Mostly Money

90: We need to talk a lot more about not dying with Dr. Daren Heyland

February 12, 2021 Preet Banerjee
Mostly Money
90: We need to talk a lot more about not dying with Dr. Daren Heyland
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Mostly Money
90: We need to talk a lot more about not dying with Dr. Daren Heyland
Feb 12, 2021
Preet Banerjee

There is a BIG difference between End Of Life Planning and Serious Illness Planning.

If you think estate planning is getting your wills and powers of attorney or healthcare directives set up for taking care of things when you die or are about to die, you might be making a big mistake.

If you end up in an ER, the doctors aren't going to look at any end of life planning you might have in place if they think they can still save your life. This requires a whole different way of thinking about planning for serious medical illnesses.

On the show today I speak with critical care physician, Dr. Daren Heyland, who is going to give us a look behind the scenes at what really happens when people and their loved ones are making decisions about their medical care when they are seriously ill, or terminal. We’ve talked a bit about estate planning on the podcast before, and my guest recently attended a financial planning seminar where the positioning of how and when certain parts of an estate plan come into place could have used some fine tuning.  He’s also going to discuss an initiative he’s been spearheading, called the Plan Well Guide, Plan Well Guide is a FREE tool to help people learn about medical treatments and prepare them for decision-making during a serious illness, like COVID-19 pneumonia for example. 

 Find out more here:

Company: https://planwellguide.com/

Twitter: https://twitter.com/darenheyland

Facebook: @planwellguide

Twitter: @plan_well_guide

Instagram: @plan_well_guide

LinkedIn: https://www.linkedin.com/in/daren-heyland-2b674a185/

 

Guest Bio:

 Dr. Daren Heyland is a critical care doctor at Kingston General Hospital and a Professor of Medicine and Epidemiology at Queen’s University. He currently serves as the Director of the Clinical Evaluation Research Unit (CERU) at the Kingston General Hospital.  For over a decade he chaired the Canadian Researchers at the End of Life Network (CARENET), which has a focus on developing and evaluating strategies to improve communication and decision-making at the end of life

Show Notes Transcript

There is a BIG difference between End Of Life Planning and Serious Illness Planning.

If you think estate planning is getting your wills and powers of attorney or healthcare directives set up for taking care of things when you die or are about to die, you might be making a big mistake.

If you end up in an ER, the doctors aren't going to look at any end of life planning you might have in place if they think they can still save your life. This requires a whole different way of thinking about planning for serious medical illnesses.

On the show today I speak with critical care physician, Dr. Daren Heyland, who is going to give us a look behind the scenes at what really happens when people and their loved ones are making decisions about their medical care when they are seriously ill, or terminal. We’ve talked a bit about estate planning on the podcast before, and my guest recently attended a financial planning seminar where the positioning of how and when certain parts of an estate plan come into place could have used some fine tuning.  He’s also going to discuss an initiative he’s been spearheading, called the Plan Well Guide, Plan Well Guide is a FREE tool to help people learn about medical treatments and prepare them for decision-making during a serious illness, like COVID-19 pneumonia for example. 

 Find out more here:

Company: https://planwellguide.com/

Twitter: https://twitter.com/darenheyland

Facebook: @planwellguide

Twitter: @plan_well_guide

Instagram: @plan_well_guide

LinkedIn: https://www.linkedin.com/in/daren-heyland-2b674a185/

 

Guest Bio:

 Dr. Daren Heyland is a critical care doctor at Kingston General Hospital and a Professor of Medicine and Epidemiology at Queen’s University. He currently serves as the Director of the Clinical Evaluation Research Unit (CERU) at the Kingston General Hospital.  For over a decade he chaired the Canadian Researchers at the End of Life Network (CARENET), which has a focus on developing and evaluating strategies to improve communication and decision-making at the end of life

Unknown:

When you present sick to me, as a doctor, at the point where I have to make decisions to effectuate whatever you might have wanted to plan, I don't know, if you're dying, I know that you're sick, I know that you could die. But you also could recover. And as soon as we introduce that concept of uncertainty into the decision making, whatever plans you laid down and your legal documents, and by the way, asked me later on how sensible it is that lawyers do health planning, but anyway, whatever plans you laid there, under conditions of certainty, like when I am dying, this is what I want, or this is what I don't want or when I am in this state, or when there is no hope, all that language based on certain conditions being arrived. Actually, the decision making is upstream. And I have to make decisions to use or not use life sustaining treatments. Well before I know the outcome is

