Video-based Advance Care Planning with MIDEO

Advance Care Directives are great in theory, but often fail in practice. The result: patients' wishes aren't respected and their families end up fighting. 

Dr. Ferdinando Mirarchi has built a whole medical practice and business around Advance Directives. HIs company, MIDEO enables patients to create video-based plans either with or without a physician's help.

I went through the process myself in preparation for this interview and learned a lot about the nuances of what to put in the directive to reflect my goals. The topics of resuscitation after cardiac arrest and mechanical ventilation were really insightful.

We also talked about more mundane matters like insurance coverage and how to make sure the directive is accessed and respected when you need it.

As of March 2025 HealthBiz is part of CareTalk. Healthcare. Unfiltered and can be found at the following links:

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• Apple https://podcasts.apple.com/us/podcast/caretalk-healthcare-unfiltered/id1532402352
• YouTube https://www.youtube.com/@CareTalkPodcast
• CareTalk website https://www.caretalkpodcast.com/

Host David E. Williams is president of healthcare strategy consulting firm Health Business Group.

Episodes through March 2025 were produced by Dafna Williams.

Transcript

0:00:00 - David Williams
Patients often turn to advanced directives with the goal of having their end-of-life treatment decisions respected, but traditional, paper-based approaches have major drawbacks that limit their effectiveness and can spur conflict in times of crisis. Can video technology be leveraged to help solve this problem? Hi everyone, I'm David Williams, president of strategy consulting firm Health Business Group and host of the Health Biz Podcast, where I interview top healthcare leaders about their lives and careers. My guest today is Dr Ferdinando Mirarchi, ceo of MIDEO, which enables a patient to work with a physician to create a video advanced care plan. Do you like this show? If so, please subscribe and leave a review. Dr Mirarchi, welcome to the Health Biz Podcast, thank you, and thank you for having me. You know we had a good session before, where we went over, and I now have my. I've got now my card, which we'll talk about later on. Before we get to that, though, I want to hear about your background, your upbringing. What was your childhood like? Any childhood influences that have stuck with you through your career Loaded questions. 

0:01:19 - Dr. Mirarchi
So my childhood, my childhood was I grew up in inner city, South Philadelphia. We were not wealthy, we grew up very poor and in an underserved population. And if there were any outside influences I guess it would just be my family, just entirety, you know, as far as what they always did and stood for. I mean, our family was the first family to graduate high school, on the street, yet alone college and yet alone professional schooling. So it was a very interesting upbringing. 

0:01:52 - David Williams
That sounds good, all right. Well, it sounds like we could do a whole podcast on that, but we won't. I'm glad the beginning of life was not the end of life, in other words. 

0:02:00 - Dr. Mirarchi
Absolutely. 

0:02:01 - David Williams
Which, unfortunately, it may have been for some people in your neighborhood. What about in terms of education? I mean, you said you know so, high school got that, but then you know, going on from there, what was you know, what was your expectation and what path did you end up taking? 

0:02:14 - Dr. Mirarchi
So I always wanted to go into medicine. I kind of I went from a Catholic high school upbringing. I went to Temple University and did pre-med in kinesiology and sports medicine. I then ended up going to medical school in an osteopathic program that opened up. It was a charter school in Erie, pennsylvania. I ended up leaving there and transferring to California, then came back east again and essentially did my residency at Allegheny General Hospital in Pittsburgh, a level one trauma center, and then after that I started my emergency medicine practice in Erie, pennsylvania, at what was then Hammett Medical Center and then subsequently became UPMC Hammett Medical Center. 

I was a practicing emergency medicine physician for 20 plus years 25 years or so and then I was also an administrator there. I was the chair of emergency services for the entire Northeastern region. You know, in my tenure there I kind of feel like McDonald's when I say this, but we saw over 2 million patients as far as my management and leadership, and we did it with the very highest quality. We did it with the very highest metrics for emergency departments. We had the largest emergency department in the UPMC system and essentially the best metrics and we produced metrics that were tops in the nation. 

