Advance Care Planning with Nina Paletta, M.D.

When a loved one becomes too sick to make their own health care decisions, conversations between families and medical teams become extremely important. Having a patient’s wishes about their future medical care known and documented can help all involved make the right care choices. Nina Paletta, M.D., a primary care physician specializing in internal medicine, shares tips to help everyone start thinking out their own advance care planning.

“Start talking to your family today about what you would want your health care to look like, even if you are healthy. Even if there is nothing going wrong. Even if everybody is totally fine. Start thinking now about what you would want for your health care and start these conversations with your family now, before it's an emergency, rather than when it's too late.”

—Nina Paletta, M.D.

Topics Covered in This Show

• Paletta says that it’s best to have discussions about future medical care decisions with either your family or your primary care doctor during times of good health.
• She explains that advance care planning discussions often include end of life decisions such as whether or not someone would want CPR, life support or special medication to extend life. Those decisions are then recorded into a legal document called an advance directive.
• Another part of advance care planning includes identifying someone in your life as your medical power of attorney and letting them know you want them to take on this responsibility. If your medical power of attorney will be someone other than next of kin, she says it’s extremely important to put that in writing as soon as possible.
• Family can have as little or as much involvement in decision making as you want, Paletta says. Some patients will want their family involved in each discussion and others will make the decisions themselves to then be relayed to the family. Paletta says that both are good options and it’s very important to respect those wishes.
• If you’re worried about a family member who is aging or ill and want them to start advanced care planning, she says you can introduce the topic during a visit with a primary care doctor. Paletta says primary care doctors are trained to help facilitate these conversations, but warns that it might still be a difficult discussion to have.

Read the Show Transcript

Erin Spain [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. When a loved one becomes too sick to make their own health care decisions, conversations between families and medical teams become extremely important. Here to discuss how to be better prepared for these difficult conversations is Dr. Nina Paletta, a primary care physician specializing in internal medicine here at MUSC Health. Welcome to the show.

Nina Paletta, M.D. [00:00:41] Hi, it's a pleasure to be here.

Erin Spain [00:00:43] Thank you for being here. You often treat patients with complex medical conditions. Tell me about your work and how important it is to you that your patients have a treatment plan that includes some thought about advance care planning.

Nina Paletta, M.D. [00:00:58] Advance care planning is something that is very, very near and dear to my heart. Based off of some of the experiences that I had when I was doing hospitalist medicine work, it is so, so important to have these discussions early with patients either in a office setting or in a family setting. It doesn't really matter. But having these kind of health care goals established early is so imperative to comprehensive and just good quality of life medical care.

Erin Spain [00:01:33] This isn't a topic that people really like to talk about. Thinking about the fact that that could be at the end of their life or if they experience some sort of catastrophic health event. But why is it so important that these conversations need to take place?

Nina Paletta, M.D. [00:01:46] Yeah. Nobody likes to have these conversations. And I know when I bring it up to my patients in clinic, it's not always the most fun conversation to have, but it is so, so important. I have had this conversation with too, too many patients' families in the hospital when it was too late. A catastrophic event happened and, you know, now the family has to deal with the complete and utter grief of that event happening. But then they also have to make these snap medical decisions for their loved one when they are just completely thrown for a loop. And if these conversations aren't had ahead of time, it can lead to so much, for lack of a better word, chaos in an already chaotic time. And you can really lose precious time with medical decision-making if these things aren't already in place. So having these conversations early, although not always fun, is one of the most important things that you can do for your health.

Erin Spain [00:02:52] So walk me through this. Walk me through a typical conversation that you have with one of your patients. And what do you hope to see happen at the end of that conversation?

Nina Paletta, M.D. [00:03:00] I like to have these conversations in my clinic rather than in the hospital when something bad has already happened. So my favorite types of advance care conversations happen when we are sitting in my office. There is nothing going wrong. My patients are healthy and we just have a little conversation and I talk about advance care planning with each and every one of my patients at their yearly annual wellness visit. There's kind of two prongs to this. So there's the obvious end of life care that, you know, most people think about when they hear in advance directives. So those are things like, would you want resuscitated, would you want CPR, cardiopulmonary resuscitation? If you are unable to breathe on your own, would you want somebody to put you on life support, meaning put a tube down your throat and hook you up to the breathing machines? That's the most obvious. And, you know, a lot of people don't necessarily think about that or if they have thought about it, it's oh, well, I've seen that done on TV. Yeah, let's do it. But they don't necessarily think about how violent it can really be. So, you know, we kind of have realistic discussions about resuscitation and what it looks like in the real world. In addition to that, there is a lot of medical decision-making that happens after a catastrophic event that most people have no idea about. Things like, would you want medications to help keep your blood pressure up if it was tanking? Would you want artificial nutrition? Would you want IV fluids to help support your blood pressure or if you were dehydrated, to give yourself that extra boost? Things of that nature that fall by the wayside. But it's really important to know what you would want done to help prolong your care. So we kind of touch on those things as well. The last thing that I really like to focus on with my patients is making sure that they not only have a medical power of attorney that they've identified, but they've also had these conversations with them. So their medical care proxy knows that, A, they are responsible for this person's medical decisions and they are OK with that. And B, they would know what to say in that situation. So there's a lot of different things to kind of consider. And the conversations that I have with my patients initially are kind of just to scratch the surface, to get those juices flowing, to start that patient thinking on what they would want. And then really the work for advance care planning comes later when we bring in the family and start those conversations with the patient and their families.

