 Okay, you're going to go first? Yeah. So welcome, everyone. This is a series called Caring Conversations, sponsored by the Amherst Senior Center. And it really grew out of a number of questions that we received that were prompted by COVID and the current pandemic. The focus is really on medical care planning and how to have difficult conversations and support people in terms of making their wishes actually concrete and settled into a plan. So today's conversation is called Aging and Medical Care Planning, and I am thrilled to have with me Attorney Anita Sorrow, who comes with a significant amount of expertise and is with me today. We're going to cover several topics, including healthcare proxies, living wills, and the most form. So welcome, Anita. How are you doing today? Very good. Thank you, Mary Beth, for asking me to be part of this presentation. There are topics that are very important to me, especially because my interest in healthcare has been a constant for most of my life, ever since I had my appendix out when I was 11 and was fascinated by the nurses and doctors who took care of me. And that experience stayed with me. And from the time I put my first candy striper uniform on at age 16, I knew that my life would be spent in some relationship with healthcare. First through as a lab technologist and then as a nurse and then as a healthcare lawyer, advising health and related facilities and practices. I've always been in and around the prevention and treatment of illness. A significant part of my practice, always especially as a healthcare lawyer and then as a risk manager in a large multi-hospital system, has centered a lot on the law and ethics in particular of treatment decisions and what they mean, what is the interaction of treating team and patients and where our relative roles and responsibilities. And as a daughter, as a wife, as a mother, as a grandmother, I have at times been personally involved in making those decisions or supporting the people who have to make those hard decisions for others. So I come at this as both from a professional and a very personal frame of reference. But all of those experiences cumulatively have strengthened my commitment to help others to be full participants in their own healthcare. So before we start, Mary Beth, you had some preliminary thoughts on this process and of this recording and our presentation. Yes. So before we go much further, your screen is shaking a little bit. So just bring that to your attention. So we're all new to the technology. I have mine on several dictionaries. So we're trying to do. I'm using Yahtzee and Mahjong. It looks like to probably. Here we are at Senior Center. The best way we can, the only way we can use our games right now to support us. But thank you so much, Anita, because I think that that's been one of the most interesting parts of working with you on this project with your significant medical care background and the way in which you see it from all of those angles as someone who participated in the medical care system as an attorney and risk management. And also as someone who's accessed and had to utilize medical care yourself and with your family. So I really appreciate the wealth of your piece and how you're bringing it all together and sharing that with our community. One of the things I just wanted to emphasize at the outset when we were discussing this topic to share with individuals is to make sure that folks understood that though we are both attorneys, that in this conversation, you do not need medical expertise nor do you need to be an attorney to follow what we're going to explain about how to execute a healthcare proxy or to make a living will. So some people choose to go to an attorney for those purposes, but you do not need to. These are very simple documents and that anybody could do this and execute them with a few minutes of attention. So this is gonna be a really simple process. And so for people who may not know me, I am the director of senior services for the town of Amherst and I'm also an attorney and a social worker. So my practice with regard to this area of law is that I represented hospitals and other behavioral health facilities when an individual came from medical care and might have been looking either at some dire circumstances where they lacked capacity and didn't have the ability to communicate healthcare decisions or they were near the end of life and also couldn't communicate. And so the hospital would hire me to obtain a guardian for an individual. So when I took this job, one of my significant goals was to get people to execute healthcare proxies because it allows you to have control over your decision. And that's really the hope, the earnest hope that we have for this presentation and really emphasizing that though we're both attorneys, this doesn't require some special knowledge. And with regard to guidelines, I'm gonna just shift to share screen here if I can do this right. Here we go. There we are. And there you are as well. Great. And I just want to go into slideshow, play from start. So here's the topic of aging and medical care planning and just a few guidelines for people who might be following along, whether you're listening at home on Amherst media or you're listening live. If you're listening live, please mute yourself. Also, we have a PowerPoint that we've prepared and we certainly would make that available to anyone who might be interested. We will reference forms, both the healthcare proxy and a living will and the Amherst Senior Center, if you contact us at 259-3060, we will make sure that we share all of those forms with you, whether you pick them up or we mail them. And by participating, if you come in live and you wanna ask a question, you are agreeing to being recorded. For questions, raise your hand or type in the chat box or you can dial star nine if you're listening on the phone and that this is an educational presentation. It's not intended to serve as legal advice. So we are both here with backgrounds in this field but this is not intended as legal advice. So those are just some of the quick guidelines around the presentation. And in terms of our introductions, is there anything that you'd like to add, Anita, about what brings you to this presentation? Yeah, it's really more about what context we'll really be talking in. I had said that my interest is to encourage people to be active participants in their own healthcare. And there is a role that a provider has and a role that we as patients have. The provider's role is to give us information and our responsibility is to accept or reject the offered treatment. So in the old days where there was absolute trust in physicians, they would say you need an operation and you need your appendix out and people would not question that. Well, certainly the world has changed if this is talk about patient autonomy. It's part of our basic human right to be able to have a choice about what treatment that we have. So there's a legal and an ethical and a moral underpinning for what we talk about because it all comes out of patient choice. So when you're fully engaged in the process, you can give your consent or reject treatment. What we'll be talking about are tools that you can use when you can't fully engage in that process, when you have to rely on someone else and you wanna make sure that the person that you choose is right, the who