So it was a very interesting background. We created emergency medicine residency training programs. From that I had to do research and in that research came about my interest in advanced directives and living wills and essentially formed something called the Triad Research Series and essentially formed something called the Triad Research Series. I'm happy to say we've published over 13 studies, all unfunded as far as any institutional biases or programmatic biases that could scrub data. So it was all pretty virgin data and it's all been very compelling and interesting Great. 

0:03:59 - David Williams
Well, in terms of the I saw also on your resume after UPMC, the Institute on Healthcare Directives, is that part of the research that you're talking about or is that related to the company? 

0:04:10 - Dr. Mirarchi
No, it was separate. When I first came up with this idea of medical practices involving physicians and advanced care planning, it wasn't really that supported within the system at that time. Essentially I had to go prove it that time. And essentially I had to go prove it. So I opened up an outside entity and did a per diem or part-time practice in advanced care planning and started to put my research ideas into clinical practice and from that came video and from that then came software development and then became to where we are. Today is when we transition and we're acquired by US Acute Care Solutions. 

0:04:46 - David Williams
Sounds good. So let's talk about advanced care planning. And what is that? Sometimes, actually, people put a D at the end, say advanced care planning, but that's not really what we're talking about. We're talking about planning in advance. So what is this concept? 

0:05:01 - Dr. Mirarchi
Yeah, so back in 2000, I don't know there was maybe around 2012 or 2016 presidential debates. 

Everything started to happen with, you know, payment for end of life and you know paying doctors to help you die and you know death panels and all that, and they formed codes to allow physicians and medical providers to talk to patients about advanced care planning. 

And it often gets termed end of life care planning, which is a really terrible thing because people don't want to do it and that people who are systems that just focus on end of life care planning with advanced care planning are doing the wrong thing. You know they really need to just centerize it and refocus the whole thing. As far as what it is called advanced care planning and that's essentially helping people make decisions for themselves that meet their vows or their values and beliefs and objectives, and help them do it in an informed, informed, non-biasing way Non-biasing is important because many people who do advanced care planning do it with a bias towards end of life. So it's really just another type of medical practice and no different than going to see a cardiologist to have your heart checked. You see a doctor to essentially put your advanced care plan into place. 

0:06:18 - David Williams
Now, I had forgotten about the whole death panel discussion, but that was really about a benefit for people to be able to go and get an advanced care plan right, and it came into that it's going to be a death panel that's going to put you to death. 

So good, well, I haven't heard that term in a while, at least. So what? So let's say, you know, advanced directive is put together and let's say there's no bias in the system. But what are? How have those worked out? For people, it sounds like a good idea. You know, some people I know in my family are good at planning and they do financial planning, for example. They may plan for a time when they're no longer capable of making their own financial decisions and they want to do the same thing in the health care side, and they may have a document that they've created. How has that actually worked out for the people that have? 

0:07:04 - Dr. Mirarchi
done it Well. So I mean, if you talk to systems, they seem to think it all works great, right? And I was part of a big system and I'm telling you it doesn't work great when you look at advanced directives. These are paper-based documents and they got a lot of legal, non-specific, vague language in them, right? So who do you want to read them? You want a doctor to read them, right, no wrong. You know those things were not very good for doctors to take and utilize in clinical practice, you know. So we tend to make a lot of mistakes with advanced directives. Systems don't like to admit it because they're medical errors and they'd have to report them as such. But advanced directives had a very good intention, right. They wanted to give you a voice in your care and, essentially, to help you make decisions in your care so that you can accept or decline care when in a certain type of condition. And what we found out from clinical practice with them is that these are not very well understood documents by doctors, nurses. Clinical practice with them is that these are not very well understood documents by doctors, nurses or paramedics. 

