the advanced directive. Then they have to be available. So, you know, if you're ta- dealing with your own doctor, they know, but you might be traveling.
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Even in, in, in Maryland, where I practice, we have patients from Maryland, we don't have their records in our hospital readily available. So they have to be available.
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And I personally use this, mydirectives.com, but there are others.
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This is free and online, and you can, if you have a other advanced directive from Five Wishes or a faith, I'm covering the QR code for obvious reasons, um, but I carry this with me everywhere, and wherever I am in the world, a clinician can get to that QR code.
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I have it when I'm jogging, it's in the glove compartment, it's on my person. They can get all that information, what my wishes are. Also, who to call. My spouse, Shelly, adult children, and so on.
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And also, a lot of my personal wishes are in there. So this is free and online. Name and password, like everything else we do these days. Mydirectives.com, nothing could be easier.
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And you can update it any time you want. Your values change, relationships change, health changes, um, you update it.
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So, and then last, clinicians need to learn to honor them, and that's something we're, we're still in the process of. Because these are, you know, infrequent documents. We don't see them often enough, but
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if can be a little bit off the wall here, it, it starts with you, individuals. And just like anything else, like the little child on the toilet says, "No job is complete till the paperwork is done."
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You can think about this and talk about this, but if you don't do the documentation, chaos tends to ensue. Confusion ensues and, you know, it, it's not a perfect document.
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It's not gonna be wonderful every single time, but think of it like wearing a seatbelt. I wear my seatbelt all the time.
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I know there's accidents wearing a seatbelt that it won't, I'll, I won't survive, and if I don't wear a seatbelt, there's probably accidents I will survive.
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But the overwhelming likelihood is wearing a seatbelt's a good thing. This is wearing a seatbelt for an inevitable event,
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and managing it better holistically, more economically, we could talk about money, family-friendly, and reflective of your own values. Now, Steve, other people on this call, your values may be different than mine.
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That's fine. I just wanna respect your values when I'm in the ER. Man, uh, this is great. And, um, and I'm gonna ju- I'd like to jump over to your book. I, I love all the comments, folks. Thanks for sharing that.
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I, I, I think it's, it's great for all of us to hear everybody's different perspectives, um, because perspectives change on death as, as we navigate through life. Uh, and, and we need to update these documents as well.
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But, um, let, let me ask you something from the physician's point of view, because you've been trained, and your colleagues have been trained, to keep people alive. That's your job. But I, I... And so,
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like you said, it's, um, without,
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y- without this document, but even with a document that says, "No heroic wet measures," or something like that, do you find that in the physician's community there's, there's challenges sort of, uh, reckoning with this in our, in your j- these professions?
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There are, but there's a shift. But it starts with- Um, people completing the forms. I mean, I don't, haven't seen them a lot, you know, routinely in my career as an ER doctor. We're getting there.
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So it's like anything else you're not familiar with. I tell my colleagues in, uh, healthcare, emergency medicine, otherwise, you know, "If you don't know what that form is, get some help.
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Call the, um, you know, hospital attorney. You know, if they've got a family in conflict, bring the hospital chaplain in, uh, the nursing leadership, whatever. Don't walk the plank alone."
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When we see these more often, but it starts with people completing them, then having them be available, not, not locked up in a safety deposit box, not necessarily part of your will.
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I've had people bring in their whole, you know, three-ring binder will thing. I don't... Not really interested in how they disperse their assets. I wanna find out the medical information.
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And then we clinicians will do better honoring them. Let me tell you what happens if you don't. Family conflict ensues. And s- and every hospital has a committee, um, that makes these decisions.
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They may not know you or anything, uh, about you.
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I have a slide which is, uh, and I do the talks of a, a group of lifeguards sitting around a table making a committee decision, and somebody saying, uh, "Somebody's flailing in the water out there.
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Peterson at the Hammond Beach wants to know what he should do." Well, [laughs] obviously you wanna save the person.
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So we have a lot of, uh, uh, work to do on this, but it all starts with us, and then bringing it up to other people. It's not just for you, your spouse, your adult children, your friends and neighbors.
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And let me digress. I, I got elected to the Maryland legislature six times. Six primary, six generals, I won them all. So we have four-year terms, 24 years in office.
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I'm out there campaigning and going to community meetings, and, uh, we go through the usual issues we talk about, and then I would say, "And now I wanna talk about your death, the death of everybody you know.
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And please don't forget to vote for me in the next election." [laughs] Oh, boy. And, and what- Hey, well, it says something about you getting reelected.
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Maybe there was a- No, what happened is people came up to me and said, "Thank you for bringing this up," because we're, there's, it's a taboo topic. We don't talk about this subject.
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You know, I think of the first women to talk about breast cancer or families to talk about a child with a learning disability or, or substance abuse issue. These were hard topics, uh, to bring up.
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Uh, but we started to do that, and things like that became more normative and accepted. Th- this is the big one because, uh, 100% of us are in the mortality category.
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And so, you know, despite all the great advances in healthcare, death rate's still the same, one per person. That's how it works. So we are empowered.
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This is really about empowerment and values and having those, um, respected and honored.
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I'll, I'd be happy to share a little bit of my own advanced directive, some unique features, if you want, just to give- Yeah, I would love for you to do- I'm never shy about sharing my own because I'm asking people to do that too.
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I... No, I, I love that because that's, uh, that's much better than a checklist, is hearing how somebody else do... Y- a- yeah, if you would do that, I would love it. Yeah.
