“So knowing when should we or when shouldn’t we jump in with interventions-really important that we get that right,” Nesbitt said.

“So how do we get that right? We’re all pretty healthy right now. We’re pretty good, but none of us know what tomorrow brings for us. So how do we figure this out ahead of time?” he added.

Nesbitt was speaking to a group at a Healthcare Decisions Day event on hospice and end-of-life care at the Steinbacher, Goodall & Yurchak law firm.

During the event, Traci Schultz, executive director of Wolf Run Village Senior Living Community, received the 12th annual Dr. Alexander Nesbitt Commitment to Caring Award.

KAREN VIBERT-KENNEDY/Sun-Gazette Julieanne Steinbacher talks about end of life conversations at the Elder and Special Needs Resource Center in Williamsport.

Nesbitt, who retired recently after being a family physician for 22 years and over 20 years in hospice and palliative care, said that there have been several paradigms presented in the past for dealing with how to make and communicate end-of-life decisions.

The first and probably most familiar is the living will, he noted.

“We’ve all heard of living wills and the initial paradigm was, this is really great. We’ll have a form and it’ll be real specific and we can have people say, I want CPR; I want dialysis; have blood transfusions; have all these interventions…then you can think about it ahead of time and you can write down what you want. You check it, you sign it and then the document is right there fan then it the person gets really from from the doctor’s standpoint, just look at the living will. There you go,” he said.

“It’s really a great, super great idea-except it didn’t really work,” he added.

One problem with the concept of a living will or advance directive, Nesbitt noted, is that most people have not done them. He cited statistics which show that only about 34 per cent of adults in this country have living wills.

KAREN VIBERT-KENNEDY/Sun-Gazette Julieanne Steinbacher talks about end of life conversations at the Elder and Special Needs Resource Center in Williamsport.

“And this is after decades and millions and millions of dollars advocating that you should do an advance directive; you should do a living will. You should do that. People have heard that,” he said, adding that 95 percent of people surveyed said that it is a good thing to do.

Another problem is that of the people who have done an advance directive, the document often is not brought to the hospital in a time of emergency.

“How often is that document in the hospital where we need it, in the moment we need it,” he said.

“But worse than that is when the form is there, very often it doesn’t tell you exactly what to do. Well, you think it would – check it off, there it is. But often it doesn’t exactly apply,” he said.

Nesbitt described a scenario where a man living alone after the death of his wife, has a detailed living will. He has a stroke and is taken to the hospital along with his living will which says what he doesn’t want done if he is terminally ill, but is his condition terminal or could he reasonably recover with weakness on his one side?

KAREN VIBERT-KENNEDY/Sun-Gazette Alexander Nesbitt, left, and Julieanne Steinbacher, right, present the annual Dr. Alexander Nesbitt Commitment to Caring Award to Traci Shultz of Wolf Run Village, center The award recognizes an individual(s) or nonprofit in the community who shows an extraordinary commitment to caring that significantly improves the lives of others.

“This happens all the time,” Nesbitt said, because in real life doctors don’t know exactly what is going to happen.

“We talk about probabilities; likely; but it could be that. It changes day by day,” he said.

“So it’s not 100 percent we don’t know, occasionally, it’s we know,” he added.

Often, too, the person can’t speak for themselves to voice what they want, so medical professionals have to turn to a health care provider attorney, or in this state, a health care agent. In any of those cases, the doctors are turning to people who can “speak” with the patient’s voice, Nesbitt said.

Since the living will scenario often fails, what is most important is the process of advanced care planning, which he described as “thinking ahead of time if things got bad, what would I want done and deciding who would you want to speak for you.”

“So, you’re naming…your healthcare power of attorney and talking about how you think about certain things,” he said.

The person designated as the healthcare power of attorney would be the one who will speak for the patient, if they are unable, to make decisions about their care, Nesbitt said, noting that it’s not an easy job.

“It’s hard because you don’t know for 100% and it’s really an emotional time,” he said.

“And whatever you choose, somebody’s going to say, ‘well, I can’t believe you did that’…and stuff changes. This doctor says things are even better. This doctor says, ‘I don’t know if things are,'” he said.

“So in the midst of all of this stuff you have to make the decision of what would most closely align with what dad would want me to do,” he added.

He explained that many people assume their loved ones know what they want, although they never definitively tell them, which places the burden on that person to make a decision and wonder if that’s really the right one.

It’s also important to designate someone who is able to make those tough decisions as Nesbitt illustrated with a man who didn’t want his kind hearted wife to be his healthcare power of attorney because she was too sweet and would not want to do anything which would end his life.

In choosing someone, Nesbitt suggested thinking about who could speak for you and who do you think would advocate for you in a tough situation.

“It may be a family member, it may not be, but if you have said this is who you want to do it and you’ve written that down and you’ve had a couple of people who have said, yup, I’ve seen that signature, yup she said that’s who she wants. Well, that person is your surrogate decision-maker and has the ability to speak with your voice,” he said.

“And I will tell you in the hospital it’s gold when we have that because sometimes it’s hard. Families are sad. There’s a lot of emotion. There’s a lot of stuff in families,” he added.

By designating that person ahead of time, families know who has been given the authority for making the medical care decisions.

“Really important, if you have people that you know, that you love, that you trust, in some way to think this through ahead of time, and to write it down So to know and have them say, yup, I’m willing to do it. And more than that, to then talk to them about how do you feel about stuff? And this does not mean choosing what tube or machine you want,” he said.

“Like, if I were to say, do you want a feeding tube? She’s smart enough to say, Yeah. Well, it depends. Like, if she gets some bad injury to her throat, she can’t swallow, and she gets feeding tube for six weeks and heals up and gets better and tube comes out, she might say, Well, yeah, but if she’s super bad, she’s never going to wake up and she’s lying there, and we can keep her body alive for a long time with tubes she might say yes, but she might say no if it’s like that, I wouldn’t want that tube,” he said.

“But everybody’s different. Some people are like, as long as I am breathing and I have a heartbeat. I want everything to keep my life going,” he said.

Nesbitt also addressed the POLST (Pennsylvania Orders for Life Sustaining Treatment) document.

“It is a specific set of orders about specific decisions. When it is signed by the patient, if you and I fill this out and we talk and I make sure I know how you think, and we fill it out. It reflects your choice,” he explained.

“Then you sign it to make sure it’s right and I sign it as your physician and then this is an actionable order,” he said.

The key thing to remember about a POLST form, Nesbitt said, is that the document is specific for people who have serious or advanced disease where you would not be surprised if within the next year or two, they’re sick enough to have to be in the hospital to make these decisions.

“It’s not a way-ahead thing to fill out,” he said.

One way it can be misused is if someone has decided that they don’t want extraordinary measures, such as CPR, if they are dying, but then they could end up in a situation where they are not terminal and CPR could be administered to save their lives.

Nesbitt offered one piece of advice in concluding his presentation-don’t assume because you’re in fairly good health that it is not necessary to think about what might happen in the future.

“There’s none of us who know this stuff isn’t going to come up. We don’t know,” he said.