People tend to think you're supposed to follow that document just because it exists, and that's the wrong thing. You know it's like a will right, you got a will. You know it doesn't mean somebody gets to come and take your estate and your assets. You know it's the same premise. With a living will or an advanced directive, something has to trigger that With your will, it's your death, right? Well, in an advanced directive it's supposed to be some sort of terminal condition or persistent vegetative state. That's when you're supposed to follow a living will or advanced directive, not just because it's present and because you tend to think you understand what that patient wants, which is another thing. 

I mean, when we look at paper, I mean paper, right. I mean this is the 21st century and we're still looking at paper when it comes to this stuff. You know, we're we're we're to a point where we don't really know you anymore, we don't know our patients anymore, because you know we don't come to the hospital like we used to physicians. You know, back in the day your primary care doctor got up at five in the morning, you know, went to the hospital, came to his office, then went back to the hospital and saw you again. Today you get me, you get a stranger, you know, and I don't really know you and I got to look at a piece of paper that I have to basically guess, and I hope I'm guessing right, that you know we're providing the right care for you. 

0:09:16 - David Williams
So sometimes you have the situation you know. So sometimes you have the situation where the patient is there and they're unable to speak for themselves and you're trying to deal with a document which is a legalistic thing and trained as a physician and so on. Help me understand the dynamic when families are involved. Now, sometimes a family is going to be there. It's an emotional situation. Sometimes the siblings haven't spoken or they've got a strange relationship. What's that like as a doctor, and how does the existence or nonexistence of an advanced directive, and in a paper form, versus other form, you know, influence what happens? 

0:09:45 - Dr. Mirarchi
you know, this is one of been one of the most rewarding things about MIDEO and using MIDEO with this approach and advanced directives, because when families come in, you know, hopefully it's just one person that's appointed to be a decision maker. 

Oftentimes they don't have anybody appointed and oftentimes they'll have multiple people appointed. 

So in situations like that, when you have a piece of paper and you really just don't know what the patient wants, it becomes a nightmare. You know, it becomes this big argument right inside your ICU or right inside your emergency department or wherever it's happening. It becomes this big family argument and families get busted up over this. I mean, they really do get broken over this because they, you know, somebody died or somebody lived and maybe they lived in a situation they didn't want to, and then other people are saying I told you so and you know, with video it's been very nice in that we can actually show you or me or that patient actually speaking for themselves, and we can show those families. We can show them exactly what the patient wanted, how they looked when they were making their decisions and so on, and give them the feeling and trust and confidence that they're actually making the right decision, because that in and of itself, that decision is a very, very guilt-ridden decision on the part of a decision maker if a family member can't make it for themselves. 

0:11:01 - David Williams
Decision on the part of a decision maker if a family member can't make it for themselves. So let's talk about MIDEO, and I get that. Basically you're taking the concept advanced directive, putting it in video form, and this is done along with a physician. How does this work in practice? And of course, I have some experience with it because I actually went through this process with you. 

0:11:19 - Dr. Mirarchi
So I guess in clinical practice you mean then there's two ways you can get one done, right, you know? So we can go through your do-it-yourself type of way to do it. But then we also have a medically facilitated approach. We feel strongly the medical facilitated approach is the best practice because it gives you the opportunity to speak with a trained physician to ask your questions and become informed. That being said, we have a do-it-yourself approach that has lots of video and educational modules in it to help people make informed decisions. 

But we typically like to use the do-it-yourself approach for those young, healthy, tech-savvy type people and so on, and use the facilitated and guided approach for those maybe that have serious illness or nearing end of life or so on, so that we could really provide some balance and benefit to seeing a physician for this practice. So in clinical practice we would see you, we evaluate you, we do a very detailed medical history and consultation and make recommendations, and then we do what's called disease-specific advanced care planning, meaning we take a look at you, that individual, your comorbid conditions or if you're healthy, and make recommendations as far as what we should put into your advanced care plan, into your video advanced care plan, so that you can read with confidence and be informative to those next medical people, that you actually knew what you were doing when you were creating this video. 