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So, so, uh, the first p- part of advanced directive is who makes decisions if you can't. So mine's clear, my wife. We've been married a long time. We're... Good relationship. I trust her judgment.
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After that, I have three adult children. They're all great people. Uh, but two of them were more on the same wave life than the third. So if Shelley's not around, then I say those, those two.
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They can all talk, and those two will make, uh, the decision if there's hard decisions to be made. I also have in there, I have a good friend of mine from medical school contacted.
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Not to make decisions, just to make sure all the medical boxes are checked. So that's that part. Basically, then I say if my m- mind's working, keeping me going, even if my body's falling apart.
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But if my mind is really gone and an intercurrent illness comes, I don't need major heroic efforts, although I'd like some moderate ones.
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I also have in my directives things you could put in that you might not consider otherwise. For example, mine says, "Take me outside as much as possible. If I can't be outside, show me the outside.
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I want control of the remote. Here's music I want to hear. Um, I'm on vodka and medical cannabis." Not substances I use now, but I would in that circumstance. "I want a bite of chocolate every day."
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I also have, um, uh, you know, uh, you know, we're very awkward in our culture, Steve. If we were friends and you got sick, I'm thinking, "Should I call Steve, or am I bothering him? He wants to be left alone."
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And you're thinking, "I thought Dan was a friend. Why isn't he calling?" So I have spelled out in my advanced directives, "Here's people I really would like to come and visit if they're comfortable."
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So they know I wanna see them, I wanna talk with them, I wanna relive our experiences. We also have a relative in our family who's a wonderful person, who will drive me crazy after 10 minutes.
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So I say, "This person, I don't want to exclude them, but I'd also like [laughs] people managing me when I'm there to graciously escort them out after 15 minutes or so," because then I find it disruptive.
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But they're a loving, loving member of the family. So that's... I frame that, kinds of things, um, that way. I also ask for early palliative care and early hospice care.
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Um, I, you know, hospice, uh, this last six months of life, average length of stay in the United States, about two and a half weeks.
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So again, a service that we've, it's covered by Medicare, we've paid for, and we don't take full advantage of it. And they can do a lot of, a lot more services than people are aware.
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And palliative care is a lot of comfort care and managing, uh, difficult care, again, covered. Um, and these are things that are, are really valuable.
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There was a study in the New England Journal of Medicine a few years ago. People with lung cancer, they divide them into two groups.
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They all got identical treatment from the medical point of view, medical surgery, radiation, whatever, chemo. Half got early palliative care, the other half did not.
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The early palliative care group lived longer, better quality of life, spent less money. It's a pretty good medical trifecta. Lived longer, spent less money, better quality of life. So, you know, these services are there.
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Advanced directives are free. Hospice and palliative care are available and covered. But we, the consumers, so to speak, have to ask for them. I, I love it, and thank you for being so transparent and sharing that.
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You, you really dove into some details that I didn't think about, um, and may need to go in and update- My advance directive after, after hearing that. Um, let's see. Okay. Um,
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we got a few, uh, questions here. Um, Kathleen says- Okay, so Steve got the, the, the early palliative care article- Yep... on your screen. Boom. Thank you. Yeah. Uh, okay.
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Kathleen says, "What kind of things are moderate heroic measures? Can you talk about the downsides of major heroic measures?"
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I think it depends on the person, their age, uh, their underlying, underlying conditions, and so forth. So it's, there's... From my point of view as a, as an ER doctor, it would depend on a lot of specificities.
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It's hard to give a general answer to that.
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So somebody who's, you know, terribly advanced, illness, multiple problems, partly demented, you're gonna treat that differently than somebody who's 45 years old or 25 years old who has some other illness.
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So, and, and it depends on their personal values and what, what, what they want. So, um, it's, it's a... These are really difficult discussions or can be very managed discussions because people are living longer.
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You know, compared to when I started as a doctor, there weren't that many choices about how to keep people alive. Now there's many more. People are living, you know, 80, 90, 100.
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Gee, when I started as an ER doctor, if we saw a patient that was 90 years old or 95, we'd go, "Wow, there's a 95-year-old here." Well, that's every day now. Nobody gets excited, you know? And, and that's good.
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So the, the decisions are more complex, and so it's hard to generalize like, "This is the way to do it."
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I know what I w- would want, and mine pretty much specifies if my brain is around, I'm kind of aware, keep me going.
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If I'm really, you know, completely out of it mentally, uh, you know, some moderate care, maybe I'll recover a bit. But if it's, you know, terrible, just when some illness comes, let me die in peace.
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And, um, y- you know, uh, one, we had a discussion not too long ago on dementia directives, meaning, um, uh, instructions if somebody was diagnosed with dementia.
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Um, is that something that you're familiar with? Yeah. And it's, and there's a chapter in the book, uh- Okay. And let's-... by Professor Moran that talks about that.
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But again, that's what you wanna do while you're still confident, [laughs] reasonably confident. Yeah. If you're over the edge, it creates a lot of difficulties. Let me also share one other thing.
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Body disposition's another topic that does not get covered, and I wanna touch on that briefly if I can, Steve. Yeah. You have a few choices.
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What do we do with these corporeal remains, the stuff that, you know, makes us up? You can donate your body to medical science. That doesn't cost anything, but you have to be sure to do it in advance.
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It can't be done late. You've gotta do that while you're still pretty aware. Um, there's conventional burial, what we call conventional burial. To me, that's a big waste of resources.
