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To get your unique link to the online program and forms by email, order the “Initial Plan” for $49 by clicking here.
Everything in the “Initial Plan” PLUS:
Everything is sent by US Postal Service, ready for your and witnesses’ signatures.
Everything in the “Initial” and “Diligent Plan” PLUS:
Receive your Living Wills printed on heavy stock bright yellow paper, and your videos on a thumb drive by 2–Day Priority Mail.
Optional Read: “Six Steps to Strategic Advance Care Planning” (pdf) or (HTML)
Want to UPDATE and strengthen your previously completed “Final” Natural Dying Living Will? Click here.
Consider the “Diligent Plan”
Your efforts to be consistent and convincing may be necessary but not sufficient.
Consider the need for strategies to overcome 14 common challenges: click here.
Click here for a 10-minute slide show that reveals the opposition and its dire consequences.
Consider “Strategic Plan”
Click here to learn why you should consider uploading to a registry.
Recommended: Upload all your forms and videos to a national registry such as MyLastWishes.org where physicians and others can quickly retrieve them.
Together, these 50 conditions comprehensively include what people dread most about prolonged dying in Advanced Dementia and other terminal illnesses.
The key question: If you reached any condition that would cause severe enough suffering—do you want others not to prolong your dying and suffering?
The online decision aid My Way Cards works on your computer, tablet, and cellphone.
First, it informs you about each clinical condition.
Then it asks: “Would it cause severe enough suffering for you to want to be allowed to die?”
If “Yes,” you can choose Natural Dying—a way to die that is effective and peaceful; and that strives for others’ acceptance.
We send you a state–specific Proxy Directive so you can legally designate one person and alternates to speak for you—if you lose your ability to make medical decisions. We also send a guide on how to select and to empower your proxies/agents.
From your responses to My Way Cards, we generate and email you, your “Initial” Natural Dying Living Will. If you want to use it as your current Living Will, we print it and mail it to you by USPS, ready for signatures so that it can be legally valid.
We recommend using this Living Will as your initial draft and continuing your advance care planning efforts by reviewing your responses with diligent deliberation and discussion.
Includes the “INITIAL PLAN” plus...
First we review your responses to the My Way Cards. Then a clinician discusses them with you on a phone call of about 10 minutes. We ask: Are your decisions consistent with “severe enough suffering”?
Using the responses you may have revised, we generate your “Final” Natural Dying Living Will and send you a second, “physician–friendly” version that is strategic. It warns future physicians about 3 dire legal consequences—if they write orders that do not honor your known end–of–life wishes.
We send you 3 forms to add to your Living Will. They clarify your refusal of force–feeding; let you refuse thickened food and fluid in advance; and let you consent to treatment to totally relieve unbearable end–of–life pain and suffering—even if medications must put you to sleep.
We print your Living Will on brightly colored, heavy stock paper and mail it by USPS, ready for signatures so it can be legally valid.
To make your wishes convincing——we recommend you respond to an interview that you record on video, where you explain the reasons WHY you made these advance treatment decisions. If you do not select one of our trained clinicians to interview you, we mail you a short “How To” guide so your responses for your oral Living Will can strive to be convincing. (Our clinicians can record on video, their opinion: Did you have enough mental capacity to make these advance treatment decisions?)
Includes the “DILIGENT PLAN” plus...
You add strategies designed to overcome common challenges and sources of sabotage—so you can avoid conflict, or at least promptly and privately resolve conflicts—without going to court.
For more information about why even Living Wills that are clear, consistent, and convincing may be only necessary but not sufficient to be compelling so you can attain your end–of–life goals, click here.
One strategy further empowers your proxies/agents by asking each to sign a binding bilateral contract and to form your Decision Committee. Another strategy insists on using your high standards of evidence presented by opposing experts—if others claim that you changed your mind, no longer want Natural Dying, and revoked your Natural Dying Living Will—even though you have reached a condition that you had judged would cause severe enough suffering.
One especially challenging conflict is: Your “future demented self” indicates the desire for others to help spoon–feeding but you (as expressed in your Living Will) had decided on Natural Dying for your current condition. This “Strategic Plan” lets you invoke a strategy to resolve this potential conflict now!
Includes 3 “physician–friendly,” comprehensive Physician Orders for Life-Sustaining Treatment (MOLST, POST, etc.) forms that have pre-printed physician orders. The first can ask for cardiopulmonary resuscitation(CPR). The second can refuse only CPR (“Do Not Attempt Resuscitation or DNR.”) The third can request “DNR plus Natural Dying.” We can provide suggested scripts so you can record 3, shorter than one–minute videos to rapidly inform emergency first responders and physicians what treatment you do, or do not want.
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.
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
