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Strategic Advance Care Planning

The only Advance Directive that includes STRATEGIES
designed so physicians will write the orders you need,
and so third parties cannot sabotage your goal
⁠ — if you ever reach Late Stage Dementia/Alzheimer’s.

Why Strategic Advance Care Planning Can Uniquely Succeed?

Prevent conflict

The only protocol offering a way to be interviewed so you can memorialize on video, precisely WHAT you want and explain WHY, and prove your mind was sound—which clinicians, judges, family members, and others can view if you no longer can speak for yourself.

Boxing Gloves

Comprehensive

The only living will you need to express your judgment about what people dread most about prolonged dying in advanced dementia and other terminal illnesses. The Natural Dying Living Will is complete, not an addendum, but you can add it to your present living will.

Convincing

SEVERE ENOUGH SUFFERING is the most compelling reason for others to allow you to die. The Natural Dying Living Will is the only advance directive that insists on this high standard.

Accessible

The only protocol that stores all your videos and forms, including POLSTs, in a national registry so first responders and physicians can readily access them, to learn your wishes.

Diligent and Deliberative

The only advance care planning protocol offering feedback and discussion with a clinician,
to help YOU be sure your decisions are consistent with each other and meet the standard, “severe enough suffering.”

Easy

The only online and printed programs that describe 50 conditions with plain words and line drawings using the patient decision aid My Way Cards (used for advance care planning since 2009).

Avoid court

The only protocol offering a way to make your forms and videos admissible as evidence.
You may be able to avoid a lawsuit by making your opponents fear they will lose so they honor your wishes.

Advantages of Strategic Advance Care Planning

It is convenient and versatile to complete. Complete the online program using your cellphone or computer. Use the printed version on your kitchen table or desk.

It is easy. It is written at the fourth grade level of reading comprehension and illustrated with line drawings so patients in early stage dementia and those who are very sick or treated with high doses of medication, can understand.

It details your personal wishes and lets you explain to your proxies/agents how to make the same decisions you would make for yourself based on their knowing your values.

It expresses your exact wishes. Review and change your responses until you feel comfortable they are accurate and complete. On average, people use the online program THREE times.

It honors your past experiences, your values, and your wish to avoid both personal suffering and to spare relatives the burdens of your disease.

Does Your Parent or Relative Need Help?

LEARN more about our NOW Care Planning Package for People Who Need Help Now.

If YOU need help, then please continue reading...

GET STARTED

Strategic Advance Care Planning begins with with sorting My Way Cards on your desk or table, or online using your computer, tablet, or cellphone.

The online version of My Way Cards generate living wills for advanced dementia & all terminal illnesses is—with one exception—what we recommend. This video explains why, and more...

What's in The Package:

1. Natural Dying Living Will

Printed on heavy stock bright yellow paper, sent by USPS Priority. Already have a Living Will? Find out how both can serve you better!

2. Physician-Friendly Version of Living Will

The “physician-friendly” version is user-friendly: it presents your advance decisions logically. It also warns physicians about possible legal consequences if they do not honor your known wishes.

3. Video Version of Living Will

You have two options: You can show the “Read-Describe-Decide-Explain Guide” to your own counselor or proxy/agent to conduct the interview, or you can ask to be interviewed by a Caring Advocates—trained counselor. (It is even possible to have both by telemedicine; for example, your counselor is sitting with you at the kitchen table, and a Caring Advocates—trained counselor joins by secure and private internet video.)

4. Ironclad Strategy Forms

The Natural Dying Agreement includes a bilateral legal contract between you and each proxy/agent and alternatives. This makes the durable power of attorney for healthcare decisions as strong as possible since all your proxies/agents will be members of your “Patient Decision Committee.”

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Strategic Advance Care Plans

Plan Now, Die Later® — To Live Longer

Initial Plan

Complete a Living Will for 50 conditions based on severe enough suffering.

Diligent Plan

Express your diligently reconsidered wishes strategically. Record them on video.

Strategic Plan

Implement strategies to compel physicians to sign orders & prevent sabotage by third parties.