is right and that you've given that person who is going to make the decisions who will speak with your voice, that they have all the information that they need from you ahead of time to form that response to what the treatment is offered. So this'll make sense a little bit more as we go along but we'll be talking about all over, how can you speak for yourself when you're no longer able to fully engage in the process? So the first one we'll talk about. And again, I echo what Mary Beth said, we both happen to be lawyers, you do not need a lawyer for any of these. We'll, we can talk about it at the other end who you might need for different steps along the way. But first let's go to healthcare proxy, Mary Beth. Great. So what is a healthcare proxy? I think it's a phrase that many of us are familiar with and we think of it as a substitute decision maker. So it is a powerful tool because it empowers you to decide who is it that will make my decisions if I am unable. And I think that that's, when you mentioned patient autonomy and human dignity, I think we often are uncomfortable to talk about those times where we may not have full control. And what I would like to suggest to people is that this is a tool that will give you control even if you are unable to communicate because you choose through that document, somebody, yourself, not a court, not a guardian or some other, it could be a stranger, you're choosing someone to make your healthcare decisions only for when you lack capacity and you're unable to communicate. And so it is a very limited scope of authority. So what people often ask, oh, if I execute a healthcare proxy, I don't want somebody to second guess me while I'm still well. And I wanna make sure that people also understand that a healthcare, the person you appoint is called the healthcare agent and they are empowered to make decisions only after a physician, a treating physician has determined that you lack capacity and you're unable to communicate those decisions. And that that scope of authority ends as soon as you may regain capacity. So you might go in for a procedure and something happens, you're unable to communicate for a brief period of time. Your healthcare agent that you appoint steps in only during that time. And then when you regain capacity or you become better after surgery and whatever might be ailing you, you regain that full power. So it can be a temporary execution of that authority. It doesn't necessarily mean you're giving everything away. So as long as you're well, you are still in charge of all of your healthcare decisions. This is only a tool for when you're unable to communicate. Anything that you wanna add to that about what it is? And you know, you said it all. I think the most important issue is the difference sometimes people will be concerned that lack of capacity is the same as being declared incompetent. And as Mary Beth pointed out, there really two very, very different things. A physician will make the decision about whether you lack capacity. And what that really means is that at that time for that decision, you are unable to fully appreciate and fully engage in that discussion. Capacity, as Mary Beth pointed out, can come and go. Confidence is something very different. It's not just a medical decision. It's a legal decision. It is the loss of some significant abilities. This is much different. It is focused only on healthcare decisions and only for those times when you are unable to fully engage and understand the process. Great. So folks ask often, why do I need a healthcare proxy? I can make my own decisions. And if I'm not well, my family can step in. And I wanna sort of disabuse people of that notion of your family can automatically step in because in Massachusetts, if you do lack capacity to express your decisions or if you don't have a healthcare proxy, depending on the circumstances and the nature of the emergency, what would happen is the healthcare provider would seek a guardian to make those decisions for you because there has to be legal authority to make medical care decisions. Though some states have family fallback provisions where a family member can in fact step in and they look to family. But in Massachusetts, if you lack capacity, they will want to have somebody who has the legal authority to make those medical care decisions. And that's really given to the hospital through two ways. The legal authority is either through a healthcare proxy or through a guardian. So it is a far better course of action to plan and choose the person that you want and someone you feel comfortable with. So that's really my why. Whenever I ask people to engage in some kind of planning I think it's important to understand the why. And again, this is about giving you more power and control over those circumstances where you may not have the ability to make your own decisions. And so you are actually able to control that to the extent that you're naming the person and that person can be made familiar with what you want to do. You know, it's interesting the background and why we, I'm old enough to remember pre-healthcare proxy days. And it goes back to the 1980s. And we really owe a debt to the gay and lesbian community of the time because they're the ones who really clarify the issue that regardless of what relationship you're in, just because there's a parent, particularly for people who were not married at that time, you know, their parents often they were estranged from them. We all have broken, may have broken relationships in their lives in the pre-healthcare proxy days. If it was a single adult, we would look to the parent. If they were married, we would automatically look to the spouse. And sometimes just because they were next of kin, they were not really the best ones to speak for the patient. So the origin of this healthcare proxy was to say, no, while I'm awake, while I'm fully conscious, I know the relationships that are important to me. And I know the people who can speak for me much better than those you assume, like my parent, like my spouse, like my sister, let me choose. And that was really why we got this law. So we should all take advantage of it because regardless how traditional our lives are, we know the people who we're closest with, regardless of relationship. Yeah, in risk management, you must have dealt with a number of cases, certainly for individuals who were in critical care or had to make critical medical decisions and there was no healthcare proxy in place, I would imagine. Yeah. Even after, and especially after this law was made in Massachusetts, it just makes life so much easier for everybody, so much easier for the treatment team. It just clarifies things. It's really a simple thing to do and probably the most important thing we can do. Yeah. Okay, let me. So who needs a healthcare proxy? Though this is presented for our seniors within the community, certainly anybody who's watching this, what we would echo, and I think that Dr. Aaron Salvador spoke to also in this series, is that anyone over 18 years old should have a healthcare proxy. And regardless of health status, this is the kind of document that you ideally should execute at any point at which you are healthy and well and anticipating an event in advance. So it isn't necessarily an end of life care decision or an emergency situation that should cause you to name the healthcare proxy. It's