 health and she is a faith community nurse and she's also a certified advanced planning, advanced care planning facilitator. It's kind of a mouthful. We'll just give a little bit more of a background on yourself too as well. Okay. Well as Jane said I am a nurse, I'm a registered nurse. I graduated from a school a little bit further north than here but anyway. But I'm also a faith community nurse. I have kind of a variety of background in my nursing career but I was a faith community nurse for 15 years at a church here in Fargo and then just recently about two years ago came on staff at Sanford and advanced care planning and I will talk a little bit about this is a very personal decision but it sometimes can be a very faith-filled decision too so it fits well with faith community nursing and but part of my job at Sanford is to do advanced care planning with those out in the community, those patients at Sanford and we do this as a community benefit not just for Sanford patients so we will do that for essential patients, VA patients, those that are receiving care from Hospice of the Red River Valley and I'll talk a little bit more about that but so advanced care planning was has really taken a change. You may have heard of living wills, advanced health directives, medical power of attorney, lots of different terms and sometimes that can be very very confusing and people are like well I think I have that done I maybe have that done and in the past too when you've maybe gone for a clinic appointment it has been kind of a check mark that gets done on your chart your clinic provider may have said to you do you have a living will and you may say yes and they say okay great and then you move on or they may you may say no and they say oh okay and they move on but we've really tried to make this more of a process more of as our science says they're changing conversations changing culture and we have a 501 3C in North Dakota that is made up of different representatives from different health institutions in North Dakota called and it's called honoring choices North Dakota and this has been modeled after honoring choices Wisconsin which was born out of the Gundersen health system in La Crosse, Wisconsin and I don't know how many of you are familiar with La Crosse, Wisconsin but it's the city much like Fargo Moorhead but it's sometimes referred to as the city that talks about death now we maybe don't want to be referred to as that but they have done a phenomenal job with the getting health care directives written with the advanced care planning process in La Crosse, Wisconsin 96% of their residents age 18 and over have a health care directive that's phenomenal nationwide the average is 30% of people over the age of 18 now here in Fargo Moorhead it is 27% so we have much work to do and as I said it's about changing that conversations changing the culture really having people talk about what they would want at their end of life and we don't want to just talk about end of life we really want to refer to it as living well and dying well really kind of normalizing it and I'll talk more about that but hopefully everybody in the room got a folder if you didn't if you could raise your hand but it looks like everybody did I just want to point out what's in there and I will come back to maybe some of those pieces of paper that are in the folder but just to let you know what you do have we do have a copy of an advanced health care directive we have really tried to normalize the document have the same document across different health systems and we have really tried to simplify this maybe some of you in the room have written your health care directive you maybe did this maybe 10 years ago 20 years ago and it was really quite written in legalese and it was really maybe hard to understand I know even just a couple years ago when I started in this position and I was helping people write their health care directives sometimes I questioned like what are we supposed to put in this blank but we've really simplified the form made it much easier to understand and then on also on the left hand side there is a pink evaluation if you wouldn't mind doing that at the end that would be great that'd be very helpful on the right hand side of your packet we do have a document about starting the conversation and you're going to hear me refer to that often during this presentation about how important the conversation is that you have with your loved ones with family members with friends and then some of you may have this document we kind of maybe have two different types of packets you have this document or a document that has a lot of red lettering on the top of it and that's really the nuts and bolts of writing a health care directive really tells you the things you need to address and then there's information about scheduling an individual consultation and as I said earlier that's a community benefit that Sanford has Essentia has that also the VA has it also so whatever health system you might utilize for your health care they do want to get health care directives done and on your electronic record so there's information about scheduling an individual consultation we also gave you a small card when you came in and if you would like us to call you to schedule the consultation we can do that there's information about group sessions that we hold at Sanford and really what you're doing today is one of the group sessions so you don't need to attend one of those but we would welcome you back if you would like to but if you want to share that information with anybody you can certainly do that and then there's information about tissue and organ donation and that is part of a piece that you need to address in writing your health care directive so for right now I'd like you to just sit back in your chair I want you to do some thinking reflecting on some statements that I am going to say and I know that for some some of these statements may be upsetting you maybe have been in this position you maybe have been faced with this in the