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A typical 10 men- 10 acre cemetery, next time you drive by one, has enough stuff buried to build 40 houses, each with a swimming pool. The amount of medicine...
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I mean, not medicine, the amount of cement, the amount of wood, you know. So for the cost, all that. I work too hard for my money to, um, uh, you know, pour it into a big hole in the ground.
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Now, some people, that's fine. They wanna have big built monuments. They build the pyramids of Egypt. That's okay. They wanna do that. Um, cremation is a huge carbon footprint for those of us who care about it.
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Basically, you're burning fossil fuels, and what comes out, you have to heat the body up to 1900, 1900 degrees for two to three hours. And what comes out the smoke stack is like when you burn any fossil fuel.
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So that is not environmental and not appealing to me. So what's come around is natural burial, green burial. And there's now green burial sites where it's very simple, low cost.
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Um, no, you know, just a little marker ground, marker and a GPS where the person is. A flat headstone, and no, and it's all biodegradable caskets. Way less expensive, and it actually restores the environment.
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And the ones that have popped up around the United States are usually people with land that they don't wanna develop, and this is how they, uh, retain the environment of their land. Uh, and they're quite beautiful.
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Uh, there's several now in Maryland, and they're worth, uh, and they're all over the United States. So check out green burial. Yeah. We've had, uh, this has come up, uh, a lot i- in our end of life discussions.
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And, um, folks are very curious about it, and many people just don't know that it exists.
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And as you had said, the, um, the footprint that more traditional burial leaves on the environment and just, you know, the landscape. Uh, so- Yeah...
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um, uh, thank you for- By the way, Steve, one, one of the chats, you don't need a lawyer to complete an advance directive. The laws vary a little bit different state to state.
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Some you have to be notarized, but most are just, you know, transportable. And, uh, if you're spending a lot of time in two states, I'd check out both state laws. I live in one state, so pretty much most of the time.
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Yeah. And I, I think the green... Or i- what, what is the, um... It's like a water-based, uh, burial, um- Yeah, there's hydrolysis. There's a number of chemical ways. Um, to, to me, I would just, uh...
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Yeah, for those who want to explore that, that's fine. I think Mother Nature handles it really well all by itself for low cost and without having... I've seen some of those machines.
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They're useful in, uh, in, uh, medical schools where they process a lot of bodies that have been, uh, um, preserved with chemicals, and that makes sense there.
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But for average people, if that's what you want, that's fine. It, it doesn't make sense to me when I could be r- my molecules could be returned to Mother Earth.
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I've consumed enough of their molecules, [laughs] I could give back. Okay. Um, well, this has been great. And I haven't even shared the, uh, the book yet, f- folks.
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So let, let me quickly share my screen, because what I w- I, I've put together is a slide that has the two books on this topic that you've co-authored and, um, uh, and some of the chapters.
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And I know it may be hard to see these on the, the, uh, the screen. I'm gonna also, uh- Provide a link at proaging.com with the recording where you can, uh, uh, find both books.
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But, uh, your most recent book that you are a part of is Improving Dying, but I guess the first book that you wrote, uh, or co-wrote on this topic is Preparing for a Better End.
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Um, first off, Dan, could you give us just an overview of what we'll, what we'll learn with both of these books and, and how they came about? Sure.
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And, and this one, there's a, a newer version of it, so if you're l- going online, you'll see the newer version.
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And, um, they're pretty much the same kind of chapters, but much more, uh, in depth and updated in the second version. Okay. The website is betterend.com. And, um, it's, uh, a lot of stories and a lot of practical stuff.
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It's not the preachy, it's not philosophical. It's like, "Here's the kinds of things that can happen. Here's what you might wanna do about them."
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And I'm proud to say that these books were endorsed by some prominent people, including Maya Angelou, uh, Senator Ben Cardin, Senator Chris Van Hollen, and to cover the political waterfront, Ben Carson, and a whole bunch of other people.
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Tara Brach, Buddhist leader, a whole bunch of people across different communities. The other book that you showed first came from the Hospice Foundation of America, and, uh, that, um, I just wrote one chapter of it.
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A- and I read the rest of the chapter, and there's a lot of good [laughs] information there, so I learned a lot by reading the other things in, in this book. But g- again, good practical advice.
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You know, we're really the first generation in human history that has some say about how, when, and where we die. I mean, 150 years ago, you stepped on a nail, got an infection, [laughs] and you were dead.
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But now, that kind of stuff doesn't happen. So we can make this whole experience more family-centered, um, comf- as comfortable as possible.
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We don't get out of the death part, but the pain, isolation, and dependency all could be managed.
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And by the way, there's, you know, significant financial implications as, as well, which we could go into, especially as they're, the f- the federal government is discussing cutting, uh, Medicare. Mm.
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There are better ways- Um, yeah. So, uh, Dan, I shared with you this email that I received before we even started this discussion. Yeah.
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And, uh, one of the attendees, I hope she's in the audience, was hoping that you might share some perspective on medical aid in dying. Sure. Um, and I see in both books it's, it's something that is addressed.
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Would you care to share your either medical aid in dying, your personal viewpoints, or what, what have you on that? Of course. And I think everybody's entitled to their own view on this.
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So my experience with it was when I was in the Maryland General Assembly, that bill came up, uh, twice in my time there. We did not, for political reasons I won't go into, vote on it. I would've voted for it.
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But let me tell you what the experience was. It was long hearings, six, seven hours. Many of the people for medical aid in dying, uh, many people against.