best to have this in place when you have all of your faculties and you're really in a calm place to make those kinds of decisions. Who should you appoint? I know we and I in preparation, we talked a lot about who makes a good healthcare agent. So certainly we would suggest that the nature of this role is that someone is a substitute decision maker. And then really the key word there is substitute and that they are substituting not their opinion for how you should be cared for, but what is your opinion? So it is really important to make sure that you choose someone who can set aside their own feelings, their own opinions about healthcare or treatment decisions. And someone who wants to critically listen and take in all of your information and follow your wishes, regardless of what their opinion is about them. So that's the one thing that we really wanted to suggest to folks is making sure that it's someone who can set aside opinions, probably also somebody who can work well with a medical treatment team who can listen to medical information. And also has the ability to make hard decisions. I've had a number of cases where there was a healthcare agent and healthcare agent given the critical nature of what was unfolding medically decided they didn't wanna serve anymore. So you wanna make sure that it's somebody who can take in that kind of situation and make those kinds of decisions. The form allows you to name an alternate and the alternate is really in case that agent is unavailable or unwilling. So perhaps your agent could be traveling unavailable for other reasons. Or again, as I illustrated in that other case, sometimes an agent is just unwilling to continue to perform the service. Anything that you'd like to add for that? Anita, anything? Yeah, I think these are two absolutely critical points. Especially the one about A1 over 18. I often remind people, especially my fellow lawyers, that the really national seminal case about substituted judgment involved a young woman, Karen Ann Quinlan, in New Jersey. And she was in her 20s. And the issue of who was the right person to make the decision and what that decision should be and how her life informed that decision was what really started this conversation around substituted decision-making. So it's really important. I mean, if any of this information is helpful for you, and I hope all of you, if you don't have a healthcare proxy, we'll have one tomorrow. Talk to your younger friends and family about it too. It's every bit as important to their well-being as it is to us all folks. Yeah, yeah. And especially college age kids who are going off to school right now, if the parents are transporting 18 and 19 year olds, make sure your college students have them too. So if you have a grandchild, that's a great reason to give them a call or shoot them a text and say, hey, did you execute that? So when does the healthcare agent have the authority to make decisions? And again, trying to make people feel comfortable about this process and it's not like you're giving away all of your autonomy. It is only when a medical provider determines that you lack capacity or you're unable to communicate and it's revoked. So it's just for that period of time on which you do not have the capacity to communicate and to make your decisions. And as you began to speak about what capacity is and it's the ability to understand, appreciate the nature and the consequences of healthcare decisions, including risks and benefits, understanding alternative treatments. So it's not as if a treating physician administers a test and says, oh, you lack capacity. They do, I kind of think it was a global assessment about your ability to take in facts as they're explaining things. Can you appreciate the consequences if they describe alternative treatment plans and are you able to take in that information, understand it and really weigh risks and benefits? That's what they look for sort of evidence of. And also that then the ability to communicate that and communication can be through variety of forms. So it's not just the ability to speak. Physicians have used other methods to determine that. So. What's important about that statement too is in the beginning I talked about, that we have a responsibility as patients to accept or reject or offer treatment. But the treatment team and physician has the responsibility to give us all the information. And this kind of gets at that. What do we need to know? What is being offered? Why it's being offered? What the risks are? What the benefits are? Are there alternative treatments? And what happens if we say no to everything? What's the outcome? So that's their responsibility. And it's our ability to require that kind of information. So even, you know, whether it's you or your healthcare agent facing a decision, the more complex, the more information that you want and the more you can press to say, I don't quite understand. Can you give me a little bit more information? What happens if I say no to that but yes to that? It should be a two-way street. And you just don't have to say yes or no if you feel that you lack information. So, you know, that's my global advice on making healthcare decisions for everybody. Great. So what are the essential requirements? And again, we've explained that it's a very simple form. We will share the form. We have it here at the Senior Center. People can also Google it. It's located, we really like the form that Bay State Healthcare provides on their website. So one-page document, but basically, it is that you would have, you name your agent, you can name alternates if you want, and that you have to have two witnesses to sign off. And one critical piece is that the witnesses have to sign the same date as you. And I know that has come up in a number of cases that I've had where the person signed one day and then the witnesses signed the next day and the court determined that that document was void because really what those two witnesses are attesting to or signifying with their signature is that you are at least 18 years old, that you have sound mind and no one has exerted undue influence on you. In other words, someone is impressing you to name a particular child or suggesting mom sign this because I really wanna be your healthcare proxy. That it's something that you are determining all on your own. In terms of sound mind, there is no necessary sort of medical determination of it. It's just the objective view of the person who is a witness. And we wanna make sure that what that really entails is that you have the capacity to execute that healthcare proxy. So sometimes people execute the healthcare proxy in the course of a hospitalization. So it could be, you know, you could still be being treated and you're about to go for surgery and if you didn't have the healthcare proxy executed, you might be signing it in that circumstance but we're really urging people to do is to take this time while you are well and sign that document, appoint somebody that you think could make your substituted decisions and then have two witnesses to sign at the same time that you're executing it. And those witnesses, the only thing is that they cannot be the same person that you're appointing to be your healthcare agent. So if I was appointing a needed to be my healthcare agent, she cannot sign as a witness that there's an inherent conflict in that. But and if you need