Problem: Advance planning enables patients to articulate wishes about pain management and death. Yet only 29 percent of U.S. adults have completed a living will. Physicians can increase the completion rate by talking to their patients about end-of-life care. But doctors are often reluctant to raise the sensitive subject with their patients.
Background: Two decades ago, an elderly woman went into cardiac arrest at Auburn Memorial Hospital in central New York. Andrea Prudom, then a rookie R.N. at the hospital, resuscitated her. But instead of thanking her for saving her life, the patient seethed with anger. “Why didn’t you just let me go?” she demanded.
The memory haunts Prudom to this day. If someone had taken the time to talk to the woman about her wishes before she had heart failure, she may have signed a Do Not Resuscitate (DNR) order—a legal document that states that resuscitation should not be attempted. If she had done that, Prudom would not have been obligated to revive her.
Now director of nursing at the Cayuga County Nursing Home in Auburn, Prudom wishes more patients took the time to complete advance directives like a DNR, a living will or a medical power of attorney (which allows patients to appoint a proxy to make medical decisions on their behalf). And more patients should talk to their loved ones about the kind of medical treatment they want, how comfortable they want to be, how they want to be treated and what they want their loved ones to know before they die, she says.
Failing to do so can cause needless suffering for the patient and emotional turmoil among loved ones, Prudom says. It can also lead to unnecessary and unwanted medical treatment at great financial expense to patients, family members, and the health care system.
“By no means am I saying that I am a proponent of euthanasia,” Prudom says. “But the trauma that we put our loved ones through for something that is unnecessary seems to be a sham. That part of nursing needs to be brought back.”
Clarity at the end of life, however, is a relative rarity. Only 29 percent of adults have completed a living will, according to a nationwide poll conducted by the Pew Research Center in 2005.
Solution: Fortunately, there is a clear solution: Studies show that patients who discuss advance planning with their physicians are more likely to complete advance directives.
The challenge, Prudom says, is getting more doctors to have these kinds of discussions with their patients. Many don’t because of time constraints or a reluctance to raise these kinds of sensitive issues with their patients, she says.
That challenge formed the basis of a team project led by Prudom and several other health professionals in central New York who participated last year in a 16-month leadership development program supported by the Robert Wood Johnson Foundation (RWJF). Called Ladder to Leadership: Developing the Next Generation of Community Health Leaders, the program supports emerging leaders in the nonprofit sector.
Initially, Prudom and her colleagues hatched a plan to create an “end-of-life” doula that could help gravely ill patients prepare for death in the same way that birthing doulas help pregnant women bring new life into the world.
But as Prudom’s team researched the project, they realized that they needed to focus first on educating physicians before they could effectively turn their attention to consumers. So instead, they came up with a plan to create the “advance care planning specialist,” a new health professional who would identify and educate physicians about how to initiate advance planning discussions with patients.
“We have a lot of tools out there to show people how to get through this,” Prudom says. “But we have nobody who is clearly identified as taking the lead on having these conversations about advanced care planning.”
Prudom and her colleagues graduated from the Ladder to Leadership program in December, and are now seeking funding to support such a specialist. Until that happens, Prudom has made it a personal goal to spread the word about the importance of advance planning at the nursing home where she works and throughout her community.
“We as nurses have to inform people of their choices,” she says. “How you want to live the end of your life is a choice that you need to be able to have.”
RWJF Perspective: Ladder to Leadership is a joint initiative between the Robert Wood Johnson Foundation and the Center for Creative Leadership (CCL) that supports community-based solutions like Prudom’s to challenges in health and health care. In addition to completing team projects, Ladder to Leadership fellows participate in face-to-face training sessions, individualized executive coaching and mentoring.
The program accepts applicants from small, community-based nonprofit organizations in targeted regions around the country. Applicants must demonstrate a proven commitment to serving vulnerable populations and have one to five years of supervisory experience.
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