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And I will tell you that everybody was sincere and serious in their position in how they got there.
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They would, of course, then come to me, uh, in, in my office or lobby me at other times, and I would sit down, and I would listen to their, you know, pros and cons and the subtleties between the two.
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It's also important to have read the bill. There is a saying in the legislature, "When in doubt, read the bill." So I did read the bill, and was reasonably comfortable that safeguards and so forth were there.
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But when people came, I would say, "I, I get your position, and it's very emotional. Have you completed your advance directive?" "No, I haven't."
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"Have you talked with your clinician about, um, medical, uh, orders or life-sustaining treatment, MOLST or POLST?" "No, I haven't." "Well, why don't you do those things?
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Because most of what you're talking about could be well managed by completing free paperwork."
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The fact of the matter is that medical aid in dying gets a tremendous amount of attention in media, and gets everybody's juices flowing, and you can start arguing about it, but it's much less exciting to say, [smacks lips]
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um, "I wanna talk about completing free paperwork that's been around since 1991." Yawn. You know?
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[laughs] So what people were worried about, a lot of it could be managed if they would just take advantage of the tools that are there right now, which we know we collectively don't do.
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So I would say, and I always had a stack of Ma- State of Maryland advance directive forms and other references, and I would give them the form [laughs] in my office and say, "Here. Do this first.
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Figure out what this is all about, and then you can decide." Now, I would have ended up voting for the bill, because I, I thought the bill, at least in our state and the few states that I've looked at, is well-crafted.
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I don't think it's a slippery slope. And there are outlier cases, and I think that should be reserved for the few folks for whom this is, uh, potentially applicable.
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But, um, you know, I think there were safeguards in the legislation. But most of what people were worried about, they, you know, y- you can h- that can be handled right now, if that's what you want.
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You want the full court press, you value that perspective, by all means. If I get a patient in the ER and they, and they say, "I want everything possible," I'll give them everything possible.
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It may not be what I would want. There's also people I've, uh, dealt with more in my personal life than professional life who, you know, in effect said, "Let me go sooner than I would've liked."
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I wrote about a friend who had, uh, Lou Gehrig's disease, ALS, and he just didn't wanna go through all the stuff. But I talked to him. I said, "If I was in your position, I would keep going.
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I'd take the tracheotomy, and the whole tracheostomy, and the tubes, and all that stuff, 'cause mine, my mind's still working in that disease." It's not what he wanted. So, you know, I respect the diversity of opinions.
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Um, that's my perspective on assisted dying. Um, it's now passed in a few states. It hasn't passed in my state, but it's passed in Delaware. And I think it's, uh, uh, you know, reasonable in those situations.
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But again, you get a lot more discussion about that. Let's have a conversation about why we don't take care of all the stuff that's readily available and free right now. Mm-hmm. Yeah.
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And, um, I actually just learned that one of my neighbor's sister had a, um, a diagnosis, and she moved from Maryland to Washington, DC Because of the medical aid in dying, but another thing that I've heard a lot, she did not utilize
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the, the, the prescriptions or, or whatever that entitled her, her to, but it gave her a peace of mind to know that if it got really bad that, uh, she could utilize those. Yeah, that's a fair point.
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And, and I think the general statistics are about a third or maybe a quarter to a third of people who have it actually use it.
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So, you know, that, that's, that's again a personal choice, and I think this really is about we have different perspectives and different stages of, of life, uh, and values, and what I would choose when I was 50, 70, or 90 would, would change.
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Yeah. Okay.
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And Shanti has a question specifically on this, and again, as we've said, everybody's got a different personal choice, but she asks, "Should I specif- should I specify medically assisted dying in my directive in order to make decision-making easier on my children?"
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Um, how, how would you answer a question like that from Shanti?
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Well, obviously first of all, it depends on the state that you're in, if it's legal, because you don't wanna try to get anybody down, going down a path of illegality, which creates various problems.
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I think you have to have conversations with those people, your children, about what you'd want under what circumstances, and the circumstances are so variable now that, um, you know, there's no quick cut-and-dried answer.
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So I think you'd, you'd sit down and talk with them and say, "Here's the situations where I'd like medical aid in dying, and if it's legal in your state, you know, s- initiate the paperwork in advance."
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You know, we, we adv- we talk about advance care planning. We spend a lot of time in the care planning. We forget the advance part. This is all best done if you do it when you're awake, alert,
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not in any medical crisis, not in any circumstance. I mean, I know in my own family when my kids call me up and they have a health issue or with one of the grandkids, I get a little unnerved, you know?
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Cool as I am in the ER, when it's me personally, I start to, "Oh my gosh, what's going on?" So we have a tendency not to think as clearly when a medical crisis is upon us. It's understandable.
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So the, the point of all of this is to do all this paperwork, put it in a safe place, make sure it's available in that safe place, make sure it's distributed appropriately to your clinicians or your hospital,
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and then forget about it. 'Cause then go back to the rest of your life. When something difficult happens, then, then the forms kick in. The, the advance part is the point. Okay.
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Another question that I think is, is really good is, is that, um, and oh, looks like this is from Shanti as well, "I have a medical directive written up by my lawyer, but I've now noted details that Dan just mentioned, like what food, friends, et cetera.
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Should I redo this document?" And she also mentions that she didn't have, she doesn't have the My Directives card that you had. I'm, I'm gonna drop, I'm gonna drop that website in again.
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Dan, from your perspective, the advance directive, we can get those done free of charge at My Directive or, um, Five Wishes. Um- Five Wishes. The most state health departments will have them.