assistance to execute the healthcare proxy, again, the senior center, we are willing to work with you. We can do execution outside with social distance. So our social workers know many of you and we're happy to serve as witnesses. So those are the essential pieces that we would be looking for to make sure that it's a valid healthcare proxy. Anything that you'd like to add, Anita? No, I think we have covered it very well and just please, you know, notice that there is not any mention at all of a lawyer. Right. So just remember, this is something that's within your power to do. You just have to grab a couple of people and to put it together once you've identified the healthcare agent. So there's no excuse, I guess is what I'm saying. And that the witnesses don't have to be attorneys or anybody with special expertise about medical background, sound mind. It's just what are we familiar with that term and what does that mean? So recommendations, just a few tips from us about when we said, geez, what should people know about this process? Most importantly, to make sure that you inform the healthcare agent that you've appointed them. So some forms have a page that is optional where they ask you to have the healthcare agent sign on the back that they know about it. I wouldn't go to that extent, especially during this time period we're getting people together to sign things and you might be appointing somebody who's not even in the same jurisdiction as you. It's just gonna, I think make it more complicated but make sure you talk to them and tell them. Right. Discuss your healthcare decisions with your healthcare agent. There's an entire conversation that we've recorded with Dr. Erin Salvador where she walks us through the process of determining how do you decide what's important to you and to have that conversation with the people who matter to you and love you. And then share the healthcare proxy with your primary care doctor, treating specialists, any healthcare workers that you have who come into your home, your family. We suggest putting it somewhere where it would be noted on a refrigerator or a bulletin board or by the phone because I've also had a number of cases where folks were in the hospital and everyone said, oh, mom executed a healthcare proxy but nobody can locate it. So we need to have it. So you can give copies to all of those persons that you have contact with. So that if something happens, somebody has that copy because that would be really critical. And is there, there's something, would you like to expound Anita about either informing the healthcare agent or discussing it, discussing decisions with the healthcare agent because I know we had a robust conversation. Yeah. And I think it, I mean, we both have horror stories to share, I'm sure where somebody is called and they said, well, you're the healthcare agent and they have no idea what you're talking about. And then there are some very difficult decisions that they have to make. But this is kind of a good segue into the second topic. So maybe if we go to the next slide. Down there, go to this one. Okay, yeah. Yeah, we can do this one because I think we could go back to the FAQs if you want to. But I think we've covered pretty much all of them anyway. So, you know, we've talked about the who and now there's kind of the what. How do we fully prepare those people who we're giving this very important responsibility to? And there are some states like Connecticut that have a legal living will. They're called living will states. They have a specific law that controls it. Massachusetts doesn't. We're a healthcare proxy state. But that doesn't stop us from writing the things that are important to us. Now, just as we talked about, it's important to talk with our healthcare agent. And I would include not just your healthcare agent but other people who love you, who care about you. They need to hear the same thing. It's interesting just to share a little bit from my own story and my mother who's now deceased. It's just my sister and me. And my mother has always kind of looked to me as the older daughter. I've, you know, because of my background, my sister is a brilliant art historian, but it's kind of a different environment. So we always knew that it was going to be me. And I had a sense of who she was, what she valued in life. But we hadn't really talked about anything specific. But there was one Christmas and it was the end of the day and all of the family had left. And it was just the three of us. And it was one of those quiet evenings where you're gonna have just one last cookie. And somehow we got onto the topic of end of life decisions. And she was able to talk and to, not get very highly specific things, but I was so grateful for that time because not just I, but my sister, heard her words about wanting to be comfortable, that she was okay with things that, you know, I mean, she just talked about her values, what she wished for, that she wanted it to be a quiet death. And thank God she got that. But it was important to have that conversation. Now, she never put anything in writing. But fortunately, you know, my sister and I had that time. And one of the things about the value of having a healthcare proxy and the pitch times, if you don't prepare that age and as well as you could, is if you have several children and you select one, you don't want a situation where two are ganging up on three and arguing about what to do with mom or that one gets resentful. And why did she pick that one and not me? So hapless conversations, if you have more than one child, have that conversation, not just with the one that you've chosen at your age and maybe you're an alternate agent as well, but talk to the other ones too. Talk to the people who might expect to be part of any of these difficult decisions. Tell them what you'd want and tell them why you're picking this child. And that doesn't mean that you don't love the other ones as much, but why you feel that, you know, this is the person to do it. That's a real gift that you can do if you have more than one child, a real gift. I would just emphasize what you just said because the family dynamics and how they play out at the end of life, I think get exacerbated and any sort of fissures are replayed and everybody sort of reduces behavior I've seen. So I think that that's, you know, if you take nothing away from this, take that, take that message. That's brilliant. Yeah. Absolutely. We all become five years old in times of crisis and mommy wants to, you know, we want to believe that mommy loves us best. So if there's any reminder, it's pretty bad. So that was the way that I received the comfort. I knew my mother. I knew again, her values, her worldview, her faith and what it meant to her and her gentleness. So I, both my sister and I felt empowered. But sometimes it and in fact, I speak to myself in this, it's helpful to have something in writing too. And even though we're not a state that officially recommends a living will, some writing, any writing, it could be a letter because there's no legal definition really of Massachusetts. What you're talking about is your belief system. Again, your faith to the extent that you have one, there's no special form to it. You don't need any witnesses. This is something highly personal. It's where you can express your thoughts and wishes about medical treatment that you might face. But