“Now Care Planning”

 “Now Care Planning” is for patients who already reached Advanced Dementia—but lack a living will that is adequate, effective, and acceptable—so their physicians honor what proxies/agents know for sure the patient would now want.

 Now Care Planning uses “Substituted Judgment.” Those who knew the patient well give their opinions on how the patient would have judged each condition using the My Way Cards—a unique decision aid that . . .

 Uses severe enough suffering as the single compelling criterion to inform others when the patient would prefer to be allowed to die of his/her underlying disease.

 Describes and illustrates about 50 conditions that are easy to understand and comprehensive as they reflect what people dread most about prolonged dying in Advanced Dementia and other terminal illnesses.

 Uses the intervention Natural Dying that can be effective for all patients, including those who have “No Plug to Pull”; that is, whose lives do not depend on continuing high-tech, life-sustaining treatment.


Use our free living will evaluation service, and complete two free online questionnaires, to answer these 5 questions:


  1. Ask us to evaluate your loved one’s living will: Is it likely to be adequate and effective? (Send it to us for our 20 point critique.)
  2. Do you qualify to be your love one’s surrogate decision-maker?
  3. Are you and at least two other qualified surrogate decision-makers willing to participate as Decision Committee members?
  4. Can your loved one who is living with Advanced Dementia likely qualify for Now Care Planning? (Online questionnaire)
  5. Does your loved one resist, or show distress while being spoon-fed? (A second online questionnaire.)
  6. If the first 4 answers are all “Yes,” consider Now Care Planning further.
    (A “Yes” to question 5 is not required, but it may motivate others to help.)

Ask an end–of–life planning counselor to be your guide.


  • Begin with a half-hour session with the counselor to make sure qualifications are met, and learn how to form the patient’s “Decision Committee.”
  • Using the My Way Cards, each member answers: “Would the patient have judged suffering severe enough to want to be allowed to die of his/her underlying disease?” (This expresses his or her independent “Substituted Judgment.”)
  • Decide: Do you and concerned others want the counselor to guide you through Now Care Planning? If so, start with answering this question...

    (A) “Is there is a Consensus of Substituted Judgment that the patient would want Natural Dying for certain conditions?”

My Way Cards sorting

  • If the answer is “Yes” proceed

Complete the task with your counselor and the patient’s treating physician:


  • Decide: Do you and concerned others want the counselor to guide you through Now Care Planning? If so, start with answering this question...

    (B) “With input from the treating physician, the counselor asks Decision Committee members: Has the patient reached any specific condition for which the patient would have wanted Natural Dying NOW?”

  • If so, then the currently acting proxy/agent and counselor and hold a “Shared Decision–Making Meeting” with the treating physician to whom they present...
  • The data that support the Consensus of Substituted Judgment;
  • A form letter for the physician to request a bioethics or independent clinician’s consultation for a second opinion; and,
  • The form, Physician Orders for Life–Sustaining Treatment, which includes
    pre–printed orders for Natural Dying.
  • * * *
  • The treating physician reviews the opinion of the bioethicist or independent clinician.

If the treating physician signs the Physician Orders for Life–Sustaining Treatment that includes orders for Natural Dying, the patient can have a peaceful and timely dying. (Note: if the patient has not yet reached a one of those specific conditions, another “Shared Decision–Making Meeting” can be held in the future. Deciding ahead of time can be less stressful for all.)

If the physician refuses to sign, even after the counselor offers clinical, ethical, and legal arguments to educate and overcome physicians’ resistance, then the currently active proxy/agent and counselor will seek out other providers and resources as they strive to attain a peaceful, timely dying for the patient.


SIX STEPS to NOW CARE PLANNING: BRIEF SUMMARY

Step 1: Do the concerned individuals who know the patient’s values think the patient qualifies for “Now Care Planning”? Are there at least 3 concerned individuals qualified to be surrogate decision-makers? (Both are required.)

Step 2: Does (or did) the patient show resistance or distress while being spoon–fed? (Not required for NCP.) Counselor facilitates forming the patient’s “Decision Committee.”

Step 3: Loved ones use the decision aid “My Way Cards” to express their “Substituted judgment” opinions about 49 end–of–life/dementia conditions: “When the patient had capacity, would s/he have judged this condition—by itself—causes severe enough suffering to want others to allow him/her to die of his/her underlying disease?”

Step 4: Decision Committee members have a group discussion with the end–of–life planning counselor. The goal is to answer 2 questions:
(a) Is there a “Consensus of Substituted Judgments” for any specific conditions for which the patient would want Natural Dying?; and,
(b) Has the patient reached any of these specific conditions, NOW
?

Step 5: The currently active proxy/agent and counselor have a “shared decision–making meeting” with the treating physician and provide the physician with four forms:
(a) Cover letter to the physician entitled, “A request to sign a POLST form with additional orders to honor the patient’s end–of–life wishes”;
(b) Is there a “Consensus of Substituted Judgments” for any specific conditions for which the patient would want Natural Dying?; and,
(c) A suggested form letter the physician can modify to request a second bioethics or independent clinician opinion; and,
(d) Physician Orders for Life–Sustaining Treatment with pre–printed orders for Natural Dying.

Step 6: The treating physician reviews the second opinion; confers with the currently active proxy/agent and counselor, and may then sign the orders for Natural Dying using the POLST form. If the physician refuses, then the proxy/agent and counselor consider other strategic options.

Click here for a more detailed explanation of the “Six Steps to Now Care Planning.”

Want to learn about our other Protocol, Strategic Advance Care Planning?