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Sometimes in a different state it might be attorney general's office. If you're of a particular devout faith, there's faith-based advance directives. You don't need a lawyer.
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You can certainly talk to a lawyer if you want. You can talk to your clinician, which is the best person to talk to, physician, um, or whoever. But, uh, you don't need a lawyer.
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And yeah, you should update it, and you know, even I, who am into this topic, occasionally forget to update mine. Fortunately, I am with My Directives, which is free to individuals.
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Every s- every year they send me, "Do you have an up- do you want to update?" I go, "Oh yeah, I forgot. There's this thing that's going on." And now I, I, I do. So I, I get it.
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I'm in denial like everybody else, to a degree. So yeah, by all means, Shanti, um, take a look at mydirectives.com or Five Wishes or any of the other ones that are out there and find the one that suits you.
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By the way, you can complete advance directive on the back of a, on a piece of paper. You don't need a form. It has to have three elements.
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Uh, who, you know, who makes decisions if I can't, how much care do I want under these circumstances, and body disposition, sign it and date it, and uh, you, and, and then have it be available.
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So forms are nice because they walk you through the process. Um, okay. Uh, let's see. Several questions or, and/or comments about death cafes, which I personally feel are a wonderful way to, uh,
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get used to communicating on this topic. Do you have any thoughts on, uh, death cafes? Yeah, I think they're fine too. I've been to one or two many years ago, and I think they're...
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Any, any vehicle that gets people to talk about this is good, you know? And we've seen taboo topics before become un-taboo. I mean, I gave you a few examples.
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Um, I think it's good to look at the instructions, the, the be- the, the lessons from La Crosse, Wisconsin. Has that been covered on your show before, Steve? Uh, uh, say that again.
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La Crosse, Wisconsin, the experience of La Crosse. So La Crosse, Wisconsin is- Uh, ex- explain that...
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midsize town in Wisconsin, 100,000 people or so, and they decided, some activists got together with their business, legal, faith, and health community to say, "We're gonna be the town that has the conversation."
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So they raised the rate of completion of advanced directives from a standard 35, 40% to 98%. Uh, this is of adults over the age of 18, and you can look up some of the articles on this subject.
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And I've talked to some people there. Two things happened.
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One, you know, when people talk about death, the, a little bit, and we do it, with all the great sages and philosophers of the world, it's contemplation of death that gives life meaning.
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So people started to see each other a little bit differently.
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The person, you know, in front of you in line at a grocery store, they're not just annoying person blocking your way, it's another human being that's going through life like you.
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So the, some of the, what, uh, feedback I got was the tone of the town changed a little bit because people saw each other as mortal, and it was just different. The other...
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And they treated with a little more respect and, and, and, um, kindness. The other thing is they reduced their healthcare costs by a third.
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Because every death that happens, you know, if you have to be in an intensive care unit and it's appropriate, that's great.
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But we've all seen, every clinician who's honest will tell you, we see too many deaths in intensive care units, which are very expensive, that shouldn't have been in an intensive care unit, maybe in the hospital.
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If not in the hospital, in a hospice. If not in a hospice, at home. And as you go down that list, um, you save a lot of money. Medicare is $900 billion plus per year.
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About 300 billion is in the last months of life, and increasing because the baby boom generation, which I'm part of, is living longer and spending more money. So 300 billion or more.
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What if the rate of completion of advanced directives was, instead of 40% or maybe is higher in the, the old, somewhat older population, 50%, let's say it was 99%.
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Because people are not choosing inte- high-intensity deaths, you save money.
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You could speculate, and La Crosse, this is the, essentially their experience, if you save 20 or 30% of that $300 billion, that's $50 or $60 billion. Wow. We talk about the Medicare crisis.
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What we talk, what unfortunately the government talks about is cutting benefits, making it more complicated. Healthcare's already complicated enough. Red- you know, increasing co-pay, all that kind of stuff.
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Here, by empowering people to complete free legal documents [laughs] and take advantage of hospice and palliative care, you'd improve quality of life, have a more holistic family-centered valued experience.
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And by the way, when families are around when people die and it's done well, it is an experience that they often feel really good about in retrospect. We of ch- of course are sad about losing somebody, but...
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And then we'd save a ton of money. Um, you know, we'd save a lot of money by people completing free forms and empowering. So that's where I get my frustration. Why, why is this such a hard sell?
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This ought to be the easiest thing in the world to sell. Um- Oh, and- But it's the death taboo, you know, we don't wanna talk about it. Um, but that's just d- denial of reality.
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But I, I was not aware of the La Crosse, Wisconsin, um, story. I dropped an NPR, um, podcast and an article in. That's fascinating.
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And, um, I would love to dive in deeper and see if any other regions have, um, attempted to replicate that, because it seems like it's, um, just a- Yeah, there have been different studies that show some, you know, op- they're all in that trend in that direction.
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It's- Mm-hmm... intuitive, isn't it? You know? It's intuitive that of course they would, um, uh, spend less money. And in this healthcare time, why not, why not do that?
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And so, uh, we got passed in Maryland some very good advanced directive bill, including, uh, we recognize National Healthcare Decisions Day, um, uh, which is, uh, every April 16th.
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I did not create that, somebody else did. April 15th is another day we all know, that's tax day. So they [laughs] they decided to link death and taxes, so we officially recognized it- [laughs]...
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in our state and other places. That's just, you know, like the other days that we have, it gives you a opportunity to raise a topic that otherwise, um, uh, gets avoided.