past I'm not saying these to upset you but to get you thinking to possibly spur you on to write your health care directive so just sit back imagine that you're in the hospital and you cannot speak soon you won't be able to swallow or breathe who will speak for you imagine that your mother your husband your child has slipped into a coma and is not expected to recover who will make decisions for them do you know their wishes imagine that you have Alzheimer's a brain injury heart disease cancer who will speak for you if you can't speak for yourself we all hope to communicate until the very end it doesn't always happen this way it's time to speak up now did you know that 90% of Americans have heard of a living will 71% of Americans have thought about their end of life preferences but only 29% have a living will without a plan your health care team won't know your wishes your family may not know what to do and this produces stress anxiety and possibly family discord we may ask am I doing the right thing for mom or dad advanced care planning conversations decisions it's how we care for each other think about what is right for you what is meaningful to you spiritual support having family nearby being at home tell someone name a health care agent what else become educated remove any barriers get the forms have conversations review and update your forms periodically it's time to start the conversation make sure your voice is heard so we are going to start the conversation right now so how many of you here today got here in a car and how many of you in that car had a spare tire hopefully yes and how many of you have had a flat tire in the past and had to rely on that spare tire yes so you had a plan just in case you had a spare tire so how many of you in this room think that you might die one day yeah and I'm not trying to be a reverent about that I'm not trying to you know surprise you by that obviously didn't because you all raised your hands but hopefully that won't happen soon but it will happen at some point in our life and we in America don't like to talk about death we kind of try to keep putting it off here in America we have really medicalized the dying process and that really has just happened in the last 30 to 50 years and we do know that life can change quickly we have been very blessed in America with lots of advancement in medical treatments but that has also maybe prolonged our suffering prolonged maybe not how we want to live so we're going to talk about the conversations that need to take place the importance of making a plan I'm passionate about this because my father who had multiple health issues died right before my senior year of college and we were faced my mother and I were standing in the hallway one day not one day kind of but we were standing in the hallway and we had to make a very quick decision about whether to do CPR for my father now this was about 35 years ago before we did advanced care planning before we had health care directives and I really truly believe no family should have to stand in the hallway and make that very quick decision now fast forward about 35 years and my mother who lived to be 96 we were very blessed she did talk about what she wanted at end of life she talked about what medical treatments she did and did not want sometimes to her grandchildren's chagrin but we knew when she passed away exactly what she wanted at her end of life and we could truly celebrate her life and not mourn the decisions that we had to make quickly so I hope today what you will take away is that it's very very important for you to have conversations with your family it's important for you to get that document written and get it on your medical record but it's important to that you review it and that this is a process and not just a check mark and I hope it's very exciting in this room to see such a variety of ages it's important that we don't think of it that we just do this when we're maybe advanced in years or when we maybe know that we have some health issues but that we do advanced care planning when we're age 18 or above it's really important for college students as they leave home to write a health care directive even if it's just appointing who will speak for them if they cannot speak for themselves and we do know that many times family situations are very different it's not the nuclear family and you may not want to maybe your parent to speak for you maybe you would want a different family member to speak for you so it's really important that as we turn 18 that we do get our health care directive written so we may have lots of different images of death we may want to maybe go to sleep one night and not wake up that's maybe the kind of ideal thing but we also know that we could either be in an accident and our family may need to make decisions for us or we may have kind of a slow progressive health condition that we really shows very slow deterioration and we will need to make decisions about our health care and it's just so important that we get those decisions written down get what our wishes are get our what our values are what our preferences are it's a good time to visit about hospice care palliative care and it's just important that we don't put that off writing that down it's a legacy that we can leave for our family letting them know what we want it's a way to pass on our faith it's a way to pass on what we value a way to pass on family history also so some of us probably have gone on a vacation in the past and we probably have an idea about what our ideal vacation would be and it's a very personal thing we may have a friend who has just a completely different idea about what a personal vacation would be many times spouses disagree about what a person at what an ideal vacation is but we will probably agree that to go on an ideal vacation it takes a lot of planning and it takes planning too with how what we want at end of life in America we plan for everything just think about when someone announces that they're going they're expecting a baby a