Preet Banerjee:

this is mostly money. And I'm your host, Preet bannerjee. And on the show, Today, I'll be speaking with a critical care physician, he's going to give us a look behind the scenes at what really happens when people in their loved ones are making decisions about their medical care when they are seriously ill, or terminal. And we've talked a bit about estate planning on the podcast before and my guest recently attended a financial planning seminar where the positioning of how and when certain parts of an estate plan or the estate planning documents, how they come into place. And maybe that positioning could have been used could have used a little bit of fine tuning. So we're also going to discuss that and an initiative that he's been spearheading called the plan well, guide. Plan Well, guide.com is a free tool to help people learn about medical treatments and prepare them for decision making during a serious illness. Like COVID-19 pneumonia for example. Dr. Darren Hyland is a critical care doctor at Kingston General Hospital and a professor of medicine and Epidemiology at Queen's University. He currently serves as the director of the clinical evaluation research unit at the Kingston General Hospital. And for over a decade, he chaired the Canadian researchers at the end of life network, which has a focus on developing and evaluating strategies to improve communication and decision making at the end of life. Darren, welcome to the show.

Unknown:

Thanks for having me pretty good to be here.

Preet Banerjee:

Now, your name was mentioned to me when a friend of the show Jason watt, who is an instructor at the Business Career College, met you at a financial planning seminar, I think and he said that there was some information being presented at that seminar that you thought maybe wasn't necessarily being framed properly, when it comes to powers of attorney, personal directives and end of life planning. So can you explain what was being positioned? what was being said and what you think need some clearing up?

Unknown:

Sure, thanks. And first of all, I gotta say it was a great financial planning seminar and the presenter, you know, the speaking to us as physicians and giving us all this really great information. But the one piece where he's given us a nudge to get our legal planning documents done as well, and in the current context, was advocating for, you know, your end of life plans, get them in place. I felt like well, wait a minute here, if you're trying to communicate best practices, particularly physicians, I think you should be, you know, with the program as to what best practices with respect to end of life plans. We're trying to change the paradigm a little bit away from planning for the end of life, to planning for serious illness. So let me tell you why. Because when you present sick to me, as a doctor, at the point where I have to make decisions to effectuate whatever you might have wanted to plan, I don't know if you're dying. I know that you're sick, I know that you could die. But you also could recover and as soon as we introduced that concept of uncertainty into the decision making whatever plans you laid down and use legal documents, and by the way, asked me later on how sensible it is that lawyers do health planning. But anyway, whatever plans you made there, under conditions of certainty, like when I am dying, the This is what I want, or this is what I don't want or when I am in this state, or when there is no hope, all that language based on certain conditions being arrived, actually, the decision making is upstream. And I have to make decisions to use or not use life sustaining treatments. Well before I know what the outcome is. And so that's, that's what I'm about. That's what I'm trying to change is move away from this certain activity that I want to happen at the end of life to Okay, we've got to talk about serious illness. And fortunately, COVID has given us that that platform or that opportunity, where people are listening, people are hearing that there's a requirement for us to plan for serious illness.

Preet Banerjee:

Yeah, and let's, let's talk about this delineation between end of life planning and serious illness. Because I think, in many people's minds who aren't exposed to, you know, the ICU, the ers, and they're not in the health services, they just sort of lump those two together. But can you explain the difference between those two?

Unknown:

Yeah, and for most Canadians, I would say 95% of Canadians who have a sickness that takes them to hospital, we're talking about serious illness. The exceptions would be, let's say, for example, I have advanced cancer, you know, metastatic disease, I'm on a known trajectory towards death. I'm being seen by palliative care clinicians or perhaps still oncology. And and I want to plan in advance my exit from life that that is end of life planning, that is still legitimate. I don't want to say anything that takes away from that. But that's not what is useful when you get sick and go to the emergency room or seen by a critical care doctor. Where's that where, you know, you may be short of breath from your COVID pneumonia. But at the point where I'm trying to make a decision, do I do I put you on a breathing machine? Do I send you to the ICU? Or another very common decision in hospital is do I resuscitate you in the event that your heart were to stop? Those are not end of life, those are serious illness there. And the big key difference is certainty versus uncertainty, probability of recovery versus, you know, no probability of recovery. And

Preet Banerjee:

part of the reason why there is confusion is this is not an area where people like to think about, right, we don't like to contemplate our mortality. And so sometimes the first time we're faced with these decisions is either you know, maybe an advisor says, hey, there's the things we need to talk about. Or it's when you're in the hospital facing this. And and it's very overwhelming, there's so many things that you're trying to take in. And so for a lot of people, this is just not something that we tend to think of in our daily lives. And so there's this barrier for people to plan and think ahead from a health planning point of view, as well as from financial and legal points of view. Can you share some of the tips or tricks that you use in your industry to motivate people to lean into this, this uncomfortable space of planning for, you know, the stuff that we don't want to really consider as we get older? Because it's not always pleasant?