Services Initial Plan Diligent Plan Strategic Plan
Suggested donation amounts cover only basic expenses. If you donate more, the extra amount may be “tax deductible.” If your financial situation is challenging, donate what you can. We want to help all who want it. Health insurance may cover part of the cost — as an alternative for the Diligent and Strategic plans. Call our staff to learn more. Donate $49 Donate $149 Donate $299
My Way Cards - 50 conditions comprehensively reflect what people dread most
Proxy Directive - Digital version - specific for your state
Natural Dying Living Will (NDLW) - Digital (PDF) version + print version by Priority Mail
Natural Dying Living Will (NDLW) - Physician-Friendly + Strategic Warning
Form to request total relief from all types of pain and suffering
Form to refuse thickened food &180 fluid—for a more peaceful dying (even if sooner)
Clinician’s video: comments about your responses

Watch example of clinician's video ⇒
Clinician discussion: by phone or internet video
Interview Guidelines: to create the oral testimony of your living will*
Natural Dying Agreement: so requests are irrevocable & advocates are effective
Natural Dying Agreement’s strategies to compel physicians to sign needed orders
Natural Dying Agreement’s strategies to prevent sabotage by third parties' claims
Natural Dying Affidavit so all forms and video can be evidence in courts of law
3 POLST forms for physicians to sign: CPR (conditional), DNR, or DNR+Natural Dying
MyLastWishes.org national registry: stores forms & videos for clinicians’ rapid retrieval Optional
Suggested donation amounts cover only basic expenses. If you donate more, the extra amount may be “tax deductible.” If your financial situation is challenging, donate what you can. We want to help all who want it. Health insurance may cover part of the cost — as an alternative for the Diligent and Strategic plans. Call our staff to learn more. Donate $49 Donate $149 Donate $299

* You will not need these guidelines if you ask a Caring Advocates trained clinician to interview you. The fee may be partially covered by your insurance; for example, (regular) Medicare allows $165 per hour. Call our staff to ask about your specific insurance. Cost of other items may or may not be covered.

Summary and comparison of the “FOUR” Plans:

1. The INITIAL Plan lets you complete a Living Will that is CLEAR and COMPREHENSIVE— by striving to avoid conflict by specifically expressing what you dread most about a prolonged dying in advanced dementia or similar terminal illnesses.

2. The DILIGENT Plan lets you complete a Living Will that is CONSISTENT with the highest standard of Severe Enough Suffering—that strives to make your requests CONVINCING.

3. The STRATEGIC Plan lets you add STRATEGIES to your completed Living Will that strives to make your advance directive COMPELLING—so your proxy/agent can be successful in persuading your treating physician to honor your end-of-life wishes and in preventing third parties from sabotaging those wishes, including possible conflicting desires expressed by your “future demented self.” The STRATEGIC Plan also lets you express your wishes in a way that is COMPATIBLE with the most widely used physician order forms.

4.Plan ZERO” is the default plan, which is really neither offered nor recommended. It replaces any real Plan above with only HOPE by NO plan—you just hope you will be among the fewer than half of people who die suddenly so they do NOT NEED Advance Care Planning.

a. Advantages of Plan ZERO: minimum time, minimum energy, and minimum cost.

b. Disadvantages of Plan ZERO for your loved ones: Your physician may ask your loved ones to make a life-determining decision for you, but they will not be sure what you wanted. Uncertainty often results in deeper and longer grief. Worse, a long, emotional conflict may ensue.

c. Disadvantages of Plan ZERO for you:
ZERO Plan does NOT ask your loved ones to advocate your thoughtfully expressed end-of-life wishes. So others may force you to endure a prolonged dying with severe suffering. You may not attain your goal of a peaceful, timely dying because you no longer can speak for yourself.

“Almost ZERO Plan” is what many people already have: a “traditional” living will that has asked them to only check a few boxes on a form that was not designed to meet the challenges of advanced dementia or similar terminal illnesses. Ineffective living wills can be as useless as none. Example: view the video, “Free Evaluation of your Living Will.