new life and what all the planning that goes in and all the preparations and then we plan for graduations we plan for marriages we plan for vacations but we really avoid planning for our end of life we avoid the conversation so we'll kind of hopefully this today will help with how you can maybe have that conversation have be ready to have that conversation so now what is advanced care planning as I said earlier it's a process where you write down what your wishes are what you value it's a converse it's about the conversation that you will have with those that you are close to and I couple weeks ago I did this presentation and I had a priest in the audience and we have that on there that hope is not a plan and we all need to have hope hope in any situation but he said you know I have had so many people tell me that they are just they're not going to write one of these directives because they're just going to leave it up to God and then everything will get taken care of he said and I thought it was great because it came from a priest but he said you know when you don't write it down what you want you're not really leaving it up to God you're leaving it up to people who don't even know you who maybe don't even care about you so he I said can you come on the road with me but so it is just so important to write down what your wishes are so it's the advanced care planning process is about learning about the treatment options for your particular health condition reflecting on your values about what is important to you what are your personal and spiritual beliefs what really matters to you what are your hopes and your wishes for your health care what makes your life worth living and then deciding on what treat what types of health care treatment you want or do not want talking about your decisions with your health care agent your loved ones your health care providers your faith leader and then documenting your wishes and it's important to note that every state recognizes health care directives if you write a health care directive in North Dakota and you travel to Arizona it will be honored if you there's each state maybe has little different requirements but they're so minimal in North Dakota probably the biggest thing that you need to know is that if you write a health care directive and you appoint to your health care agent is they need to sign off on the directive that they accept that responsibility and that is just so important because we've seen so many different situations where maybe I know of this one situation where a son who was taking his mother to all of her medical appointments found out when she was in the hospital he thought he was her health care agent found out he was not it was his sister who lived several miles away she thought the brother was also mom had never told them who the health care agent was she'd written it in a different state so it's important that if you pick someone who will speak for you when you cannot speak for yourself that's who the health care agent is that you let them know that they do sign off on it so we do have five steps in advanced care planning one is become educated you're here today you can mark that one off remove any barriers get the forms you've also been provided with the forms now have the conversations with your family members they will be relieved so many times we think that our loved ones don't want to talk about it but they will be relieved if you have that conversation complete the forms it's important to complete that form get a cop on your medical record and you know it used to be that we kind of locked up our health care directive we put it in the safety deposit box because it's an important document so we want to keep it safe we really have the opinion now and the practice now of making lots of copies for you a copy that you can have at your home a copy that you can give to your health care agent a copy that you can give to your health care provider we really recommend that you give a copy to all of your children so that they are all on the same page we will make as many copies as you need and then take that health care directive with you if you travel take it with you if when you go see your health care provider making sure that they have a copy on your chart and again across the different health systems we've really tried to standardize this and you should have if you have a health care directive on file at your health care provider there should be a gold banner across your face sheet and will come up and it says health care directive on file so the next time you go to the doctor you can say you know if you've got one on filing you could say does it say that do I have my gold banner across so and then the importance too of reviewing and updating these forms so many times we wrote you know we wrote it we said okay we got that done and we never looked at it for maybe 20 years if you had the foresight to get that done but review it change it as your wishes change as your values change as your health changes and then there are four people that are kind of involved in this process of advanced care planning the first person it's different than this slide that I have up here but the very first person to talk about is you the role that you will have and that's the most important role your role is to really start the process talk to your loved ones talk to your health care provider the facilitator I'm a facilitator for this we have at Sanford we have nurses we have social workers we have chaplains who are trained facilitators to help in the process of advanced care planning and their role is not to tell you what to do what not to do but to really help you in that discernment process and really empower you to ask the questions that you might need to ask of your health care provider and really give you the tools to talk to your family and really assist you in defining what your preferences might be and then they will be talking to you about things about like what does a good day look like for you what trade-offs are you willing to