Unknown:

Well, Preet, I appreciate the question. And I, at some point, this afternoon, I'd love to flip it back to you and have you share your tips and tricks, because I think we can learn from each other. We're both, you know, in the financial planning industry, and in the health planning industry, we're trying to get people to think ahead and plan ahead. And I know from national surveys that I've done, regarding how much lay people have engaged in advanced care planning that only 18% of Canadians have have done it. And again, most of that is done under the context of planning for end of life. And so it's not that useful. And one of the barriers and and we we did a lot of qualitative research where we're talking to people about Hey, what do you think about and why not and, and, and it's this issue of death and dying and not wanting to go there. But we'll have 83 year olds with, you know, chronic health disease, but still feeling like, you know, it's not that time that I have to think about it, you know, I I'm still gonna, you know, I still got a few good years. And so what has been helpful to us is to shift the language away from end of life, we're not talking about death and dying. Now, I'm talking about serious illness, you know, sir, you know, 83 or 23, you could cross the road right now and get hit by a truck and, and end up needing life sustaining interventions, or at least decisions about life sustaining interventions. So the moment we introduced that concept of serious illness, preparing for the future periods when you're so sick, you can't represent yourself. You're incapacitated in some sense, who's going to represent you and what can you do to prepare them because my lived experience has a critical care doctors when you come in so sick, all right, you're not able to participate in decision making. So now I'm grabbing a family member. And I'm forcing that's a hard word. But I mean, we're constraining them to participate with us in these life and death decisions. Can you imagine how stressful that is? Can you imagine how stressful it is on top of the fact that they're already overwhelmed, because they got a loved one who's critically ill. And all of that extra stress could have been prevented by doing the planning for decision making in advance. So that's what motivated me as a critical care doctor to sort of step out of the critical care space and say, you know, what, if I work upstream with lay people are in primary care, and help them realize that at one day, one day, we're all going to develop some serious illness and to the extent that we prepare for ourselves, and are able to verbalize in the way that the doctor can use that information, better treatment decisions will be made, I'm more likely to get the medical care, that's right for me, I'm more likely to have a better journey in my own serious illness. And I've prevented extra stress and anxiety that my family member might might experience. And so really speaking to the benefits of the thinking ahead and planning ahead, both for the person themselves individually, and the benefits for the family member plus this, reframing it around serious illness, not end of life has been so far, what's been very helpful to us. Does that make sense?

Preet Banerjee:

Absolutely. And I think, you know, when the challenges from, you know, a personal finance perspective as to why, you know, some people find it very difficult to save for the future, get insurance, and what have you is that these conditions, in the case of life insurance that you're trying to mitigate the risk of or not consuming now, so that you can consume much more later on in life. Those conditions are very abstract. And the more abstract things are, the less real they seem, and the less likely we are to plan for that. But I think now, you know, with COVID-19, especially when people who have had people around them get ill, and they thought it never would have thought that this would have happened, there's an opportunity to at least engage some more people than normal to say, Listen, this is why you need to think about it, because it may not be COVID-19 for you, but it may be getting hit by a car that puts you into a situation like this. And I think, you know, with the practitioners perspective, in the financial services, these things are all part of kind of like financial hygiene, things that you're supposed to do and take care of to prevent pain down the road, if you can. And I think that's why it's challenging. But you have this service that you've set up plainwell guide.com, which looks like it's something that many people in the financial services, legal industry should be looking at. So can you explain what this is? What is the elevator pitch? And why should people learn more about plainwell? guide.com?

Unknown:

Sure, can I just go back and react though, first to something that you said pre in terms of people have difficulty thinking ahead and planning ahead, because it's so abstract, and it's so downstream. So it's not motivating to, you know, plan for 20, something that might happen 25 years in advance, I just want to speak to one of the other tips that we find very helpful. And that is speaking about the short term benefit of planning ahead, and this will resonate with you, I'm sure that there's that peace of mind, and increased mental emotional well being that you experienced today. As you go through life, knowing that you have a plan in place. So that's also important to draw out into this conversation with with clients, patients, your clients, my future patients that by planning today, you'll enjoy a greater peace of mind a greater mental well being. And frankly, during COVID you know, anything you can do to increase your mental well being is a value to people today. So, so you can't control the future. You can't control the pandemic, but you can control your own life and what preparations you put in place and you'll your level of mental wellness will go up tomorrow when you put these plans in place today. So that's part of the elevator speech, I guess is you know, spend 20 minutes today to buy peace of mind tomorrow, and better health care in the future and reduced distress and anxiety on your family member who has to step in and represent you. plan well guide is you know, it's a virtual or online website where we have a lot of content to explain to you the difference. The difference between serious illness decision making, and and end of life decision making. And in fact, we don't actually advocate making decisions in advance. And we're trying to move away from that. And this is a big part of my conversation with the legal professional. They tend in their documents to put instructions, instructions that are meant to be for the agent to operationalize. But you know, why? Why would does it make sense for you to sort of have a person make a healthcare decision in a legal office 25 years, or even two years or even two days in advance, when they have no knowledge of the context and the possibilities of the various treatment options and what their outcomes might be. And so the pitch to the legal profession is stopped doing, you know, instructional directives in your planning documents and, and focus really on the naming and the capacitation of the agent in Alberta, or the substitute decision maker is a generic term that is applicable across the country. So if they would do that, then the capacitation then comes by, you know, educating that substitute decision maker about the person's values and preferences. Now, now, here's the pitch to the healthcare professionals, because historically, we rely on open ended questions like Tell me what's important to you. And if you're facing someone who's seriously ill, you know, those statements that they utter, are then get translated in our brains into a medical order for the use or non use of life sustaining treatments. But what our research shows is that the open ended question the whatever answer is not reproducible, and it results in a lot of medical error. And you can get 10 different physicians, listening to the same words of a person and interpreting them differently. And that lack of reproducibility, lack of transparency and clinical decision making is what results in a lot of medical errors by medical errors, I mean, people getting the wrong treatments, right, usually resulting in increased suffering. So we can reduce that suffering improves medical decision making, in the way that we abstract values or illicit values. You know, with your clients in the financial planning industry, I'm sure you're you're trying to get at that what's important to you, because that helps you make planning decisions. It's the same for us only there's robust and sophisticated, yet simple and elegant tools that we use on plan more guide to how to highlight what people's values are, and then a very transparent and innovative way we connect that to medical treatments. And so the whole process has increased reliability, validity and transparency, which leads to better decision making, which leads to better patient outcomes.

Preet Banerjee:

I want to ask you, if you have had specific situations that have stayed with you, where someone has come in with these contingency planning documents, personal directives, whatever it is, that have been crafted, you know, maybe 10 or 20 years ago, and they're at odds with the actual situation that you're facing in the room, what happens in those situations?

Unknown:

Yeah, here's the spark for me. Now, I'm going back 20 years, to an incident where I was called down to the emergency room urgently for a gentleman who was short of breath in Extremis, actually, respiratory distress. So the ER Doc's trying to manage this patient, and feeling like a person imminently needs to be intubated, which means breathing to put down and put on a breathing machine and, and the person relaxed. So the machine does all the work, yet the family come in with the patient, and they have a living well, that basically says, you know, if there are, you know, when I you know, when there's no hope, I don't want heroics, just some some vague language like that, but the implication that the family was communicating is he wouldn't want machines. And so I, you know, I got like two minutes to look at the patient in two minutes to read this document. And I sit with the family and I say, Did, let's call him john, did john know when he signed this document that was 12 hours of positive pressure ventilation and a little bit of medication? I could probably get him off the machines again and back out the door, as per his usual function. Did he know that when he signed it? Oh, no, no, no. He didn't know that. So what do you think john meant when he signed this document with these instructions? Well, he was trying to say what when he's dying, what do you know what, why why would we put anybody on machines when they're dying when we know they're dying? Right? Well, and I tried to explain Well, that's not the case today. He's extremely short of breath. He needs machines, but there's a high probability that I can get them off machines within 24 hours and he'll be fine. Oh, okay. You know, and they were fine. And so then we went And that was what happened, we had debated him, he got better, and he's happy to still be alive. So. So again, that case illustrates my key point, right that planning today, under conditions of certainty, where there's legal instructions that this these are my wishes, doesn't fit with the clinical paradigm where I'm seeing sick people who need decisions made about using or not using licensing treatments, where those plans don't connect. And so we're reframing This is let's plan for serious illness. Let's not make decisions in advance, but rather, let's prepare for future decision making. Where the doctor really wants to hear from me, what are my values? And what are my preferences, and then they put that together in the moment in the clinical context, to make the best treatment decision for me.

Preet Banerjee:

So on one hand, you're you're kind of making a plea to the legal community, there's certain things that maybe you want to stay away from being so rigid in planning for every eventuality from a legal perspective, but what should they be doing instead of that?

Unknown:

Yeah, just referring them to plan well guide for their client to codify their values and preferences, because the legal language is relevant, where it says, you know, my agent should make decisions based on my values and my preferences in consultation with my doctor, period. Okay, so what's the best way to codify that? Well, that's what we've developed with plan well guide. The output of plan well guide, the output of the planning process is what we call the dear doctor letter. And it goes something like this dear doctor, I've been through this planning exercise, I understand I'm not planning my death I'm planning for when I'm sick. And I see you or a colleague, and we have to make treatment decisions. And here are my authentic values. And here are my informed treatment preferences. And you know, I trust that you'll make decisions with my substitute decision maker in my best interest. So either the person, you know, if if they're able to speak, they can recite this, these statements to their or show them to the doctor. or more commonly, when you're, seriously, you're not able to participate. And so the substitute decision maker has a script that they can follow, you follow, you know, the documented values and preferences, and that'll lead to better treatment decisions.