0:12:39 - David Williams
What are some of the issues that people have to think about? I mean sometimes you think about I want aggressive care versus not. Is it more nuanced than that, and how much does it depend on the patient? 

0:12:50 - Dr. Mirarchi
Yeah, it's definitely more nuanced than that. 

You know, if you're young and healthy, there's really no reason that we shouldn't be just assuming that you want aggressive care and treatment to initially save your life, right as you progress and develop illnesses and age, then we have to start wondering, like, what the benefit for you is and what kind of conversations you had. 

So those nuances typically get teased out, you know, and we tease that out pretty well. 

So if a COPD or someone with obstructive lung disease comes in and essentially says they never want to be intubated or put on a ventilator, well that's a very concerning and even damaging type of statement to make in a healthcare setting, because then you're giving the impression that you wouldn't want care, when the reality of it is that those patients, when they make that statement, don't want to be kept alive forever on a ventilator rather than treating their acute, treating their acute illness you know, whether they had a pneumonia, whether they went into congestive heart failure, things that would actually be treatment beneficial for us to use forms of aggressive, life-saving treatment for to help resolve their condition and actually get them the point of walking out of the hospital with a good quality of life. 

On the opposite end of that spectrum, though, david, the same thing can be very beneficial as well. We have lots of end-of-life patients that tend to get over-resuscitated because of those same nuances. Right, you come in with a urinary tract infection, you have an advanced directive, you're at end-stage dementia. Somebody really needs to take the time to have a conversation with that patient's family or agent to tease out that nuance on whether or not it would be beneficial to do antibiotics or just to allow them to die naturally with their sepsis that developed. 

0:14:28 - David Williams
One of the things that we talked about maybe this will help to make it give an example of specificity was we talked about cardiac arrest, which, just so you know, I'm not planning to have one, but since I'm otherwise healthy, it could always come and get you and we talked about how sometimes this is an issue, with people put down about what they, what they want, and and you stress the difference between something that's witnessed versus unwitnessed why did we have that conversation and why, you know, why is that a key distinction? 

0:14:55 - Dr. Mirarchi
Yeah, great question. So when? When you look at advanced directives, they typically say these checkboxes right, you got to check the box. I do, or I do not want mechanical ventilation, I do not want cardiac resuscitation and so on. Yeah, when you know. The question is when. 

And in a witness cardiac arrest you have to tune out all the other noise. You know you'll hear all the negatives about CPR and that people. You know you're going to break ribs, puncture lungs and all this other whatever that they want to say. But the issue is is in certain situations that stuff is very beneficial and it's actually not best practice to talk people out of it. If you have a witness cardiac arrest and again, I'm in my fifties, you know. So chances are, if I have a witness cardiac arrest, it's going to be from a cardiac event or something, something that we can do something for. 

Where CPR is beneficial, where defibrillation or AEDs in the community is beneficial, we get those people into the cath lab a high percentage of the time with a pulse. They do well, you know, especially the after ICU care that we do for them now. You know especially the after ICU care that we do for them. Now you know, if we get to the point of just lumping everything into death or cardiac arrest, then people tend to get undertreated. So we want to make clear distinction. 

That, witness, cardiac arrest is a lot different than an unwitnessed cardiac arrest. In people who do resuscitative medicine and have to make decisions for you Witness cardiac arrest, there's a lot we can do. We want people to do CPR, we want you to get to a hospital, we want you in a cath lab. In an unwitnessed cardiac arrest, that's typically someone who's been found down. They're down, they're cold, they're stiff, they're pale, they've been dead for some time. In situations like that, resuscitation is not going to be helpful and those will be the patients that we end up breaking ribs or puncturing lungs on because they've already been cold, stiff and dead for a period of time. And in situations like that, cpr is not going to be helpful. So it was a great question as far as bringing up the clarifications of the two. 

0:16:55 - David Williams
Now, you talked before about how you know we were talking about with the death panel discussion. There's this comes into coverage. You mentioned best practices to have a physician-guided approach to putting this together. That's what we did. Would that typically be covered by insurance? Is it covered by Medicare? Is it covered by commercial insurance? 