don't worry about being precise. Don't worry about checklist so much. There's time, there are ways of doing that as well. But if you can think of examples, if you can think of stories, if you can think of what is important to you. In the Jewish tradition, there is a revival of the ethical will where you write to your descendants to your children and grandchildren to say, this is how I live my life. This is what I felt important. I think a lot of what you may have heard from Dr. Salvador and other people in this series about what's important to you. What is the thing that makes you feel fully alive? And for my mother, it was holding her grandchild. And if she couldn't do that, that was something important. So things like that fill in the blanks, give us much information. This is such vital comforting information that you could give to your healthcare agent and believe me, the treatment team would welcome that too. So again, it doesn't have to be all in one sitting. It doesn't have to be pretty. But write what's in your heart. So write it, sign it, date it, because it's you. It's just like, you know, in the old days when we wrote letters and we would put the date on the top and sign it and share it. Share it with your healthcare agent. Share it with other people who you love. Given that gift now, really, you know, and talk to them. Use it as a tool. There are official things out there. There's one instrument called Five Wishes. It's available online. It costs some money. There's good stuff in there. And I always see lists like that. There were also free ones on the internet. I find them helpful, not as a checklist, but as a point of discussion that you can have. And that was really what happened among my sister and me and my mother because I didn't have a list in front of me, but I had kind of examples in my head of what to talk about. So, you know, think about those, but don't be concerned about ticking off boxes because we can't predict the future. What we can do is inform the future and give the person who's gonna be making those hard decisions. Give them all the ammunition, all the information that you can think of. And you can do this over time. You know, it doesn't have to be done, as I said in one sitting, but do it over time, you know, and give them the advantage. And that will help them start thinking about their own frame of reference too. So it's helpful to you. It's helpful to the people you're talking about, you know, that you can really start something within your circle of friends or your family very quickly. And would you recommend sharing the living will with health care agents and the family as you suggest in terms of the health care proxy itself? Yes. Definitely. And engage them in those conversations to the extent that you can. But it really does amazing things for the process if people have that. And it's interesting to have a physical thing to hold on and to read and to reread and to come to grips, you know, with very difficult decisions sometimes. Yeah, yeah. I think that what I like most about it is that what you just talked about gives you a physical document to look at and reread because just like medical appointments where so much can happen in the course of 20 minutes and you don't retain it all, I honestly think that the conversations with someone that you deeply love about end of life can be very flooding emotionally. And sometimes four of us are part of that conversation. We will all come away with a different fragment of it, but not the whole thing. And I think that that's what I really like about the living will is it really summarizes and everybody has the same reference point because as someone might be appointed as a health care agent or even as a family member have that discussion. But the point of decision isn't until 10 years later. And what do you remember of a conversation 10 years later? It might be very different or just fragmented. So those of us who are turning, we really do like things written down. Yes, yes. This is a hell. Tangible, tangible evidence. Yeah, yeah, I know, I know. But yeah, it would give you more control. So I'll go to the next screen. So we tried to create, actually Anita created for us this fabulous chart comparing a health care proxy and a living will. So I'll just go through the health care proxy. Again, that's a legal document. So it has legal significance. It's recognized by your medical providers as such, signed by you and two witnesses that appoints the health care agent and it's a substitute decision maker. Someone who's gonna make your choices for you only when you are unable and it will be your choice, your opinion and reflect your choices. And then you want to share the difference with the living will. Yeah, and as we've been saying, it's a voluntary writing. You're the only one who writes it. You're the only one who should sign it and I'd say dated as well. And this is the content. If the health care proxy is the who, the living will is the what. So this describes your wishes, describes your values, describes who you are so that that decision that the decision maker is making is gonna be as fully informed as we can make it ahead of time. Because as I said, we can't look into the future. So we can... Next. Can I just ask one last question about the living will? So we talked about the health care proxy should be shared with medical providers, et cetera. What is your recommendation around sharing the living will other than the health care agent and family members? Is there any, should those other individuals, medical providers have the living will? Or is it just more about the decision making of the living will? You know, if you have, I think of perhaps the, the prime, if you have a primary care practitioner who, I mean, not every, every treater, you know, treating practitioner is maybe receptive to this. But if you have one that you've seen for a while that knows about your health care, that health care proxy, perhaps this is one who you feel you've already had a conversation about this next topic, the medical orders. And if you feel within the context, yeah, I would go ahead. I wouldn't necessarily put it out there because I don't know if it would have an impact on specialists who you have a short-term relationship with, although you never know. You look at your relationships with your treating providers and see which ones. Look, I want them to know me more fully than they know me now because this treating professional may very well be involved in some, you know, difficult decisions. So it's more important that your health care agent and other loved ones know the information that is in that kind of writing. Which is a pretty good segue to the next topic or last topic. And we wanted to talk about this because it is quite different from the other two, has some very specific characteristics and requirements. And right off the bat, right in its title, it's medical orders for life-sustaining treatment. And there's a lot that's piled into those words. It's called a most or sometimes it's a, I forget why it's called a post with a P. I forget what the first word is, I'm so used to most. But it starts with medical orders for life-sustaining treatment. So this is something that has been developed you may have heard of do not resuscitate orders that are sometimes put in place or you're asked if you want one, if you're going into major surgery or anything