make or unwilling to make in light of your health care situation is it important to you to have quantity of days or quality of days is there some goal like I have a one of my cohorts who is an advanced care planning facilitator she her son is getting married and her father is going through some health issues right now and he really wants to see his grandson get married and so he's really doing making health care decisions based on that so and what outcomes are acceptable to you unacceptable to you will help you discern all of that and then we'll talk to you about what are your wishes for physical emotional and spiritual comfort and really talking to you like if you know if there's no reasonable chance to regain your life physically or mentally what would you want if you have physical limitations but can relate to family and friends what would you want if you cannot relate to family and friends what would you want so lots of different things that we will be discussing with you and then we'll talk to you about what are your wishes about how you want to live and again I want to just really reiterate that this is just such an important gift that you can give your family if you have the conversation with them if you document what you truly want as a faith community nurse I've been able to walk with lots of different people at end of life and walk with lots of different families and it's been such a blessing now situations where what you would call like a beautiful death where the family is gathered around and they are helping mom or dad with their last days it's usually when there's been an advanced care plan done and they know what mom or dad want and they know they are helping mom or dad carry out their wishes now there have been some situations where maybe it has been a little bit tense there's been a lot of stress and anxiety around a person's death and many times it is because they don't know what mom or dad want you may have a couple siblings that want this and a couple siblings that want that and there's some discord going on so it's just such a gift you can give your family and then part of the advanced care planning process too is saying maybe what you want for your funeral again a wonderful gift that you can give your family we won't you know do all the funeral planning with you but we can help you write down a few things that you might want and then there are decisions that you will need to make in regards to CPR artificial breathing artificial food and fluids kidney dialysis tissue and organ donation and we'll help you document all of that in your health care directive and again I just want to say too that we will not tell you what you should do and what you shouldn't do you may have really definite ideas or you may not and we'll help you write statements that will reflect that in your health care directive at this point I kind of like to ask if there's any questions about what I've covered so far well I'll take questions at the end too but yes yes no they really aren't in well it's part of like that and that's starting the conversation but there's it's not maybe laid out but yeah yeah no we will go over that with you yeah yes I'm sorry yeah um that is a great question they will it's important to take your directive with you and yes they will they have a process for that too but they would probably have different forms but your medical team if you were in Canada and had some type of health crisis that you were in the hospital they would look at your directive and they would honor it they would yeah that is a great question though and you know because we do because of where we live we are going up into other countries and we are a mobile society so it is really important then that you do take your directive with you when you do travel a lot of people just keep a copy in their glove box interestingly and this just popped in my head that we do know for these younger people in the room you probably aren't going to want to carry around a piece of paper I mean in our culture is changing that way there is a smartphone app and it's called my health care directive and soon people will be able to just download that onto their smartphone and there will be like a to prove that I think there's there be like a fingerprint identification so they know that it is a valid document um so let's go on a little bit more and then we if you think of questions please ask so we probably all have different visions about you know how we maybe would want our end of life to look like this gentleman here unfortunately sometimes it does look like there and we do know that the medical model is really based on cure and recovery but that may not be what we want or might might not be possible for us and your health care provider will kind of help you discern that but it's important then that you write down what your wishes are if a recovery and a cure is not in the in the picture at that time and we will talk to you about hospice care palliative care so many times people don't really understand what that is but palliative care is for anybody who is has a health care how it's a health condition that really where recovery and cure might not be in the picture maybe a chronic disease and where you would just do comfort measures I don't want to say just do because that's so important but where you will do comfort measures where you you may still maybe be doing some medical treatment but it's really to give you comfort to give you good quality of life hospice care includes palliative care but hospice care is care that is done at when you maybe have six months of life left and it does include that comfort care palliative care can be given in your home in a nursing home in the hospital and part of hospice care any questions about that okay that's great so what is your role as the patient your role is to talk with your health care team get the support that you need and learn as much as you can about your health condition and really in the importance of appointing that health care agent and so many times people say