so who wants to think and talk about deaf other than woody allen and a few of my relatives have family picnics death is not exactly the most comfortable topic for most people to ponder but if we don't assume the responsibility of making choices about the kind of medical care we want at the end of our lives who ends up taking on the burden in this program we are going to learn about advanced directives also known as living wills also will learn about pole store practitioner orders for life sustaining treatment and other issues that will help us hopefully make more informed decisions about the most inevitable event reich earned an advanced law degree from seton hall university school of law where she was a member of the first l l am class in health and hospital law she writes in lectures frequently on issues in bioethics and serves as a bioethics attorney for chilton hospital a member of the atlantic health system she is an adjunct professor of law at william patterson university and a leader in the alternate dispute resolution community with a private practice specializing in commercial disputes and elder mediations she is the two thousand and sixteen recipient of the j dell award for professionalism ethics and service to the ada your community is it getting easier for people to talk about these issues statistically if you read in the literature they'll tell you that maybe one out of five people have living wills vance directives but when i lecture throughout the community in many different venues and met quite often it's often in senior centers more many more seniors have them than the one in five i think what has happened is let me give you a little historical perspective there are the trio with a trilogy of famous cases we quinlan case which was right here in new jersey which is considered the first right to die case after quit after the play in the case there was a u s supreme court case called cruzan which is really the most instrumental related to this topic and then there's a follow up case terry and you know that it was in the papers as you said they have been made for t v movie this so people are much more aware of these things everyone has the right to express what their wishes would be in a clear and convincing way they allowed that right to be taken over by the states and every state had the right to decide what would be clear and convincing evidence in their state because new jersey has such a strong history of being involved in right to die cases with the karen and what quinlan case we were in fact the forty ninth that a fiftieth state to have a living will legislation because our courts was so much more sophisticated that the legislature didn't really feel the need to jump in where in other states it was somewhat different but now all the states have what's called advanced directive  legislation or advanced directive statutory guidelines and in some manner shape or form a new jersey says fairly standard so just to kind of define our terms if we can begin with what is an advance directive because most i think a lot of people have heard it heard about it as a living will they tend to when they hear the two think that there are different so advanced directives and living wills and then i  know you're also going to talk about polls so let's start with the term living well because that's the most commonly use sure ok the biggest problem is that in this it in this nomenclature people have called it living wills people non lawyers hear the word will and you immediately think of your money right and living will has to do with your health care choices not your money choices right so that is where most of the confusion comes from but no i'll get a little technical on you but but not very much advanced directive is the technical term right within advanced directive this is technically two components one is the instruction directive or the living will right which basically says yes i want to be intimated no i want a feeding tube all those things that those medical concerns that you've dealt with the second component of an advance directive is in fact it is in fact the proxy directive and the proxy directive is the place in which you pick your representative your picking your spokes person and simply put pick your person so think of it as your pick your person part of the document in crime technically you can have one or the other i very much recommend both but with the and when i say with a coffee i shared with you before the program a couple of simple living wills so this might be a good time to share with the audience when you can get them so that living wills or very easily obtained you can get them from any of the hospitals so if there is a hospital you tend to use they will have one you can any of the clergy have them because all the religions tend to have ones that are in that they so they're readily again as readily accessible readily accessible without a fee ok and the advance directive arguably does not need an attorney to complete it but this is this is the the rub a little bit what happens often is that a family will go to an estate planning lawyer to take care of their stuff as they would say and they are very bus worrying about the tax aspects of and the way they give it in who they give their their assets to and then the estate planning lawyer of which i was one for many many years i would say well in order for the package to be complete i need you to give you an advance directive and it's sort of thrown in as the rodney dangerfield or just sort of estate planning and what happens is it's not uncommon that a lawyer when they're doing it for you will in fact give you a fairly complicated advance directive my recommendation is i'm not saying is that because lawyers always make things complicated and now we all know we are partial the words  my recommendation is although an advance directive is a legal document it's a legal document that only jumps into being so to speak at the bedside if someone can no longer speak for themselves so if you want to increase the odds of your living will being followed to the extent that you executed it you're in a much better position to one keep a simple one because you're asking the doctors and nurses to interpret it at the bedside in a crisis and you're much better off or you using the form that the hospital has generated because it's the form they know what they know what's in right they know how to to to in fact i'm by it so from that perspective it's there's no reason for anyone not to have a living will so a living will in advance directive really can be completed by any competent person eighteen years old and older typically