like that. And that has some effect in some environments and in some contexts. But this was intended particularly in situations where you may have a patient who is on hospice care or palliative care at home. There are situations where maybe, there are usual caregivers and they know that this patient would not want to be transferred to the hospital under certain conditions. But sometimes there are situations where maybe a substitute caregiver is there who doesn't know the patient very well and they panic when that patient goes south. So they call the ambulance. And well, the ambulance is trained to treat, resuscitate, get that patient to the hospital. Well, if that's something that you didn't want to do that even if you told the healthcare agent may not be available right in that minute. And they are, remember that healthcare proxy is your desire who talks up for you. Living will is what you would like to happen but this is a tool for what must happen. And that is a fundamental difference. And that's why it's carved out for very specific situations that it is really for adults. There are some exceptions for children. It's kind of complicated. So we'll leave that for another day. But it's for adults with a current serious condition which usually means an illness or an injury that is advanced and life-threatening. And sometimes the same measure that's used for palliative care or sometimes even for hospice care would it be a surprise if this patient were to expire within the next year or two. It's kind of a measure. So it's around only very specific decisions. It's on resuscitation, cardiopulmonary resuscitation, chest compressions, airway, ventilation. There's a lot of talk about ventilation now because of COVID and ventilators and when to put somebody on the ventilator. And thirdly, the transfer to the hospital. So because this is a medical order and not something that anyone other than a doctor, a nurse practitioner or a physician's assistant can write for you, it must follow discussion. There's a lot of discussion that should precede a most. And it's the ultimate in informed decision-making because it is grounded in what is your current condition? What is the prognosis? What are your goals? What are the treatment preferences? What is important to you? So it's very specific and it's grounded in the now. It's not in the future, it's how do I feel now? There is a very standard form that must be completed and signed by your doctor or nurse practitioner or physician assistant and by you and dated. So I treat these things with a lot of respect. And if you're thinking about this, if you do have a current serious condition and I do not consider aging as a de facto serious current condition that would warrant this, this is something to bring up with preferably your primary care practitioner, someone who knows you the best. So if we can go to the next slide, this is, and I don't expect you to read it, this is what the form looks like and you notice it's a hideous pink and there is a reason for that. So what it has is choices and when we go to the next slide, I can read you the content because there are boxes and these boxes have to have to be filled out. It is an official form and it is something that your doctor will have. So if we go to the next slide, then we can explain what we cannot see on that slide. So what it has, that first page has five sections and the first one is do not resuscitate or attempt to resuscitate. If something happens to you tomorrow and cardiopulmonary resuscitation is a possibility, do you want it or not? Very fundamental issue. Ventilation, where there's a tube that to support you're hooked up to machines. Do not, these are your choices. Do not intubate and ventilate. Do you use non-invasive ventilation, kind of masks rather than something more invasive. Go ahead, give me the full, I want the full menu, intubation and ventilation or I don't want anything. So again, there's not enough time and we are in a position to go into how, what the nuances of these choices are and that's why it needs a full and frank discussion with your primary care physician. And the third thing is to transfer to a hospital and this is why it's ugly pink. Again, what I described, this is a patient who didn't want any of this stuff, certainly didn't want to go into the transfer to a hospital and something happens and there's this effort to get the patient back into the hospital. The point of a most is not only that it exists and it's hidden somewhere, but it's prominently displayed and the refrigerator often is the best place or a door that will just hit somebody in the face because EMTs, ambulance people, others who will come through are used to seeing this now. When these first came out several years ago, they had to be in this ugly pink. Now they can be done, the color doesn't matter. I still prefer that because I think this, something this important that you wanna have prominently displayed, you want it to be something eye-catching. So again, talk to your PCP about this because or if you have a specialist who is treating like a gerontologist, some people will have this conversation and get this in place if they're being treated for some sort of cancer and they're concerned because of the stage of their illness and their prognosis. But this has to be done with people who know what your condition is right now. And as I said, it's signed by the patient, signed by the practitioner and you keep the ugly pink one. The patient who keeps it, okay? She keeps the original. But again, just like we've said, make sure your healthcare agent knows this, you can make copies, you can make a lot of copies so that not only the practitioner who helped you write this and sign this with you, but everyone who might be involved in your care should know this as well. So you keep one, make sure your healthcare agent has a copy and make sure that everybody knows it. And this again is a really good tool to spark conversation with someone who says, so why are you saying this? I don't want you to go, you know? Because those of us who are going to marry a name don't wanna let go. So any kind of information that you can give them to say, it's okay, it's okay to make those decisions. The better off you all are. So we've talked about it. Have I missed anything, Mary-Ann? No, but I think the thing that I would highlight is that the outset is we were framing the discussion of what we were trying to encourage people to do is to execute the healthcare proxy and the living will and noting that those two documents do not require medical or legal expertise. The most is in a different category as you've laid out that it is more about looking more towards end of life and it does require the assistance of a medical provider and that conversation and their signature and they provide that document. So I just wanna make sure that we are differentiating and the reason why we're presenting all three at the same time is I've also had individuals contact me with questions to say, I have a most, I don't need a healthcare proxy. So we really wanted to make sure people understood the use and the execution of all three of them and the different ways in which you approach it. It's part of a long conversation of medical care planning but that the most is really more for that very serious illness looking towards the end of life and does require medical input, expertise and