Erin Spain [00:05:37] So tell me the role that the family plays when it comes time when you have to start making some decisions and let's say they do have a plan in place, the patient.

Nina Paletta, M.D. [00:05:47] So it really is different for every patient on how much family involvement they have. Obviously, it is very, very important for patients to have the support of their family because usually their medical power of attorney comes from somebody in their family. Patients having the support of their family and being able to have this conversation with them and kind of get their opinion on things also can kind of help make realistic decisions and kind of make it a little bit less emotionally charged in some cases where we can have a rational conversation about the patient's health. In other cases, sometimes the patient would rather make these decisions on their own and just tell everybody like it is, and I respect that as well. So whether or not the patient's family is involved or how much they're involved is really dependent on your patient. And it's very, very important to respect what they want.

Erin Spain [00:06:41] You were talking about an advance directive, which is really a legal document. Tell me about that and what happens with that document after you fill one out and when is it pulled out?

Nina Paletta, M.D. [00:06:54] So an advance directive is the legal documentation basically laying out everything that I had already talked about. You can do this through a lawyer, and lawyers usually have these very, very detailed forms that goes through all of these different medical scenarios where you can put down exactly how you would want your care to be. But you don't necessarily need to go through a lawyer. In the state of South Carolina, you can get the advance directive form off of several different places. And the MUSC website actually has a link to the advance directive for South Carolina, as well as the form for the medical power of attorney. And you don't even need an appointment with a lawyer. All you need is someone to notarize it with a witness signature. So you don't need to pay exorbitant amounts of legal fees unless you want to. Having a notarized advance directive is extremely important, especially in the scenario where a power of attorney or medical proxy is not next of kin or a family member. So let's say mom was very, very close with her best friend. They got very close over the years. Dad died and she really wanted her friend to make the decisions for her so that it didn't fall to the burden of her children. And she really felt strongly about that. And in that scenario, it would be extremely, extremely imperative for her to put that in writing, because typically speaking, in the hospital, if there isn't anybody designated in writing, it defaults to next of kin. So that is an instance where having that in writing would be extremely, extremely important. Not everybody has those kind of circumstances. So if mom wants dad or her oldest child to be making these decisions, it's nice to have it in writing because that means that there is absolutely no confusion, but it might not be as necessary as a specialized circumstance.

Erin Spain [00:08:55] Now you can have all these things in writing, but sometimes there's still gray areas, isn't that right?

Nina Paletta, M.D. [00:09:00] Absolutely. And not only are there gray areas, but things can change over time as well. So an advance directive isn't necessarily something that is set in stone and you can change your mind at any given time, which is why it's so important to not only have these conversations early, but to continue to have them throughout the course of your life. So what I usually recommend is any time you have a new medical diagnosis, if you've been to the hospital, if your health is deteriorating or just every, I'd say, at least every year, come back and revisit what your wishes are. And if things are unclear, if things have changed, if your quality of life has changed, and you say, "Nope, I don't want anything that I wanted before, let's change it." Easy peasy. We go in, we make the changes. That is not anything that needs to be worried about.

Erin Spain [00:09:57] We're talking about people doing this for themselves, that they have their own plan in place. But sometimes it may be a family member that you feel responsible for and you would like them to get an advance directive or to start a care plan. How should people approach that conversation with a loved one, for example, an elderly family member?

Nina Paletta, M.D. [00:10:17] That is a great question. And a lot of times that's kind of the scenario that I deal with. I have somebody come in and they say, "Oh, Mom's getting older. She has a lot of medical problems. We need to talk about this, but I don't know how." And that is a fantastic time to bring in your primary care doctor. We have the ability to sit down with you and bridge the gap in this conversation to get it started to start thinking about things. Now, that being said, just because we start the conversation doesn't necessarily mean that everybody would be open to it at first. That is why it is extremely important to start these conversations as early as possible so that people have time to not only come to grips with the fact that we have to have these conversations, but also to talk with family members, to continue to look things up, to do their own research, to really think about their medical care, about their medical conditions, about their own quality of life, and how that factors in to what kind of treatment they would want in the future. This is not a sprint. This is a marathon of a conversation. And really, in all honesty, the only way to start it is to just start, bring it up, say, "Hey, have you ever thought about what you would want if the worst were to happen?" And you might be met with a little bit of resistance, like, "Oh, why would you even say that? What's going on?" But in the end, that is what needs to happen, and that is the doorway that you are opening to help them make their decisions.