Preet Banerjee:

Yeah. And so in this guide, there's a pamphlet that I took a look at. And there's a couple of things that I want to talk about to help sort of demystify what this is for the listeners out there, the planners out there. And one of the things that you talk about is the idea of a shared medical decision. So can you talk about who the inputs are that go into the shared decision making?

Unknown:

Sure. And that, and this is actually a really good point, because, again, it's a fundamental paradigm shift from the old way of doing end of life planning where, you know, either we as a medical community, or perhaps the legal community, they position the lay person, as an autonomous decision maker, as someone that knows all the details about health care and can say I want to be resuscitated, or I don't want to be resuscitated. And that, that that has any legitimacy. And let me digress and just tell you, I did a survey of over 400 older folks on many hospitals in Canada, who had resuscitation orders on their chart, and we surveyed them, and we asked them if they understood anything about the processes or the natures of the treatments that they would get if they were resuscitated. No. We asked them if they understood the outcomes. What's the probability that you'll walk out of here normal again, if you get resuscitated? And it only 2% of new knew the right answer to the question. And so here we have a paradigm where we treat people as a autonomous informed decision. And we simply ask them well, do you know if your hardware to stop, you know, what do you want us to do? As if that answer has any validity? And so No, we're trying to change that paradigm to share decision making share decision making means that you as a person or your substitute, collaborate equally with a physician to make the treatment decision that's best with you. So we, we don't put you off in the corner and say, tick this box and tell me what you want. But rather, we have dialogue, and there's information exchange, there's deliberation and clarification of values. And the physicians role is to provide best, best knowledge about the possible treatments, their risks and benefits and possible outcomes. And then, you know, as a physician, when I when I hear what the values and preferences are, and I combine that with my understanding of the possible treatments, the risk benefits, and I can, I can then offer up you know, a really solid decision as to what might be best for the patient. And that's, that's the way serious illness decision making should look. And so what I need from the patient then is for them to come in They'll articulate their values and preferences in a way I can connect the dots and make the best treatment decisions.

Preet Banerjee:

Yeah, you know, my partner and I, we've talked casually about, you know, what would happen if you, you know, got into an accident, and the prognosis was dire. And we both kind of shoot from the hip sort of responses. Yeah, pull the plug. But it's easy to say that when you're not putting pen to paper and make any actual decisions, right. And so I think this concept of a shared medical decision with talks about the approach based on your values, taking into account that what situation you actually face at that time is really unknowable. And there's so many different different situations, and you'd have different courses of action, but they would be rooted in these values that you have delineated and made clear in this guide for people to sort of choose from, and that can help inform those decisions. That's a much better way of thinking of it, because it It removes that sense of finality. That, yeah, I'm making decisions now when I have no idea what the situations are, where they're, those decisions are going to be applied. And so this speaks a little bit to, there was an infographic. In your brochure, it talks about the intersection of quality of life and quantity of life. And these are two things people need to consider as part of their their planning for their medical care. And particularly what I was drawn to was that the quality of life on this chart, there are conditions that exist where the quality of life when you're ill, is characterized as worse than death. Can you explain what that means?

Unknown:

Yeah, certainly. And let me start by saying that another key difference with plan will guides approach and end of life planning is your planning for serious illness as of today, okay, this is not for some, if you got hit by a car today, you've got a plan, right? So you're not hypothetically thinking about if I arrive in some certain state, I, you know, what do you want? What do you not want? So Preet someone as young and healthy as you, there's no reason why if you got hit by a car, there's probably no reason why you wouldn't say, well, treat me full meal deal, I want everything possible. Because I'm young and unhealthy. The problem we get into is that with some serious illnesses with prolonged critical illnesses, people suffer a deterioration in the quality of their life or their function. Okay. So for some people, quality becomes more important than quantity. So I'll just make some blanket statements, young people, it's all about quality lives and, you know, enjoy life. For older people, there's a shift from you know what, it's not about living till I'm 100, it's about enjoying the quality of my remaining days. For some people, it's like I'm barely hanging on at my current level of function, my current level of quality, any further decrease would be unacceptable to me. And those are the kind of people who are, if they get serious illness, they would rather check out then run the risk of being kept alive, which is still a possibility, but being kept alive in a further reduced health state. And so there's that trade off, right? If I'm pushing to keep you alive at all costs, it may come at the expense of quality. In contrast, if I really focus on just quality, I may not be able to use the life prolonging measures available to me. So it comes at the cost of quantity. And so it's really important for me as a physician, that you answer that question on plan, well, guy that says, you know, what type of person are you the kind of person that wants us to focus on quality or quantity because, you know, you can't have both, they compete, they trade off with each other. So we I alluded to the fact that, you know, sometimes prolonged critical illness or sometimes given the nature of the serious illness that you've had say that via traumatic brain injury or catastrophic injury that severs your spinal cord, and you're a paraplegic or quadriplegic or whatever, just some catastrophic injury, or some prolonged critical illness takes people into a health state that day, not me, I'm not passing judgment in here and saying that's a health state worse than death. They're saying that they're saying things like if I'm left, you know, in a nursing home totally dependent on others unable to interact with people that are familiar with to me, I would that is worse than death. So that's really important for us to understand as physicians are what are those health states that you consider to be worse than death? That's one of the questions in plan well guide as well. In the event that in the future, you arrive there we will we know that information and then we would take that into consideration when deciding about your treatment plans.