Six Steps to Strategic Advance Care Planning

The goal of Strategic Advance Care Planning is a private, peaceful, and timely dying so you can feel peaceful about your
      plan now. Confidence that your plan will succeed—meaning that others will honor your wishes when you cannot speak for
      yourself—can prevent you from considering hastening your dying as the “only certain way” to prevent being forced to endure
      an unwanted prolonged dying with suffering.

➜  Steps 1 to 4 let you clearly state what treatment you want when (condition).

➜  Step 5 includes strategies designed to motivate your future physician to write the orders you will need, and to prevent
     anyone from sabotaging your goal.

➜  Step 6 is an optional way to make all your forms and videos available to clinicians when needed.

We recommend completing all steps, but you can complete as few as one, if you wish.

Learn More

IS YOUR GOAL a PRIVATE, PEACEFUL, and TIMELY DYING — BASED on YOUR VALUES?

Our MISSION is to help YOU and your LOVED ONES avoid
prolonged dying with unnecessary suffering.

➜ Don’t sacrifice years of relatively good living by hastening your death prematurely.

➜ Complete “Strategic Advance Care Planning” to feel confident others will honor your plan.

➜ Then enjoy living until a future condition causes severe suffering.

➜ That’s what it means to Plan Now, Die Later®–To Live Longer.

My Way Cards examples

For Most:
No Suffering

For Most:
Severe Enough Suffering

People’s judgments vary

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Not Sure Which Package Is Right For You?

Call Dr. Stanley Now for a Free Consultation!

Short Bio & CV Link

Stanley A. Terman, PhD, MD

Dr. Terman has devoted the last 15 years of his career in psychiatry and bioethics to developing a user-friendly, clinically effective patient decision aid plus a set of strategies that will likely succeed where other living wills/advance directives may fail.

The goal is to facilitate patients’ success in experiencing a private, peaceful, and timely dying and to avoid prolonged dying with suffering for any terminal illness, especially advanced dementia. Dr. Terman considers the greatest reward he can receive is to reduce the suffering of patients and their relatives who face the huge challenge of advanced dementia.

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Dr. Stan Terman and
Bruno who is now 15 ½.

Stanley A. Terman’s career is dedicated to empowering people to make informed decisions so they can successfully meet challenges in their lives with more pleasure, less suffering, and improved relationships. He considers life a journey that includes major transitions, some of which are quite challenging. His approach to planning for life’s final transition is detailed on this site. This webpage features several short (3-minute) videos. Dr. Terman founded and has led the non-profit organization, Caring Advocates since 2000. He has published several books and articles on end-of-life planning and ethics, including “The Best Way to Say Goodbye,” “Lethal Choice,” and “Peaceful Transitions.” In 2009, he created an illustrated patient decision aid that generates a living will that is for all terminal illnesses but especially focused on the challenges of advanced dementia. These “My Way Cards” are now available online and can even be completed by using a cellphone. He also developed a protocol for patients who have already reached an advanced stage of dementia without an effective (or any) living will. Applications for both Strategic Advance Care Planning and Now Care Planning protocols are patent pending (UPTPO). Dr. Terman’s latest presentation was at the California Coalition for Compassionate Care, and focused on Common Flaws in Living Wills for Dementia.

Dr. Terman received his AB from Brown University, his PhD from MIT, and his MD from the University of Iowa. He taught in the Department of Psychiatry at University of California, Irvine, before going into private practice and becoming a bioethicist.

DrTerman@CaringAdvocates.org

(800) 647 – 3223 (64 PEACE)

Available by telepsychiatry worldwide via Zoom/SecureVideo, offices in San Francisco area.

Money-Back Guarantee

Caring Advocates is sure that your Natural Dying Living Will can express your end–of–life wishes specifically, clearly, and comprehensively. If you are not completely satisfied, you will receive a 100% refund of your payment.

Dr. Terman explores a way of dying that is relatively painless, effective, legal, and in keeping with many religious traditions. Critically important for individuals, families, health care professionals, and public policy experts, his book really does point to The BEST WAY to Say Goodbye.