Erin Spain [00:11:53] So as we've been talking about, having this plan and having an advanced directive is critical to making sure that, you know, your wishes are met if you are at the end of your life. And then let's shift gears a little bit and talk about end-of-life care. What is end-of-life care?

Nina Paletta, M.D. [00:12:10] That is a fantastic question. So end-of-life care basically means that you are looking at the quality of life for the patient at the end of their life. OK. So it is inevitable everybody will get to this point where either we age, we have medical problems that will take us to the point where we are not living like we used to and having the medical care at the end of your life to not only make the most of the time that you have left, make sure that your quality of life is what you want it to be, and make sure that you and your family are both supported through this next little phase is so important. Now, there's a few different things that we can consider with end-of-life care. One is something called palliative care. So palliative care is a relatively new branch of medicine. It really focuses on the management of symptoms and quality of life in patients with chronic medical conditions. So if people hear palliative care and they automatically think hospice, which fair that is an arm of hospice. However, I have plenty of patients who got established with palliative care early in their life because they have a chronic medical condition that they'll be dealing with forever. For example, my heart failure patients, they can be diagnosed with heart failure as early as in their thirties or forties. That's something that's going to follow them for the rest of their life. However, having a palliative care specialist on board will make sure that not only are their medications good for them, they're working for them instead of against them, but also their quality of life and how they're living is what they want it to be, that they're not just going from doctor's appointment to doctor's appointment, going on several different medications that might just make them feel worse rather than actually helping them, even though that is what the guidelines may say. So it's really about keeping the patient at the heart of the decision making that is the key to palliative care. Separate that now from hospice care. Hospice care does include palliative care to an extent. However, hospice care is more about whether there is a finite amount of time that we have left and how do we support the patient and the family through the transition to the end of their life. Now, hospice not only does things like medication to help with pain and anxiety at the end of somebody's life, but they also have incredible, incredible resources. Hospice nurses can come to the house if there's any questions, if there's any change in status. They have a fantastic resource line that's available 24/7 where if you have any questions about anything, you can give it a call. The patient does not need to be immediately dying to have hospice care. Typically, we engage hospice care if the patient has about a projected lifespan of about six months or less. Does that always happen? No. I had a patient when I was in residency. She was 93 years old. She had newly diagnosed lung cancer. We weren't going to treat her because we figured that the chemotherapy would make her feel worse. And she said, “Let's get hospice in here and we'll see what happens.” She lived another three years on hospice. They actually dismissed her from hospice because she was doing so well. So just because we bring in hospice doesn't necessarily mean that's the end. That's what a lot of people unfortunately think when they hear hospice. Hospice really is a fantastic set of resources for patients who have terminal illnesses. And it really is something that I wish that more people took advantage of as having that resource in their back pocket.

Erin Spain [00:16:00] This is valuable information for listeners. And before we wrap up today, I would like you to think if there's just one thing that someone listening will remember from the conversation today, what would you like that to be?

Nina Paletta, M.D. [00:16:11] If you don't hear anything else, it's talk to your family. Start these conversations, as awkward and as uncomfortable as it might be. Start talking to your family today about what you would want your health care to look like, even if you are healthy. Even if there is nothing going wrong. Even if everybody is totally fine. Start thinking now about what you would want for your health care and start these conversations with your family now before it's an emergency rather than when it's too late.

Erin Spain [00:16:48] I want to ask you the question that we ask everyone on this podcast. What do you do to optimize your health and live well?

Nina Paletta, M.D. [00:16:54] Well, that's definitely an ongoing battle for me. So one of the things that I have been trying to do is find balance with my work and my health because I know that I do put a lot into my patients and my practice and finding that balance, that work-life balance for me has been very, very important and something that I have been really, really working to find. My husband and I just came up on our first year of marriage and we are finding ways to be healthy together. We like to go on walks with our dogs together. We really try to find new ways to make healthy meals together, to really help keep each other accountable for our health, as well as also to, you know, spend a little time together. And enjoy our life together. So that's kind of where… where we're at with our dual health journey.

Erin Spain [00:17:43] I love it. No, that's always the thing balance.

Nina Paletta, M.D. [00:17:46] Yeah, I need to find some time. So, you know, nobody's perfect. We all are trying to find it and it's definitely something that we're working on.

Erin Spain [00:17:55] Well, thank you so much for coming on the show and telling us about this sometimes tricky conversation that we're encouraging folks to have. We really appreciate it.

Nina Paletta, M.D. [00:18:04] Thank you for having me. This has been wonderful.

Erin Spain [00:18:12] For more information on this podcast, check out advance.muschealth.org.