0:17:14 - Dr. Mirarchi
Yep. 

So that was one of the most rewarding things of what we did and why we actually aligned with USAQ Care Solutions to do this because we've created it such that it's a medical practice and that we get credential with Medicare and fortunately Medicare just about in in every state reimburses for our practice of policies and procedures not the technology but just the medical practice of it and so on. 

So and it gets reimbursed, and then the major players essentially follow suit as well. We get reimbursed from United, we get reimbursed by Aetna, we get reimbursed by Highmarks and the Blues and some of the UPMC health plans and so on. So that part has been really rewarding in that we could actually make it a medical visit. We could bill your insurance for it. You don't end up paying anything more than a copay or maybe even nothing. We have lots of our Medicare patients that come in, that have Medicare and a supplemental plan and they pay zero out of pocket for what we do with them and it's a very rewarding thing as opposed to them getting sent off to either an internet site that's going to cost money or a law practice that's going to cost lots of money and so on to do this. 

0:18:22 - David Williams
So this is my card here for those that are watching on the video on YouTube, and I noticed that it has well, first of all, it has some security features on it, so you can see it's something real and not just something that I laminated, and has a QR code and it's got my picture. Let's talk about what's on there. What will the QR code do for someone? 

0:18:43 - Dr. Mirarchi
So that's a great question as far as the card setup itself. So on that card there's a front and a back right, and on the front of the card there are things that we need to do for what's called joint commission compliances and identification purposes, and I think it's two. Naming date of birth is usually an uppatient identifier. We throw a third facet in for added security and that's your photo right. And then on the card itself, on the the front, is information that's on there and we use it as a form of the mnemonic called code. So we give people information about your code, status, your stance on organ donation, If you have any documents, if you have an emergency contact or a health care agent, how to get a hold of them, and then, if you have one of these fancy medical orders that happen in a number of states, like the Pulse or the Mulse, we put that information on there as well. So that's quick and scannable, easy access information. The second piece that's quick and scannable, easy access is the QR code on the front of the card that actually pulls up your video, and I'm happy to say that that happens anywhere in the country in five seconds or less any in the world really in five seconds or less. That'll pull up your video statement and essentially be a video that that provider can then look on your behalf and see exactly what you wanted. 

And then the back of the card is set up such that it has the compliances right. It has your signature as a patient, two witnessing signatures, a physician signature and it has another QR code. And that other QR code on the back of the card is to all those paper documents that everyone feels like they must have. You know, like every health system wants to say, oh no, we can't do video because we only want a document. Well, now you get both you get the video and you get the paper-based, standard-approved, state-approved documents in five seconds or less, anywhere in the world. So now there's really no reason to say that you couldn't access it, because we've now made it all portable to everyone as far as those traditional paper-based documents. 

0:20:31 - David Williams
Great, and this is the back of my card here and it has a magnet on this one. I've got that I don't have in my wallet and I think the understanding is that if an EMT or anybody comes into the house, they're going to look on the fridge. That's actually a standard thing to do, so you don't have to worry about where it is or if your wallet's with you or whatever Correct. 

0:20:49 - Dr. Mirarchi
We actually train paramedics to look on the sides of refrigerators for either advanced directive information or medical orders. Interestingly, for some reason I'm not sure why it all came about the way it did too we also train medics to look on the top drawer of a nightstand, but our recommendation is to essentially keep it all in the refrigerator, got it? 

0:21:08 - David Williams
Now the front of the cart also has an expiration date, which for me was five years from when I did this. What's the thinking behind how? You know you do these things over time and in some ways it's obvious, right, if I did it yesterday, it's probably current. If I did it 20 years ago, you're going to have more thought about it. But what's the thought and the timing? 

0:21:27 - Dr. Mirarchi
I think the issue is validity, that you made your decision and you're sticking to your decisions too. 

