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End-of-life care is a crucial and often overlooked aspect of health care. In this episode, we speak with Kevin Haselhorst, an emergency physician and author who shares his insights on the challenges and opportunities in this area. He discusses the limitations of the current Medicare system and the importance of advance directives. He also advocates for greater empowerment and self-determination for seniors in their end-of-life decisions. Tune in to learn more about the state of end-of-life care in the U.S. and how we can improve it for the benefit of seniors and their families.

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.

He shares his story and discusses his KevinMD article, “Can Medicare advance directives be simple?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Kevin Haselhorst. He’s an emergency physician, and he’s the author of the book “Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.” His KevinMD article that we’re going to talk about today is titled “Can Medicare advance directives be simple?” Kevin, welcome to the show.

Kevin Haselhorst: Thank you, Kevin. I appreciate it.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Kevin Haselhorst: Well, I grew up in a small town in Illinois and trained in St. Louis. Southern Illinois University is where I went to medical school. Ultimately, I did an internal medicine residency in St. Louis, and then I worked in the emergency room there for about eight years. I had moonlighted there after my residency. Then I moved to Arizona, and I’ve been here for approximately 25 years now.

Kevin Pho: All right, so a lot of your KevinMD articles deal with advance directives. You’ve written a book on advance directives from your experience in the emergency department. Just paint us a picture of how advance directives come into play in the ER setting.

Kevin Haselhorst: They’re extremely confusing, because most times people don’t know what’s in their advance directive. It’s not necessarily found. It’s very unhelpful. Sean Morrison did a perfect review last year, saying how they haven’t served us in the last 30 years, and I can attest to that. On the receiving end of these advance directives, they don’t really provide me the guidance I need, and we need to simplify them so that I know what people really want at the time that they’re making life-and-death decisions.

Kevin Pho: So when you say that sometimes living wills or advance directives don’t tell you, as an emergency physician, the information you need at that moment, can you give me a story, a case, or an example that would illustrate that?

Kevin Haselhorst: Oh, the person comes in from the nursing home, and they’re septic. Their quality of life is already compromised. I would go back, and the normal standard of care is to intubate them and send them to the ICU. We put them on pressors. After writing the book, I’m realizing, “I don’t think this is what people really want. I think we should have a conversation first before I just dive in.” So that’s been my practice in some respects: providing palliative care conversations before I dive in and try to resuscitate them.

So, you know, there’s the advance directive, but they will always want something done, because it’s not right if you don’t do something to save their life. The challenge is that saving their life adds to more misery. So I’m up against a wall, wanting to provide care but them realizing that the care they receive is not in their best interest. So it really is important for people to be able to tell me, because I can’t tell them what to wish for. They need to tell me what their wishes are so I can grant them.

Kevin Pho: So you’re saying that sometimes patients will come to the emergency department with, say, some type of advance care directive, but in that acute setting, the patient or the patient’s family may want you as the emergency physician to do something.

Kevin Haselhorst: Yes. Here’s the deal. There’s a JAMA Network article that just came out, “Death and end-of-life care in emergency departments,” and it basically gives this stunning statistic: If you’re over 80 years old, the chance of you dying within one month is one out of 12. One out of 12 people will die within one month of presenting to the ER. That, to me, should be a wake-up call for anybody over 80. When somebody is calling 911, do you know what your wish is at this point? Because most people don’t know. Most people are too beside themselves. They get their fear in front of their wishes, so they don’t quite remember what the intention was when things go south.

This is a huge wake-up call, and this is what prompted my article that really said, “OK, we need to talk about this,” because this is what I’m experiencing: These people are not having a conversation. Medicare can actually provide this conversation during enrollment. They can encourage people to look at the three options that I’m presenting.

But first I want to say, when people come to the emergency room, what do people wish from me? They either want standard treatment, they want uncompromising compassion, or they want personal empowerment. Standard practice, uncompromising compassion, personal empowerment: huge wishes, and very heart-centered. You don’t know what you want until you look inside your heart to know what’s important at that moment.

And so again, you’re over 80 years old, and you’re having a heart attack, a stroke, sepsis, organ failure, or trauma. I’m going to grant you three wishes, but you can only choose one. You can’t mix them up. It’s either inpatient medical treatment, it’s homebound comfort care, or it’s outpatient palliative services. Those three wishes need to be sat with, so people, when they’re filling out their Medicare enrollment, have some idea of what’s important to them, what they value.

Kevin Pho: So like you said, this is a topic that you talk about in your KevinMD article, “Can Medicare advance directives be simple?” Now, in your ideal world, walk us through the workflow that you would like to see when patients enroll in Medicare.

Kevin Haselhorst: You start out with the process of “I don’t know.” My yoga instructor would say, “Uncertainty is my path of freedom.” Freedom means having an open mind during open enrollment. Only an open mind can make an informed decision. So part of this problem is we’ve become a polarized society, and each of us has become polarized in our own way. We hear what we want to hear. We see what we want to see.

I’m asking you, during this period of light, ’tis the season, to open your mind to the possibility that in the next year you might be confronted with an end-of-life decision. What are your choices? You could die within a month. What do we need to know? So again, I would say at the end of the year we talk about examining your life. You want to examine your life before you enroll in Medicare, and this is a good opportunity for you to declare your wishes at that point, wishes that align with your values. So that’s part of the thing: You’re going to come up with one decision. You’re going to sit with these three options, and you’re going to say, “What makes the most sense to me if something happens, given my quality of life at this point?”

Kevin Pho: And to reiterate, what would those three options be?

