avoid a prolonged dying with unnecessary suffering.

A private, peaceful, and timely dying based on THEIR values.

If you feel confident that others will honor your loved one’s end–of–life wishes, you will...

NOT let them die prematurely of an infection in Mid-Stage Dementia, and

NOT consider “mercy killing” in Advanced Dementia.

“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 feel compelled to honor what proxies/agents and loved ones know for sure the patient would now want.

 Now Care Planning uses “Substituted Judgment”: Surrogate decision-makers who previously learned the patient’s values use their working mind to express what the patient would have judged for each condition using My Way Cards—a unique decision aid that . . .

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

 Describes and illustrates almost 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.

Free: Learn if “Now Care Planning” may help:

• Ask us to evaluate your loved one’s living will using our 20–point checklist.

If not adequate and effective, complete one online questionnaire to answer:

  1. Do you qualify to be your love one’s surrogate decision–maker?
  2. Are you and at least two other qualified surrogate decision–makers willing to participate as Decision Committee members?
  3. Can your loved one who is living with Advanced Dementia likely qualify for Now Care Planning?
  4. And a second questionnaire to answer:

  5. Does your loved one resist, or show distress while being spoon–fed?
  6. If the first 3 answers are all “Yes,” consider Now Care Planning further.

    (A “Yes” to question 4 is not required, but it may motivate others to help.)

My Way Cards examples

For Most:
No Suffering

For Most:
Severe Enough Suffering

Condition 0.0 Condition 8.3
Condition 3.3 Condition 3.3

People’s judgments vary

Condition 4.5 Condition 5.5

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 each member’s independent “Substituted Judgment.”)
  • Decide: Do you and concerned others want the counselor to guide you through Now Care Planning? (End-of-life counselors charge fees based on time.) 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: With input from the treating physician, answer:
  • (B) Has the patient reached any specific condition for which the patient would have wanted Natural Dying NOW?

If the answers to (A) the patient would have judged this condition to cause severe enough suffering,

and (B) the patient has NOW clinically reached at least one of these conditions, are both “YES”...

Then the currently acting proxy/agent and counselor can hold a “Shared Decision–Making Meeting” with the treating physician to whom they present four items:

  1. Cover letter to request the physician write the order for Natural Dying NOW;
  2. Proof (both summary and raw data) that members of the Decision Committee reached a Consensus of Substituted Judgment regarding what the patient would want NOW;
  3. The form, Physician Orders for Life–Sustaining Treatment, which includes pre–printed orders for Natural Dying, which the physician can sign; and,
  4. A form letter the physician can revise to request a bioethicist or independent clinician to render a second opinion.
* * *
  • The treating physician reviews the opinion of the bioethicist or independent clinician.

Mission Accomplished?

The treating physician signs the Physician Orders for Life–Sustaining Treatment that includes orders for Natural Dying, and the patient has a peaceful and timely dying.

Is Waiting Clinically Appropriate?

All agree that the patient would want Natural Dying someday but has not reached one of those specific conditions YET.

The plan is to hold another “Shared Decision–Making Meeting” in the future.

Important: Deciding ahead of time is usually much less stressful.

This set of actions is the second way the Protocol can let patients Live Longer by Plan Now, Die Later®

(The other way is to decide on full feasible treatment in Mid–Stage Dementia if there is a reasonable chance the patient could return to previous functioning to enjoy simple pleasures of life.)

Physician Refuses?

The physician will not sign the POLST, even after the counselor offers clinical, ethical, and legal arguments to educate and overcome physicians’ resistance.

If Decision Committee members agree, the currently active proxy/agent and counselor will seek out other providers and resources so the patient can have a private, peaceful, and timely dying.

“Now Care Planning” for Advanced Dementia, suffering-timely, peaceful dying if NO Living Will

Six Steps to “Now Care Planning”

Now Care Planning” is for patients who want a peaceful, timely dying, but who:
(A) Have already reached the advanced stage of dementia;
(B) Depend on another’s hand to put food and fluid in their mouth; and,
(C) Have lost mental capacity so they cannot either complete a new living will or revise their existing living will that is not adequate and/or not effective.

Defining what makes living wills adequate and effective:

A living will is adequate if it clearly informs future physicians and others precisely “when” patients would want others to allow them to die of their underlying disease.

A living will is effective if (i) the intervention it offers (its “what”) can allow patients to have a private, peaceful, and timely dying, and if (ii) physicians and other authorities can view the intervention as acceptable.

Unfortunately, few living wills meet these criteria and the results can be sad. Loved ones may feel helpless for years as they watch patients endure prolonged dying with possible suffering.

These Six Steps expand the traditional protocol of Substituted Judgment, which is widely accepted as legal and ethical. The “Now Care Planning” Protocol strives to present robust data and convincing arguments to treating physicians. It also includes several layers of safeguards designed to prevent premature dying. A counseling healthcare provider is required to guide the legally designated currently active proxy/agent and two or more proxy/agent alternates and possibly concerned others through the Protocol. The intermediate goal is to make the same treatment decisions patients would have made—if patients had been asked when they still possessed decision—making capacity to judge if their present condition would cause “severe enough suffering.”

The ultimate goal is to convince a physician to write the orders for Natural Dying so the patient can avoid a prolonged dying with severe suffering by having a private, peaceful, and timely dying that is based on their values.

Step 1: Do concerned individuals who know the patient’s values, think the patient qualifies for “Now Care Planning”? Are these individuals legally and clinically qualified to serve as members of a new patient’s Decision Committee? Are they willing to give their informed consent to serve?

* * *

Click to Continue to Read How Each of the Six Steps Works,
How it can Benefit Your Loved One, and Why it is Unique...