actual execution with you. So healthcare proxy and living will go home and you can do it tonight, tomorrow. The most you're gonna have to wait for a medical appointment and that's a conversation. And do you have any sense? I guess the only other question I had about this for people who might be listening is should they ask a primary care physician to have the conversation around the moles or do you think that at this juncture, many primary care physicians initiate that conversation? So I just, I think people might wonder, geez, do I initiate this? Should I wait for the doctor to initiate it? Because they'll know when I'm approaching the requisite medical condition that would warrant this kind of detailed plan. So I don't- No, it's a good point and it goes back to, you know, my fundamental mantra about being full participants in our healthcare. We should feel comfortable in raising any topic with health professionals. We should be able to say, you know, I just listened to these people talking about moles and I kind of understand and I'm not quite sure. And what do you think? And open up that conversation, you know, be your own healthcare agent in some ways in that, you know, you're entitled to have those conversations and it may be a busy visit and it may not be the time, but you might just say, you know, maybe we can talk about it another time or, you know, I've been thinking about this and they may have more information to give you. Or, you know, what's interesting is that there's some confusion among doctors about how to use this instrument too. About, you know, when to put it in place. So open up the conversation. Even if you don't feel that you're ready for it yet, you know, it all depends on the conversation. You know, the relationship that you have and continue to gather your own information and have discussions with other people maybe in less formal settings. But one thing that I really have to, you know, I've become a broken record, but what's so important about this is that unlike the other two things, this is a medical order and you have to treat it. It's just as if it's a doctor wrote out a prescription and you take it to the pharmacist and the pharmacist has to follow it. If it's ordering a blood pressure medication, the pharmacist can't say, you don't need that. Here's the cerebral supplement. That can happen. What is really fundamental about this is that it is a medical order, which means other healthcare professionals must follow it. And no one, not the healthcare agent, no one else can override the decision that you make on this piece of paper. So that's why and because it takes effect immediately, think about who you are in this moment. And if in this moment something happened and you needed ventilation, COVID's, you know, even in Western Massachusetts is a reality. If you had, if you got COVID, God forbid, and went into a hospital and you had one of these and you had made a choice, it would have to be followed. So please, please, as long as you are no longer conscious. Now that's the other thing. Can it be changed? Of course, you rip it up, you start all over again. But it's not a fluid piece of paper. Think of it as a medical order that goes in place the day that the doctor and you sign it and it is effective and if something happens when you walk out the door, the things that you wish for will happen because they must. So that's the ends of my sermon on most. But it is a difficult concept to wrap our minds around. Like I said, there are even some doctors who struggle with it at the margins. So, you know, I think we just have to keep the conversations going and collect as much information as you can on all of these subjects. To do well by yourself first and by your loved ones second. So this is the wrap up, isn't it? Mm-hmm, here we go. There's a wonderful chart prepared by Anita that really distinguishes each of the three documents that we discussed today. So the healthcare proxy, the living will and the most. Do you wanna go through it or just put it on the screen? What do you think? It's worth, maybe I could take the first couple. You know, just in summary, remember that the healthcare proxy is a legal form. The living will is a voluntary just you form and most is a medical form, as I just said. And when should you make it? This healthcare proxy and living will anytime, right now, do it. And for a most, if you have some serious condition that you have been thinking seriously about end of life, you have been watching the coverage on about COVID and because we're talking a lot more, at least about ventilation than we ever have in the past. So, you know, that requires some thought. But I would not say anytime for that. So you wanna take the next two, Miranda? So what does it do? A healthcare proxy, again, substitute decision maker. So someone who is going to implement your opinions and choices and speak your voice in terms of a living will, that's an opportunity for you to write down and scribe what your desires are, your wishes, your thoughts about quality of life or treatment. And then again, the most is where you are executing and participating and creating medical orders about certain medical treatment. Sometimes we call them extraordinary medical treatment that has to be followed by anyone, including if you had an EMT respond to your house, they're gonna respond and follow the medical order. Who fills it out and signs and dates it? So the healthcare proxy is you and two witnesses. In terms of a living will, something that you will do all on your own and sign and date it. And then the most is one that you will, I'm gonna just move our box of our voices over to the other side of the screen. That would be completed only with the assistance and input and signature of either your doctor, a nurse practitioner or a physician assistant. So that's the one thing about the most is that that does require medical input, but the healthcare proxy and living will, you don't require or need specific assistance. When's it effective? Healthcare proxy is only for that period of time in which you're determined to lack capacity. And again, capacity can come and go. Someone who has, one thing I just wanna really asterisk this is someone might be in early stages of dementia and again, with the assistance maybe of your treating physician that just because you have a diagnosis of dementia does not mean that you necessarily lack capacity to execute a healthcare proxy because there are stages of dementia. So I just wanna make sure people are alert to that and I'm happy those specifics. Living will, it's effective in terms of, it's looked at as guidance or other information. So as soon as you sign it, it would have that import in terms of giving more help to your decision makers about what would be important to you. And then again, I'm gonna just move the screen for where our thumbnails are located. The medical order is immediately effective when you and your physician sign it together. So, and then you wanna follow up with the last two. Sure, you know, as we've been saying, it's always good to keep the originals of all of these in a prominent place. And especially as I said, about the most. And also the other documents too, they don't all have to be on the refrigerator but near the myosate. So, you know, and then people know how to, where you've put them, if you haven't gotten a chance to give them copies. But it would