what happens is when you go into a hospital in a non crisis situation they will say did you have an advance directive right now what's happening right that comes from rules of the originally came into play that if the hospital participates in medicare they're obligated to to educate their community their community what has been interpreted as a an educational component for the community is to ask whether you have one and then the standard question the follow up question if you say yes they say they check the box and then they say do you have it in if you came in for an m r i you obviously don't have it with you and then if you say no i don't have one then the next follow up question is supposed to be would you like some assistance in filling one out so that they will either bring someone from they will make available to you forms the social workers the clergy different people within the hospital can help you fill can fill it out but going back to your scenario what happens is the odds are that person may have their license and credit cards on them but the odds are they don't have  living will on them right when you contact e m t or any emergency services the emphasis is on emergency so by calling them you are obligating them to provide you with whatever emergency services they can once you are stabilized and if someone in your family is aware that you have a living will and they can access that living well then they will bring it and then you're living will will ultimately be will be followed  so years ago way back in the seventy's when the technology was improving such there was ahead of the law the old adage was once you're on the machine you're never come off the machine that longer true these living wills provide for the safe withdraw if it is of if it is right propre it so in your emergency scenario you would be stabilized you would be treated in my urgently and then your family would produce the advance directive but but that brings me if it's ok that brings me to an important part short of this sure the living will is intended to be a tool a tool to get the conversation going to have the communication with your family members if you just fill out the form and stick it in the safety deposit box you really haven't accomplished what the living will is intended  the other misconception because less you carry it with you when you're driving less it becomes part of your license or what's in your wallet or there are states and there are there are people that are committed to this right who will register their living will with a natural national registry and they will have a card that is the very rare person current kind or the other thing that may happen and again this is  in the future we now have proliferation of electronic medical records right so years ago they would say once you give us a living well year ago it got lost in your records theoretically your living will should be able to be accessed much more easily but again this is in the infancy in pricey the average person does not drive around with a living will however the misconception in this field is when you have a testament well when i say test men who will i mean the well that that divides off the lawyer will say we have one signed copy you have to put it in a fireproof place put it in there the lawyers office or in a safety deposit and it really needs to be safeguarded with your advance directive you arguably want to complete least six copies if you want to have one for yourself one for your proxy one for your alternate proxy one for your doctor or a couple of a couple of extras so people will say oh i have this state package i'm going to put it all in the safety deposit box and then your advance directive isn't accessible exactly so that's that's another thing that the people need to distinguish this legal document from the testamentary wills and trusts that they may be compelled the other thing you brought up the aspect of medical technology advancing so rapidly and you know god help us maybe one day intubation is going to be done differently where it's not something you know someone who fears having a tube down their throat it's going to be who knows done differently so doing it seems as though you need to the form when it comes to the instruction directive is very very simple the form arguably says i want all medical treatment i want no it's no medical treatment or i want this very limited demand and they give you a few choices and then there's a line where you can fill in my opinion and i've been dealing with this subject since it is the field has evolved  that the most important thing for you to fill out is the proxy meaning pick the right person right make sure there isn't alternate have the discussion with them so that they know what you really want right and keep so that deals with the aspect of keeping it really simple now this is another problem with this area if you go to a lawyers office and do a testament well right and you actually read the will that they draft feel the first line invariably in every will will say i hear by revoke what my previous ok the assumption is that during people's life time they may have done a few wells right if you examine the form that i gave you for an advance directive or the other ones on line or in the others resources i have never seen unless  custom one that a lawyer who has taken some care never says i hereby revoke my previous living well some code so my advice to someone assuming they don't have a custom living well with a lawyer in fact said i hereby revoke my previous living will and i did such and such my advice is to take the living will which is just a few pages long and every few years if you're comfortable with it if your proxy is still the person you want to be your proxy in your option it is still on their phone numbers and addresses is still accurate just i recommend on the bottom of the end of the form reviewed and then give the current date so it indicates even though it might have been completed ten years ago it's still right went two years right that's my best recommendation it at this point because i have not seen forms at this point that say i hereby revoke my previous living right my previous so so i do want to get to i know where i don't want to say we're running out of time but i definitely want to get to polls sure and if you could give the definition of ok we have five minutes how that happened ok so post actually stands for and you corrected me i thought it was physician it's actually practitioners orders for life sustaining treatment in new jersey because you have  ok some other states it's physicians ok and in new jersey it is not