Preet Banerjee:

The conversation with Dr. Darren Hyland continues in June. estimate, if you're enjoying the show, leaving a rating and or review on Apple podcasts helps with getting high quality guests like Dr. Hylan thank you to Allison out of St. JOHN, New Brunswick for leaving a review and for the nudge for me to get my butt back to St. JOHN, to sample the local beers, which I miss and love, also to Northern BC, who mentioned that they completed my financial advice survey for my dissertation that I'm still working on. Hope you've done that soon. Don't hold your breath. And thank you to everyone who has already left ratings and reviews. I really do appreciate it. And now, back to the conversation with Dr. Darren Hyland. You know, I don't know if I want to answer or ask this question. It'll depend on your answer. I guess. One of the fears that I have is if I were to ever become incapacitated, I don't think I'm the only person who's ever thought about this. I wonder if you know, if I was, you know, in a vegetative state, would I be able to perceive things happening around me or be cognizant, but unable to move or interact with people who are unable to signal that I'm in excruciating pain? And you know, please pull that plug? Is that? Is that something that happens? Like? Again, I don't know if I want to know the answer. But what's the answer?

Unknown:

Well, unfortunately, the answer is yes, it does happen. Fortunately, it's very rare. And as I think of my 20 years in critical care, I probably had a handful of patients who I would consider to be what we call a locked in state where they're alive and conscious but not able to respond, I'm thinking of, and this actually speaks to the value of advanced, serious illness planning. I had a patient who is a young Lumberjack, and was involved in an accident where he hurt his neck. And as a consequence, went to a chiropractor had a neck adjustment, and don't over interpret what I'm about to say here, because I'm not saying neck adjustment shouldn't happen. But just as a consequence of the constellation of things that happened to this man in his 40s, he thrombosed, one of the vessels that was at the feeder to the brainstem. So basically, the pathways between his cortex and the rest of his body where we're cut off, so all he could do is blink, to communicate to us. And of course, he could perceive and, and, you know, integrate, and think and, and he couldn't talk because he couldn't move his mouth, he couldn't move any extremities. He's He's in bed. And he's a very active young man. And he was super distressed. And I could interpret that because of his heart rate and his respiratory rate, and that could either be distress or pain. So we had to keep him, you know, sedated, we had a really important decision to make about continuance of his care versus, you know, remove the things that were keeping him alive and let them go. And can you imagine how difficult a decision that would be, but yet his family, because they knew this individual, because they talked about it, they knew what his wish they knew he would not tolerate that, that would be a health state worse than death to be in an institution like that. And so we had to make a hard decision to remove life sustaining treatments. And he passed away, you know, quite quickly after that in peace and comfort. The point also being though, that if you know that this is a particular health state that you, you know, you would not want you document that and realize that your substitute decision maker with your physician will be able to change your treatment goals. So if you sign up for ICU care, I want everything done. But you get to the point where, you know, you've got this health date, that's not acceptable to you, there can be changes made where your substitute decision makers now advocating with your physician to say, No, no, no, he or she said, This isn't what they would have wanted. So there can be a change.

Preet Banerjee:

Man, I, you know, I don't want to abuse the time that you're giving to me on this podcast, but I just I have to know. So when you've got someone who has been in a vegetative state for a prolonged period of time years, and they come around, and they they recover somewhat. Do they ever say that? Yeah, I dreamed or I remember when you came into the office for your into the room for your rounds and stuff like that? Do they? Do they remember what it's like for you to be you know, vegetative for years? Well, I

Unknown:

can't I can't speak for the years I haven't had patients like that. What I can say is that your memories are all jumbled and gibert and you don't have a you have a lot of hallucinations. You have a lot of disorganized thinking. You have a lot of absent memories, actually, when you emerge from the coma related to serious illness. Actually, that's one of the things people find most distressing is six months. 12 months laters they can't piece together what really happened and And they suffer a lot of psychological symptoms as a consequence of that.