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So we have a lot of discussions, um, still to take place on this topic, and I don't have all the answers, but I keep bringing it up and hope...
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You know, I'm at the gym, in the grocery store, run into a friend, uh, we talk, and I'd say, "H- and have you completed your advance directive?"
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Now, a certain number of them run the other direction, [laughs] but a lot of them later come back and, you know, several months later and say, "Gee, what was that you were talking about, that advance directive thing?
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'Cause my Aunt Betty now has got some problems, and we're trying to figure it out," and so forth and so on. Um, okay. A question from Wally, who says, "What about the burden that living much longer puts on the family?"
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I, I think, I've heard this come up a lot when people are planning, uh, on this. It's like, "I don't wanna be a burden on my, my, my family," and that's their choice to, when they're doing this end of life planning.
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Well, uh, you know, unless you're planning to... Like I don't, I don't, really haven't thought that one through, so I'll leave it to others to comment.
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But unless you're contemplating suicide, um, you know, you, you are gonna be a burden, but also hopefully your presence is a gift [laughs] and, and valuable and appreciated by others.
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And this really, you know, I stick pretty much to the medical perspective because we want to, um, you know, do the right thing by patients and respect their values.
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I think there are, you know, numerous ancillary causes, ancillary issues, but let's keep our eye on the ball. Can I share an anecdote that changed my- Yeah, absolutely... this topic?
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I was working a 4:00 to midnight shift in the ER. We get a call from the paramedics, uh, LOLFOF, that's ER talk for little old lady found on floor. [laughs] Um, common demographic, older woman living alone.
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And it's clear from the paramedics that, uh, she has had a major intracranial, you know, neurological catastrophe.
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She comes in the ER, we do all the standard procedures in, in getting the CAT scans and the workups and the blood tests, and this takes a few hours. Meanwhile, her family's starting to arrive, 'cause the call goes out.
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Nobody, you know, has on their to-do list, go shopping, pick up the kids, get the car washed, oh, and run to see grandma in the emergency room. That's not on the list.
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So they're all arriving, and I'm shuttling back and forth, giving them information as it becomes available to me. We're getting all the consults and so forth.
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What I observe in the family is that the people who knew her best say, "Let grandma die in peace." And the people who are more remote or saw her less frequently were saying, "Do everything for her."
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Kind of like, "You do everything for her." And a conflict is breaking out in the family, and I could see the conflicts erupting.
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You know, there was screaming and yelling, and people are s- you know, staring at each other.
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And you, you may know families for whom these issues are carried on for decades at family gatherings, Thanksgiving, holiday season, they're still bringing up, "You did that thing with grandma," you know, with mom or whatever.
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Anyway, it turns out she had an advanced directive. It was one of the first ones I'd seen. I was aware of them, but it was actually one of the first ones I'd actually had a chance to deal with. It was many years ago.
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So I go in the room, and all hell is broken, breaking loose. One guy's staring at the floor, somebody else is sobbing, two people are screaming at each other. Finally, they calm down enough, barely.
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It's time for the doctor to say something. So they all look at me, and I say, "Well, I've got this advanced [paper rustles] directive here, and it's very clear.
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And she says, 'If I'm in extremis and there's no hope of recovery,' so well detailed, 'I want no heroic efforts.'" So I said, "I'm gonna go... That's what she says.
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I'm legally and honor-bound to follow that, so I'm gonna go in the room and take the tube out of the windpipe, stop the medicines that are keeping her heartbeat and blood pressure and all that.
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And you can come in the room with me if you want." Now, you think at that my moment would get more explosive. Actually, the opposite happens. [sighs] Everybody calms down.
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The decision had been lifted from their shoulders. They come in the room with me. I disconnect everything.
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The family gathers at the head of the bed, and they hold her hand and they stroke her brow and they whisper in her ear. Maybe they said prayers or sang songs, little whispers. I don't know.
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I watch this for about 10 or 15 minutes, then I'd return to the rest of the patients in the ER.
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I check back in every so often, and this family that had only a half hour before been at each other's throats had now come together.
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And it hit me that, and I did not process this in the moment, by the way, this was days and days [laughs] and weeks later. This woman, it's not about me. We're a very me-oriented culture.
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This was taking care of her family. And so if we really love the people we say we love, we do this so they aren't left in conflict.
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Advanced directive only becomes operative if you can't make medical decisions for yourself, for whatever reason. So this woman who, you know, changed my life, really, that launched me in part on this...
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I don't know her name, you know? [laughs] I don't know anything.
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She, she not only impacted her family, she impacted me, because I saw other families in conflict and I thought, if they'd only had the advanced directive like she had provided. I brought it up to Shelly. We had one kid.
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We were young then. You know, live forever, you know? And I said, "We gotta complete those advanced directives for them. They've been sitting here someplace. [laughs] Let's take care of it." Wow. And- That's great...
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that was a, a profound change experience. That's a big part of what got me into this.
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And I think that does probably relate to Wally's question, is that- As Marie writes, uh, uh, advanced directives are a gift to the family. Thank you, Marie. Yeah. Yeah, exactly. Yeah, I know. Um, so, uh, I've, I've...
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Y- you brought up the, you know, single woman or what, what have you. Um, and as I... You may have heard in my intro, solo aging is our number one topic, and there's often a lot...
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When we talk about solo aging, there's often a lot of agonizing on, um, the m- medical powers and financial powers of attorney.