considered it's not a legal document it is a medical order because it's a medical order it can only be completed by a medical person ok and the acceptable medical persons in new jersey a licensed physician a d o o or a nurse practitioner and so those are the people that can complete it with your input now the post is a very very limited document where the advance directive was for anyone over eighteen right the pulse has a very limited specific audience so it's can supplement the advance to recommend a pulse for this person is the practitioner would not be surprised if the person were to die within the year ok the the other thing is where i kept saying the forms are  ubiquitous or advanced directives for paul says there is one statutory form it is recommended that it come on a bright green paper and the very interesting thing they do with the beginning besides they do go into more detail in terms of to what extent you want feeding to nutrition resuscitation the very beginning of the form has what's called the goals of care and goals of care really human eyes is the form which basically is the physicians time to talk to you or the nurse practitioners to talk to you just say you most likely have a very limited time period remaining to live  what would you what are what you want what you see what would you like to happen and it's not uncommon for someone to say i really like to live long enough to see my granddaughter marry my grandson's graduation and that's the appropriate place on the document technically that's not a medical order but it was felt that in order to have a meaningful discussion you needed to stored it with that and with that question co why wouldn't the advance directive cover this host is meant to to in fact be transportable from all different venues ok so or ghibli someone in the very last days not uncommon a bounced around from nursing home hospital hospice ho and by having this very distinctive green form ok that's identifiable by the mts i say that can be transported from place to place it is it is much more spot on and it now it doesn't mean that you should you can't have an advance directive but this really deals with  the reality of someone who is it sounds like it's much more specific and it much more i mean you are do you are making these decisions when death is is assuming you're completing an advance directive i don't recommend that what i recommend is first of all people seumas their spouse if they have a spouse if your spouse does not share your same philosophy on end of life you may be asking this by a spouse to do something that they are not comfortable doing right it's much better to have the conversation and say i don't want to put you in that tough position perhaps we're less one of the children the other thing the other guideline is if you have anyone in the family who is involved in the medical field is comfortable being in a hospital setting they are usually much better proxy then the accountant child for instance so often if i when i'm counseling people when i was in private practice in doing doing the testimony wills and the living wills what i would say is ok your accountant child will be a fabulous executor for the estate but perhaps your your nurse child will really be the one that you want to have as your as your proxy now going back to the question if the family doesn't agree or if it's not a donna reed family and then there's something that the hospitals have which is called a bioethics committee and they're the physician the nurse a social worker or a member of the family can in fact call for that member of their multi disciplinary  committees people on the committees are trained i've served on our hospital committees in nursing home committees for decades and it in fact becomes an elder mediation where the parties or informed of the different options but a decision is not rammed down their throat who sits on a bioethics committee and most house most hospitals they will invite the treating physician for the patient the family members then you will often have as the social worker we usually have an attorney we usually will have an attorney you usually have a clergy person and most hospital bioethics committee nurses you don't call the whole committee for a consultation but the committees usually have what they call a community member or two which are just interested people who who have had an experience in their lives that they want to give back  in some way and typically the when you're asking for a consultation you will have or google for people in the room plus the family you don't want to be you don't want to be too large  in your experience how do most people feel once they've gone through the process and they've created the advanced directive generally speaking it's very cathartic and one of the things i can share with you i'm going to share with you in the last minute or so is some sort of resources i keep saying that one of the things i'm most partial to in the hospital advanced directive forms but there's a kinder gentler form out there ok and it's called the five wishes ok it's easy to google yeah anyone can find it ok it has in fact it was stored it in florida over twenty years ago and it was  distributed widely through the auspices of the robert wood johnson foundation it's a kinder gentler advanced directive so if someone wants to put their toe into into it that's where i recommend they start and now if pulse spoke to them if there's someone in their family that they said boy this is really what they need right there is a fabulous three minute you tube called max's story own and it's called max's story an advance directive is enough and as most of these things they stored in oregon and this was from the west coast and they're much more sophisticated about their registries and thing there but it's a wonderful three minute  little video clip and i would recommend anyone who is thinks that post may be appropriate for a friend or family member that would be a wonderful place to start a great resource as well i will definitely put up links on the pro s nation website the point that i'd love to leave with the audience is that these documents or tools of kit intended to engage and have the communication but think of them as opportunities it's an opportunity to when you can no longer speak for yourself that you have in fact been able to speak ahead of time and it's an opportunity for you to control for you to be a participant and  equally as important it gives your family members the comfort of knowing when they're faced with a decision that you have in fact guided them yes and it is really a blessing to the people that you