Elliot N. Dorff, Rabbi, Ph.D.
Rector and Distinguished Professor of Philosophy, University of Judaism
author of Matters of Life and Death: A Jewish Approach to Modern Medical Ethics

Meeting the Challenges of Advance Care Planning for Advanced Dementia – A Social Justice Imperative. 🔗

Posted: 20 Mar 2020 05:36 AM PDT

By Dr. Stanley Terman

It is not easy to die of advanced dementia. Yet almost everyone has this goal: a dying that is private, peaceful, and timely.

Dementia patients cannot qualify for Medical Aid in Dying (Physician-Assisted Suicide). Usually, their only legal, peaceful option is to stop ingesting food and fluid. Yet some authorities strongly oppose this way of dying. Knowing that traditional advance directives are not effective, and learning that authorities may oppose newer “dementia-specific” directives/living wills, many patients harbor the “Dementia Fear.” They have reason to worry that others will force them to endure prolonged dying, possibly with increased suffering, perhaps for years.

Some patients strive to make their ultimate existential decision at “five minutes before midnight”—to live as long as possible. But they live with this source of daily anxiety, which decreases their ability to enjoy life: “If I wait too long, I will miss the opportunity to kill myself by losing my mental or physical capacity.” Some commit preemptive suicide, an option that requires sacrificing up to years of good living that is not only sad but tragic. Premature dying would not be necessary if patients could trust others to honor their end-of-life wishes.

End of Life Choices of New York’s directive attempts to overcome opposition by offering an “aggressive” option that totally dismisses patients’ feeding behavior as criteria to stop assisted feeding. But their alternative–reaching Stage 6 of any version of the Functional Assessment Staging Tool—brings up another problem: most physicians will continue assisted feeding even if patients manifest all the tool’s listed behaviors: patient needs help putting on clothes, bathing, and toileting; and has urinary and fecal incontinence.

Compassion & Choices’ Dementia Values and Priorities Tool lets planning principals choose one or two of 15 conditions as sufficient to be allowed to die naturally, and a separate list of 7 behaviors as sufficient to stop assisted feeding. Yet treating physicians and their organizations may insist patients’ best interest is to continue assisted feeding unless they manifest distress.

To overcome physician refusal, one could insist on the criterion, severe enough suffering. But clinicians recognize it is difficult to determine if non-verbal advanced dementia patients are experiencing severe suffering—especially with the certainty needed to allow patients to die.

Strategic Advance Care Planning could offer a possible solution: During advance care planning, planning principals judge each condition by responding to: “Would this condition cause severe enough suffering for you to want to die of your underlying disease?” To determine if it is time to stop assisted feeding, treating physicians then need only assess if their patients have contemporaneously reached at least one of these pre-judged clinical conditions.

The online patient decision aid informs planning principals what it is like to live with advanced dementia using 50 illustrated descriptions at a level of reading comprehension of grade 4, which many early stage dementia patients can understand. It achieves this by broadening the concept of suffering to comprehensively reflect what people dread most about prolonged dying in advanced dementia and other terminal illnesses. In addition to physical and emotional suffering, it considers existential suffering (loss of meaning in life and the ability to relate to others); suffering due to disruption of life narrative; suffering the disease causes loved ones; and moderate suffering from several conditions that add up to severe.

Recording planning principals’ semi-structured interviews on video can: memorialize their advance decisions; demonstrate if they possessed decision-making capacity; let them add personal details about their end-of-life wishes; and, most importantly, give them an opportunity to be convincing.

In cases of advanced dementia, clear, comprehensive, consistent, and convincing directives/living wills may not, by themselves, be effective. It is important that an advance directive include over a dozen strategies in order to compel physicians to honor, and to prevent third parties from sabotaging planning principals’ end-of-life goal.

The post Meeting the Challenges of Advance Care Planning for Advanced Dementia – A Social Justice Imperative appeared first on Bill of Health. Bill of Health was launched in September 2012 by the Petrie-Flom Center at Harvard Law School to provide a one-stop shop for readers interested in news, commentary, and scholarship in the fields of health law policy, biotechnology, and bioethics.

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