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But also related to all of this is, is that, y- you know, you talked about talking about this with your wife, and there's a lot of people out there that don't have a support network, or they've outlived their support network, or their support network's all over the country.
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Any words of wisdom for folks that might be in that type of family situation? Yeah, that's a, that's a tough place to be, so you have my sympathies. But you can be somewhat more creative.
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You don't have to choose your spouse. You can choose anybody you want. I had a friend, uh, who had two, uh, teenage girls then, and his wife died suddenly.
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He asked me to be his healthcare agent in working with the teenage daughters. Um, we're not... We're, we're well acquainted, but we're not intimate friends. But that's...
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When his daughters, a number of years passed, and he called me up, he said, "Hey, the, the, the girls are now young women, and, uh, you know, we're gonna let them do it." I said, "Fine."
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I mean, I could choose you, Steve, to be on my advanced directive. Oh, no, and y- You could choose me... and w- And- This comes up on a regular basis...
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unless you're totally isolated and cut off from anybody and everybody that you trust, um, you're, you should be able to find somebody. But you need to have the conversation with them. Mm-hmm.
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You can't just put down Jane Smith, Joe Jones on your advanced directive. You need to talk with them and say, "This is where I'm at."
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But again, with mydirectives.com or Five Wishes, you can write a lot of narrative that describes your circumstances, what you want, how you want it, uh, under what situations.
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And I, and, and so you don't just leave them with, like, a couple of boxes checked. Um, but you have to initiate that conversation, have it, and then... And, and they may be uncomfortable the first time.
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You may have to go back a couple of times. You know, not many people, including me, as I shared before, jump into this, you know, both feet first the first time. Uh, it takes some process. But the benefits are manifold.
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Um- Family, yourself, society, finances, culture, and so on. So again, why, why this is a hard sell, not entirely clear.
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But, but, uh, our job, if you're listening to this and you've completed your advanced directive, great, then update it. I want you to, if you haven't done it, complete it. I want you to bring it up to everybody you know.
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I mean, you know, you just gotta talk to people, over the backyard fence [laughs] Yeah... where you worship, where you work.
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I mean, I was just in a business meeting, and there was an opportunity because we were talking about, had nothing to do with healthcare. I said, "This is an advanced directive.
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You should, by the way, everybody here should complete an advanced directive." That's all I said. I didn't pitch. But you're seeding the environment. Yeah.
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I, uh, I, I've sort of dr- I'm driving my circle of friends and family crazy because it seems like at every gathering I'm bringing up something related to end of life. But what I've...
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It's part of the fact that having conversations like these, talking about how we want to end our life, I, I feel that it's not a shallow conversation. It's n- No... this is not small talk.
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But it also makes you reflect on, uh, what you might do between now and that point in time. Uh, and, a- And I, I've seen other things that have seemed impossible at the time become normative.
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I mean, we talk about women with breast cancer... people with epilepsy, we can talk about it. But I'll s- do a legislative story. My first term in the Maryland General Assembly was 1995.
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There was this super controversial bill. I'm a newbie just trying to figure out what's going on and where everything is, and people come up to me and say, "Delaware Morehim, you gotta vote for this bill.
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It's so important," blah, blah, blah. Walk down the hall and another come and go, "Delaware Morehim, you gotta vote against this bill. It's a disaster. It will destroy, you know, jobs and the economy."
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Wow, what was the bill? The bill was to ban smoking in restaurants. It was to ban smoking in restaurants. It was hugely controversial. Uh, w- it was boom, boom, boom. We finally passed it.
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Uh, all the bad things were supposed to happen did not happen. It took 10 years in our state to ban smoking in bars, relatively, you know, quote liberal progressive state. You couldn't in this state reintroduce a bill.
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Most people wear seat belts now. Those were big fights. Taking babies home in a, uh, safety seat, um, you know, was, uh, was...
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People, "Who, who are you to tell me, the state, that I have to get, spend $100 on a bucket to dri- You know, I drove around my whole time and blah, blah, blah, blah, blah." Well, we kinda stuck with it and, you know,
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childhood ch- children injured or [laughs] killed in car accidents has dropped dramatically because they're in those safety seats. So y- you know, they're, that, these were big fights.
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This should not be a fight, but I'm hoping that if enough of us speak up, it becomes the normative thing. Mm-hmm. When our kids turned 18, Mommy and Daddy gave them advance [laughs] directives to complete. Yeah.
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Two are married. They've updated them.
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In, now it's just part of our family routine and it, it doesn't have to be this big emotional, you know, catastrophe, iceberg [laughs] in front of you as your ship of state goes down. No, just do what you do routinely.
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I get in the car, I click my seat belt. Mm-hmm. That's it. This is like, that's all it should be.
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And, and one day I hope it will if we all work hard enough together, and, you know, what you're doing is hugely valuable, and everybody here is empowered.
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You're all deputized now to talk about advance directives with everybody you know. Yeah. No, it's funny.
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Uh, when I made the comment about talking about end of life, several people [laughs] are like, "Yeah, I'm doing the same thing. This is great." Good. Good.
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And lots of, lots of comments about what a wonderful, uh, guest you've been, and the, they want you back. Uh, so, so we'll be doing that.
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But th- and, and as I'm looking at- I'm available by my web, uh, email, by the way. It's just my name without a dot in the middle, danmorehim@gmail.com. So I am available. Okay.
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So that's great if I share that on the, um- Yeah. Yeah. Okay. And I work out whatever details. Sometimes people pay me for it, sometimes it's free. I, you know, it's a matter of scheduling and convenience. But- Okay...