be good to make sure that those people who are prominent in your life have copies. Can you change your mind? Yes, on all of these things, you can change your mind. But what is critically important is, if you make a change in your healthcare agent makes, because that's a legal form, destroy that first one after you've signed a new one, always state these forms. Because if for some reason a copy of an earlier healthcare proxy still exists, the fact that you have a second subsequently signed one that has a later date, that's gonna be the one that controls the situation. So for any of these, dating is most important for most and for healthcare proxy, less so for living well. But you can certainly, I would not necessarily, unless you have a real change of mind, I wouldn't necessarily worry about ripping up a prior writing, but you might wanna add to it. So again, the dates are important. And we can certainly make this table available as a resource at the senior center, couldn't we make more online copies of that separately? Because I think it does encapsulate and it at least helps me keep things straight in my mind. As I was writing it up, I found that, yeah, now I think better in columns sometimes. And one thing I'd like to, two things that I just wanted to add was about changing your mind, also considering that topic of reviewing. So if someone has already executed a healthcare proxy and they say, oh, I'm all set, it is good to occasionally look at that. And two major events that I think should always cause you to look at, particularly I'm referring to the healthcare proxy, though it might impact your decision on your living well is a change in marital status. So if you oftentimes people appoint a spouse and if your spouse predeceases you, that's another opportunity where you should think, oh, I have to look at my healthcare proxy. If you haven't named an alternate, you might have a healthcare proxy that's void because your agent named is now deceased. So think about changes in marital status and then also a change in a diagnosis. So often you might get a diagnosis and if it's a significant diagnosis, that might change your decision in your healthcare proxy and also particularly your voluntary wishes that you would be writing down in a living well. Sometimes I find that people have a change around that. And then one last piece, I wanna ask you one last question, Anita. Most importantly, we do get occasion to have phone calls here where someone says, I would love to have a healthcare proxy, but I don't have anybody that I can name. And so we will often try to help them to figure out, you know, beyond a family system, who might be willing to serve. I've had people contact former coworkers and things like that, but if your network is limited, because we do have people who live here that don't have family in the immediate area or might be estranged, what would you suggest somebody does in that instance if you don't have somebody to name? That's a really difficult one. It really is- I think it's a laugh. Yeah, thanks. The one thing that you don't wanna do is ask your doctor or nurse practitioner to be a healthcare agent. Because remember, I talked about the treating team here and you know, it's required to give you information. You are required to respond. They should be separate without a conflict. So a treating physician. Now, if you know of a physician who is a friend of yours or a nurse who is a friend of yours and not at all involved in your care, that's fine. But it can't be anyone who's involved in your care. So, you know, I mean, sometimes I've seen case workers, case managers who have developed a relationship, but boy, it is hard. I don't think there is any clear answer. I think it's just so important. That's why it's good to start thinking about this while we're healthy. And we can, you know, if there are relationships to repair or new relationships that we wanna make stronger, now's the time. But I think it's a good time to think about who are the people in my life who would I trust? Because otherwise, there's an emptiness on that side of the equation if you're not able to be fully engaged. And that's the worst experience for a treatment team, the worst, you know, because, I mean, in hospital situations, you know, some they have had like an ethics committee for, you know, very, very difficult decisions. A lot of them will have ethics consults, but you don't wanna wind up meeting an ethics consult. You want as much control over your life and your health as possible. So, you know, that's kind of a non-answer because there isn't a good one for that question. It's really just encouraging all of us to think of all the people we interact with. I mean, I'm the healthcare agent for a friend who has, you know, a couple of kids, adult kids who she loves dearly, but she reached outside the family because of dynamics. So, you know, think carefully about that person, but think broadly too. You know, don't think that you're stuck with your family. That's exactly what the law was designed to do, was to broaden your choices. So, you know, and, you know, if someone is involved in some sort of agency, sometime, you know, there might be a path there, but that's usually for guardianship. So, that's a tough one. Yeah, it's a tough one. Would your living will that you've discussed certainly would at least provide some guidance to whoever ends up? If you and nobody, like a total fallback. Yes, that would help tremendously. You're right. I had connected the dots there, thank you. But certainly with at least that document, that information, even if you don't have one person that you want to entrust with a decision, and maybe you have a good relationship with a treating practitioner, but you just want to let them know, look, you know, just in case nobody steps up, we've had that talk. That's the advantage of having these talks, you know? I mean, a primary care practitioner, while they might not be able to serve as your decision maker, they through you and your efforts and your discussions with them can inform the decision and help the specialist who might be more involved in your immediate care to come to the right conclusion. So yes, yes, we can all do that at least, you're right. Well, thank you. Any other final thoughts to share other than our resources, the forms we've referred to, and any assistance the Amherst Senior Center stands here ready to help anyone in the community. You need copies of the healthcare proxy, scaffolding in terms of other documents that talk about how to do a living will or what questions to think about. And also we can assist you with executing healthcare proxies by providing witnesses so that you can make sure that your document isn't partially filled out and sitting on your kitchen table for three months thinking, oh, someday I'm gonna... Right, right. And just to put a pitch in for the next one we'll also be doing a session on something that you can consider in the context of your living will. And that's the topic of organ and tissue donation. We're never too old to be useful. So we'll be talking about that in a couple of days. And that's something that is worth considering as well. Great. Well, thank you so much for your expertise, Anita. You are a pleasure in your community. And thank you for serving in this capacity to the community and serving as a resource. So thank you very much. Okay, sure. Thanks.