You know it's not uncommon for us to see patients that have documents that are 10, 20 years old and we're thinking is this really their wishes anymore? 

And that's again why we medicalize this whole process, because you can't be one and done with advanced care planning. 

You're doing a disservice to patients. You know the best practice when it comes to advanced care planning is to see people on a scheduled basis. So if you have certain comorbidities, maybe we want to see you back every year. If you're a certain age, maybe we want to see you back every year. If you're young and healthy, then typically we release our cards and videos for five years, because nothing should change there within that five-year period of time, unless something drastic has changed, in which case, again, we make recommendations for people to see us and follow up in that fashion so that we can update their medical histories and so on. But so I guess the point of this is to not make it one and done, and that's the important point behind the expiration dates and the validity dates and so on, because at some point in time somebody's decisions are going to change and they really need to be having guided conversations as far as what to accept or not accept, as far as treatment choices and so on. 

0:22:39 - David Williams
So I'm not sure how long this has been around or how many cards are out there, but do you have success stories to share from Mideo or, more broadly, from doing this type of advanced care planning? 

0:22:52 - Dr. Mirarchi
So we have lots of success stories. It's always hard to pick one and I hope I don't offend anyone by not picking them and so on. But more recently I had a cancer patient that ended up in a hospital and had his living will misinterpreted as a DNR order and when he was sick he almost didn't get treated, almost died. Being he's a cancer patient of a certain age, he tends to go in and out of emergency departments and hospitals quite frequently and after he saw us and we put a video together for him, he did come back into a hospital again and, you know, was in critical illness and they immediately got access to his video ID card and they immediately went into resuscitation mode. 

I also have stories and this doesn't seem like it's a positive story, but we have end-of-life patients that have gotten over-resuscitated with their standard documents, came in to see us with MIDEO and then, when they got again sick, ill and to a point of activating an emergency response system, we're able to use their MIDEO ID cards to essentially help them not get transported to a hospital and to allow that natural dying process. 

It's very important for end-of-life patients and people to realize that most doctors don't want to take care of patients that don't want to be resuscitated. So it's really important to get information and they tend to resuscitate because they just don't know what else to do for that particular patient. But to a family that's made that decision to allow their loved one to die and that patient to come with that decision that they're ready to die, and then you stop that process, that's hurtful as well and I've seen many patients either become harmed from the resuscitation or again the the families become broken up over the whole issue of this person now live, they could have died, and now they have to figure out what to do as far as next step in their care fair enough. 

0:24:37 - David Williams
Well, it's a good topic to have an open conversation about. I know you certainly are comfortable with it, having led the field here, but, uh, it's good, I think, to have a broader conversation about it. I want to ask, as a last question, something that's not necessarily related to what we've been talking about so far, which is just about book recommendations. Have you read any good books lately, anything that you would recommend for our audience? 

0:24:58 - Dr. Mirarchi
So this will be a surprising one for you. I'm a physician, right. I've done research, I've written books. I've yet to read a book. I've just always been one of these audio visual type people, and that's probably why I kind of went the way of video itself, but I've never read a book. Cover to cover. I've read chapters of textbooks, I've read chapters of medical journals and so on. It's just I've yet to find a book that would actually just make me sit down and read it. 

0:25:21 - David Williams
That's fair enough. That's a good. It's a good point. You know, I always. I sometimes ask on the other side if there's any book that you would recommend avoiding, but it sounds like we don't have that category either. Good, well, I appreciate that. Well, dr Ferdinando Mirarchi, ceo of MIDEO, thanks for joining me today on the Health Biz Podcast. Thank you, you've been listening to the Health Biz Podcast with me. David Williams, president of Health Business Group. I conduct in-depth interviews with leaders in healthcare, business and policy. If you like what you hear, go ahead and subscribe on your favorite service. While you're at it, go ahead and subscribe on your second and third favorite services as well. There's more good stuff to come and you won't want to miss an episode. If your organization is seeking strategy consulting services in healthcare, check out our website, healthbusinessgroupcom.