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sure, if you want me to give a talk, I'm all into doing that. Okay. And then, um, and folks, uh, there's somebody who arrived late, this is recorded.
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It'll be at proaging.com later this afternoon with all of the chat, with all these resources, with Dan's email. Um, Dan, we've got a few minutes left. Sure.
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Uh, anything that you haven't, uh, shared today that, that, that you'd like to share wi- with, with the audience? Um, yeah, a couple things. One, know your own state.
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The states are slightly different in how they do these things. Um, so that's, that's one thing. Um, be sure that you take care of this paperwork and have it be readily available.
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That's why I carry it with me sorta wherever, uh, I am. And, uh, let me see.
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The other thing is there are other forms called medical orders for life-sustaining treatment or physician orders for life-sustaining treatment, depending on the state.
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That's often where the do not resuscitate term, uh, is gonna be done in each state, so you wanna look at that. Um, I never liked the, by the way, I never liked DNR, do not resuscitate as a term.
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Some, uh, institutions and places have taken on allow natural death as a term, AND.
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And I didn't like do not resuscitate 'cause as a clinician in ER, I didn't know, well, how much of what I'm doing, when do I cross the line into resuscitation? You know? Start IV fluids, is that resuscitation?
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Give somebody nasal oxygen flow, is that... Put a tube in their windpipe, well, you're getting close, [laughs] you know?
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So i- i- i- it, it, that, that often is in our state and other states, that is the legal document for do not resuscitate, so you wanna check out that in your own state.
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That's a level of detail that, uh, you may need to get to, but the important thing is to start with the advance directive, and the most important portion of the advance directive is who makes decisions if you can't.
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That would be, if you only complete one part and then put the form down and then come back and go through the details later, that's fine. The number one issue that we face in the ER is who do I speak to?
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By the way, we've had situations, you know, you get... First of all, you can't get onto people's cell phones now. Used to have some, you know, they may have a...
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In the old days, they had a date book that you could look up or, you know, address book in their pocket and call up a nice, uh, calling their spouse, say, "Listen."
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You know, then the patient wakes and goes, "You didn't call, you didn't call my spouse. I hate that person. We're in the midst of a bitter divorce." [laughs] "Well, well, that's all I, all I had."
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So, you know, you do what you... Or the, "It's a pizza parlor." "No, I don't want the pizza parlor. I want, you know, who's gonna give me the information I need." So those are all things.
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There's a lot of subtleties to this, so it does take some time to work through. Be patient, but it's really helpful when you do it, not only for you, but for your loved ones.
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And, and, it, you, you reminded me of a question that I started reading you and then I got sidetracked. A- and, and this is a good... It's, um, obviously if something is in writing, we cannot, um, misinterpret it.
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But, uh, but if, let's say that y- you're a doctor in the ER and they don't have the advance directives in writing, but somebody comes in and says, "I had a conversation with my mom.
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This is what she told me she wanted," how, h- would that go to committee, or is that, um- Well, that's, that's better than nothing.
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I mean, we're grasping for whatever we can get, and if I begin to get the feeling in a clinical setting that there's some conflicts, I always get help. Mm-hmm.
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So I think somebody wrote there, what if there's a, you know, estranged but still legal wife and a, and a girlfriend? Yeah, and if they're screaming at each other, I'm not gonna try and solve it.
334
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I'm gonna get some other folks in there with me, the hospital attorney, the hospital chaplain, social worker, whoever. I'm not gonna, you know- Uh, they can't...
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If I can't resolve it between them, I'm going to bring in others.
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Um, these are not things that you wanna walk the plank by yourself, and they're co- they can be complicated and heated, and I've seen those family conflicts.
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But more often than not, those are the outliers, so they get the attention, just like assisted dying. What if this, you know, s- can I create a scenario that's so conflicted? Yeah, that you can.
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But more common is the person has advanced directive and it eases the situation. That's the common event that takes place, not the uncommon one. Sort of like saying, "Well, my seatbelt, what if I drive into a river?
339
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I can't get my seatbelt off." Yeah, I suppose that's possible, but that isn't how most car accidents happen, you know? [laughs] So, uh, yeah, there are conflicts. Nothing is perfect. Um, but you can...
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You're shifting likelihoods to the care that you want with decisions made by the people you trust, and it's not perfect, but it goes a long way.
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So yeah, there are scenarios that are tough, but most of the scenarios that are, have been problematic historically could be addressed by doing the things that we're talking about.
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There'll always be things that are difficult. So we want- And, uh, this, this- To have, to have, to have a bracelet or a ID ba- all those things are helpful, any way that information gets shared.
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In our state, we're now getting this stuff into our electronic medical database, but I know in other states it doesn't work as well. So you have to take some of that burden upon yourself. I love it. All right.
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Well, Dan, thank you so much. This was great. You're, uh... I will definitely be inviting you back again.
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But, um, folks, just as a reminder, I'll have all Dan's contact info, all the chat, uh, the recording, it'll be on podcast so you could share it with your friends to, when they're walking their dog, they could listen to this.
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And, uh, you've been wonderful and, uh, and great questions again, uh, to kind of drive our conversation here as well. Yeah. Let me thank you, Steve, and everybody that participated. Much appreciated.
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I can't wait to read all... I couldn't read all the chat while it was happening, but I will look for it and read them all later. Thank you. I love it. Okay, thanks a lot. Have a great day, everybody.