Preet Banerjee:

Okay, I'm gonna stop there, sort of irrational fear based questions. But let's go back to the plan well guide. So how long did this guide take to complete? in case people are wondering Yo, this is like, is this a week long process to sit down with people or how long is this process,

Unknown:

the online process, on average is 20 to 30 minutes. And we know that from tracking users experience, some take up to an hour, some take five minutes. If you're sort of a healthcare professional, and you kind of know all the facts, it'll take you five minutes just to, you know, and you're done. But if you're really interested in the information that we have, there's both written and video content to show and explain and talk about, you know how to best clarify your values. We also explain the difference between ICU care, medical care and comfort care if I may, just for a minute, because I see two very frequent problems that lay people get into that results in medical error. The most frequent is an older person who doesn't understand what CPR is. And so they sign up for full resuscitation including CPR. We have a seven minute video decision aid around cardiopulmonary resuscitation, and they and they see that and they get informed. And they say, what, why would I want that? Why would I sign up for something like that, that puts me through this, and ends up with this kind of outcome. And so they come back off CPR as their treatment decision. On the other end of the scale, a very common scenario is typically older, but not that old of a person who signs up for comfort measures. Comfort measures means that the whole focus of your medical treatment is just to alleviate symptoms. And there, you don't get curative treatment. So you could come in with pneumonia and be short of breath. And you give oxygen and morphine to treat your breathlessness but you're not getting antibiotics for your, for your pneumonia, because, you know, there's no plan for cure curative therapy here. So I look at the 65 year old across for me who's healthy and well, and he's signed up for comfort measures. And I explained to him that you know, we come into pneumonia or whatever your heart attack or stroke or whatever, you won't get curative treatment, you'll just get measures to treat your symptoms. You're saying you don't want a chance at recovery? Oh, no, no, no, I wasn't saying that I and again, they thought or not these people think that they're signing up for their dying care or when they're dying. This is why why wouldn't we keep them comfortable, right? It makes sense when you think you're signing up for your final, you know, dying episode. But when you come back to this paradigm of serious illness where I don't know if you're dying. And if you're open to an attempt to curative treatments, you shouldn't be on comfort care. So we're, we're removing people off comfort care, removing people off or solicitation and more in the middle for the most part. Obviously, those are generalizations but the key point on plan will guide is we we give the lay consumer a little more information. So they have a sense of what are the risks and benefits and possible outcomes of ICU care medical care, or comfort care so they can express an informed preference.

Preet Banerjee:

Now, they're the the listenership of this podcast is quite varied. So there's a lot of, you know, consumers in general. But there's also a lot of people from the financial planning financial advice, industry, people in the legal industry who listened to the podcast. And so what should they be considering? What is do you have a message to them about plan will guide in how they can incorporate that into the advice that they're giving to people?

Unknown:

Yeah, and again, this is part of a dialogue that I'm starting, and I don't necessarily have the final answer to those working in the financial planning, planning industry. But it seems to me that we have an opportunity to collaborate in a way that will be a win win for both of us, I'm offering a free tool that provides value to your clients. So if you're seen as the purveyor of that that will add value to your relationship with the client, you're in a position where the person is primed, right, you're thinking you're you've got this person thinking ahead and planning ahead. So please, why not throw that message in to also think about their health care, I think it's a good fit when you're counseling your clients, not only about their financial goals, but that legal piece that we've already talked about, or insurance or critical illness insurance or emergency fund, use, you know, the concept that something bad might happen to you, you need to prepare for that period of incapacitation. And so that's a good fit for that and all we're asking them is that they would refer them to plan well guide and I've developed a number of tools, either paper or electronic that can be passed to your clients to facilitate that. That referral. We've also developed an E reminder system. Because you know, you know how it is when you know, people know, they need to plan and they know they thought the forums and do this. But, you know, in the moment, they may say yes, oh, that's important, but then life comes right and they get distracted with 1000 other things. So if they sign up for our email reminder program, then will nudge them every two weeks. Have you done your planning yet, and we'll give them a cogent message in a visual to try and stimulate them just to keep them on track. There's,

Preet Banerjee:

there's a couple of blog posts that you have that I think are would be very helpful to people as well. One is talking how to prepare for serious illness. And there's another one that talks about how to work with your lawyers to effectively plan for your future medical care. And so we'll include those in the show notes. The the website to visit is plan. Well, guide.com. I think everyone should check this out. I looked at it. And it was really eye opening a lot of things there that I had never even considered before. It's a really incredible resource. Now I have two last questions for you can choose to answer one or both of them. And this is a little bit off topic. Well, one is off topic one isn't. So the one that isn't off topic is with your experience working in critical care. Do you feel like your decisions would be different than the average person's would be when it comes to your serious illness decision making? And the second question is, there's this common perspective that doctors are not very good with money? I'd like to hear your thoughts on that. So you can tackle those in any order you like?