Kevin Haselhorst: Inpatient medical treatment, homebound comfort care, and outpatient palliative services. You know, Pelé has been dealing with this in the media right now. He stopped treatment for colon cancer, and so there’s this question: Is he on palliative care? Is he on comfort care? We don’t have a common language around what’s occurring, around how we describe the care that he’s receiving, and it’s extremely confusing to people, because comfort care and palliative care are not separated. They’re lumped together oftentimes, and that does a huge disservice to people.

Kevin Pho: So currently we have these Welcome to Medicare visits that I do as a primary care physician, and one component of that is to talk about advance care directives. How is what you’re proposing different from what I’m doing in these Welcome to Medicare visits?

Kevin Haselhorst: Well, you’re giving them a menu of options to choose from. A lot of these are put in POLSTs or MOLSTs, where people will select from a menu of options: “Do you want the feeding tube? Do you want the respirator? Do you want IV fluids? Do you want antibiotics?” People will piecemeal these wishes into some sort of a form. But my medical protocols aren’t based on a patient’s menu of options. If I’m going to go all in, I need to follow a protocol that’s standardized and that I can defend in court. I can’t defend in court that I chose certain things over other things and didn’t abide by the standard of care. So I’m kind of up against the wall in terms of how I would normally treat a person versus how they may wish to be treated, but they don’t quite have the whole package of information to know that sometimes you need to include IV fluids with antibiotics to make them effective.

Kevin Pho: So tell us a story or a hypothetical case study. Let’s say we implemented your system, where if a patient applies to Medicare, they have to choose from one of the three options that you suggested. Tell me a hypothetical of that happening and then that patient coming to the emergency department already having those choices preselected. Tell me a success story, in your mind.

Kevin Haselhorst: A woman comes in with a hemorrhagic bleed in her brain. She’s basically semi-comatose. Her husband doesn’t even say he’s her husband. He identifies himself as the medical power of attorney, her medical power of attorney, which I thought was stunning. I’ve never seen anybody introduce himself that way. So he was already on target, knowing, “This is a life-threatening situation. I’m going to be involved in her care.”

So we determined she does have a bleed in her brain by the CT scan. I’m on the phone calling the tertiary neuro center, saying, “We have this patient that needs to be transferred,” and he’s like, “Wait a minute. What would her quality of life be after this bleed?” I’m saying, “It won’t be the same,” and he says, “I don’t want her transferred.” I hang up the phone, and I’m kind of dumbfounded, because, you know, I have not seen that kind of proactive energy coming from a family member: a husband who’s losing his wife and being able to have the courage to make the decision, “Let’s not do something to add to her suffering or challenge her or make life miserable for her.”

I go back into the room and explain to her that her husband and I have talked this out. She knows the dust is settled. “This is what’s going on, and we’ve decided it’s in your best interest to keep you comfortable.” Because, “Doctor, I trust you.” So that broke my heart, to know the amount of effort I had put in over the years of thinking about this, and really supporting this man in his decision, because he could have easily been derailed. Somebody could have said, “No, we have to do this. We have to save her life.” And I tell you, other family members came in, and they questioned, “Doctor, shouldn’t we be doing something more than just letting her die?” I’m like, “Well, her self-determination, according to her husband, was, ‘If this happens, I’m to die.'” To honor that wish is always unsettling in many respects, but it was actually joyous to know that we honored her in a way that many people do not get honored.

Kevin Pho: Tell us what happens if their wishes aren’t honored. Someone gets intubated, perhaps against their advance directives and living will. Tell us what happens next in a lot of cases.

Kevin Haselhorst: Well, in a lot of cases, it’s “Well, let’s wait and see.” There’s a lot of hedging, because once you’ve entered that realm of care, you feel like you’re killing the person by taking them off the ventilator. So it is kind of backtracking, in terms of, you know, not providing hope at this point and recognizing that if we’re going to provide compassion, we need to withdraw care. Now, it’s nice if we can withhold care and we don’t have to make the decision about withdrawing care. I’ve told one family member in particular that I remember, “If you make the decision to put her on the ventilator, you will make the decision to take her off the vent. Do you really want to make that decision to end her life, or do you want nature to end her life at this point?” They decided not to put her on the ventilator, because they didn’t want to take that responsibility.

Kevin Pho: So what do you anticipate as a path forward? I think, as you’d imagine, we do live in a polarized society. Sometimes if you invoke advance care directives in connection with Medicare, some people may say “death panels.” How do you propose a path forward in our current political environment?

Kevin Haselhorst: You have to make people understand that this is in their best interest, and it will take an act of Congress to force Medicare to comply with the self-determination, where we ask people to declare what their wishes are, that you be self-determined in your end-of-life care journey. So Medicare will have to make people complete advance directives during enrollment, so we have that information on board. That wish should be their registration number. Their Medicare number should end in an A, B, or C. I know if they want medical treatment. I know if they want comfort care. I know if they want palliative services. A, B, C. That’s simple enough.

I don’t need to go searching any website and looking for papers in the freezer, you know, where they’re hidden, or the refrigerator, wherever it’s hidden. We don’t need to look, and we don’t have this confusion around a DNR being an advance directive, which is just, again, you don’t use common sense in these situations. We don’t get great results, because we’re not using common sense.

Kevin Pho: We’re talking to Kevin Haselhorst. He’s an emergency physician. His KevinMD article is titled “Can Medicare advance directives be simple?” Kevin, what are some of your take-home messages that you want to leave with the KevinMD audience?

Kevin Haselhorst: The U.S. ranks 43rd in quality end-of-life care. There was a recent article just printed that documented this. I want people to join my crusade for Medicare advance directives. Sign on to mad-act.com. Find out what I’m doing to ask Congress to pass this law, to make Medicare have seniors complete medical directives during enrollment.

Kevin Pho: Kevin, thank you so much for sharing your time and insight, and thanks again for being on the show.

Kevin Haselhorst: Thank you, Kevin. I appreciate it.