Unknown:

I might not touch the last question. But the first question is, obviously a personal question. But I would, you know, I am very much more conservative in my desire for aggressive treatment. Not that I don't love life, don't get me wrong, I love life. I think I'm more jaded by the consequences of prolonged critical illness and having produced many health states that are worse than death, that if you you shared a fear with me about you know, health conditions that your My fear is being in a health state worse than death, because of my asking for aggressive medical treatments. So for example, my personal preference for medical treatment is I want to go to the ICU. But if I end up with a heart stoppage, don't don't, you know, don't resuscitate me, I don't want to wake up in a brain impaired state. That's, that's my limit. So So I but you know, I think that's a little less conservative than the average person who perhaps hasn't been colored by my clinical experience or isn't as informed about the outcome data as I am.

Preet Banerjee:

So I have a follow up question on that. So because you have your planning in place for your medical care, and as you've thought deeply about this, do you think you live your life differently today, like you and adventurous person? Do you try to take advantage of things more than the average person because you feel like, I didn't know like, you feel like you've made that decision? You've made peace with that. And so you've contemplated seriously the future which, you know, serious illness death? Do you feel that you live your life differently?

Unknown:

I feel like I live my life to the fullest. I've jumped out of an airplane four times. That's what I thought. I'm not afraid of what life has to deal with. But but get back to that peace of mind though, like I got my plans in place, both financial and otherwise. And so you know, I have a high sense of well being and, and seek adventure, just to enrich the quality of my life.

Preet Banerjee:

There you go. Yeah, I think I saw in your Twitter profile that the headshot I think you were hiking somewhere was at like, Machu Picchu. Where was that?

Unknown:

Oh, in the Andes. Yeah.

Preet Banerjee:

Okay. Very nice. Yeah. Excellent. All right, Darren, we'll leave it there. Thank you so much for coming on.

Unknown:

Preet. Do I have time for one more, take home? You do. I feel like it and please go to piramal guy.com before him any more information, what we talked about, but I feel like we've talked about financial to financial planners, to lawyers, and to the general public, but I'm worried a little bit that younger people listening to this might say this is not relevant to me, I have an immortality syndrome. I'm gonna live forever. And that might that might be the case. But I want you to consider one other thing that you part of a family in a society where we have we're not we haven't normalized the conversation about death, dying incapacitation, serious illness, bad things happening to us. Imagine the impact you would have going to the director Have a one day when you you've got your parents and maybe even your grandparents at the table. And you bring this up as an experience that, you know, you took five minutes you went to the series did this and your talk and you just normalize that, and give them the impetus to go and do that yourself. I really want to stress the importance of that just because that role modeling is powerful. Your older grandparents, and perhaps even your parents might need a little coaching or hand holding on the web, to navigate the internet. And so please see yourself as an ambassador, for serious illness planning human isn't as relevant to yourself, you've got people in your circles where it's more relevant.

Preet Banerjee:

Yeah, that is a fantastic point. I think that that role modeling behavior is so important, because that is that is a particularly tough nut to crack for younger people who are not just not focused on those things. They're focused, they've got so many other stresses to deal with right now. But it is important so yeah, everyone should be going to plan world guide.com I am in a future podcast friend of mine, he's a psychiatrist. And we talk often about physicians and finance will have that that that conversation some other time about physicians and money because it's, it's a very interesting thing. You know, these are these are type a people they have, you know, years and years where they're not making a lot of money going through extended schooling and residency. And they see their friends around them buying stuff and starting their careers, relatively speaking earlier. And they're working with people you know, who are had this clip in income, they go from very, not a lot to quite a bit. And then they buy a lot of stuff. And it's fascinating, especially talking to a psychiatrist because he's not only a physician, but he also studies the way people think it's, it's fascinating, so I'm going to have him on a future podcast. But Darren, thank you so much. This has been a fantastic conversation. I really appreciate it.

Unknown:

Thanks for having me.

Preet Banerjee:

If you want more personal finance content, or you have questions for me or topic suggestions for the podcast, you can follow me on Twitter or Instagram. It's the same handle in both cases at Preet Banerjee also have two YouTube channels you can subscribe to my main channel covers more personal finance investing topics that are global in scope. I also have a Canadian specific channel as well. That's it for this episode. Thank you so much for listening.