I don't want to appoint somebody because they'll just kind of take over my a lot of time people say that about their children more but they're just going to take over my health care decisions and it's only if you cannot speak for yourself that that health care agents role comes into play and it's really by you doing these conversations by really writing it down it's a way of showing love to those that you care about a lot of times it's not easy questions and not easy to talk about with your family but hopefully by starting this process we will make it easier for you and then that health care agent it's really important that you know that it's somebody that you can trust somebody that knows you well somebody that you're willing to share what's going on with you as far as your health and is willing to advocate for you and really has that resiliency to stick up for you if there does come into play where there's maybe some family discord it can be anyone over the age of 18 it can be a family member it can be your spouse it can be a child doesn't have to be your spouse doesn't have to be your oldest child but somebody that you truly trust and want to walk with you and to include in on that any questions about the health care agent yes I'm not doing real good at identifying we do really recommend that you name two people and it's in that likelihood that you know because that because we do know that that could happen so then and if you don't have somebody they there's kind of a hierarchy that like the court system would go to and that medical and ethical boards would look at if there wasn't somebody if you know it's like spouse children parents grandparents and then sometimes they do do a court-appointed person if they just if there just isn't anybody does that answer your question okay we would try to encourage you to pick two people yeah yes we encourage that because they do have to sign off on it in North Dakota we do encourage you to bring your health care agent with now you may have somebody that maybe doesn't live in the area and with the accessibility with cell phones and stuff it doesn't have to be somebody that lives in the exact same town as you somebody that is accessible somebody that maybe could travel quickly if needed so any other questions about the health care agent okay and then your health care provider it's important that you know that you can ask these questions of your health care provider that you can that they really explain what is going on with whatever health diagnosis you may have it's important that they will talk to you about what your goals are what might happen if you do this treatment what might not happen and you need to know too that if your health care provider feels that they can't really carry out what your wishes are that they have that duty to transfer your care to another health care provider and but really to know that it's important to have the conversations about your end of life when you're not in a stressful situation so we really encourage people to do that with their primary care provider now you may not have anything going on as far as your health right now so it would maybe be a shorter conversation but as your health changes it's important to do that with your primary care provider in a non stressful situation and then we really have really tried to work on that process where your primary care provider would document in your chart make documentation about what your wishes are and talk about your that you do have a health care directive and then if there is some type of crisis situation where we'll say that you're brought in by ambulance and you're in the emergency room the emergency room physician then will have access to that note will know then what your wishes are for your health care and can follow through with what you've discussed with your primary care provider we've really tried to make that more seamless so and then the importance of finishing that advanced care planning process by getting the documentation done and I talked about that we know we will help you get that on your electronic record I talked about the importance of having lots of copies having giving copies to those that that are important to you that might be in the presence when you might have a health care situation but also we say there's kind of 5d's of when you need to review your document and that is in the time in if there is a death well especially if there is if the person you named as your agent dies you would want to maybe possibly appoint another person but many times when we experience the death of a loved one it maybe changes what we would maybe want at the end of our life also so that's just a good time to review your documents it's if there is a divorce and especially if the person you're divorcing was your health care agent you might not want them making health care decisions for you maybe maybe not if you do still want the person that you are divorcing to make health care decisions for you there is an addendum form that we recommend that you fill out that you still give that person that right to make health care decisions for you but again it's one of those important life moments to where maybe we need to review what we want it at end of life to it's just one of those times and then every decade you would want to review your document now if you're a little bit more advanced in age maybe every five years you would want to do that and then if you have a new diagnosis where maybe it might change what you would want and then also if you've had a decline in your health you'd want to review your health care directive and keep a copy you know we've talked a lot about the importance of having lots of copies so and there's lots of resources that are available to you these are the numbers for the different health care systems for writing your health care directive and like I said we at Sanford and at Ascension we will do it for whoever and we will help you get it to the appropriate health care provider so any other questions that's all of my presentation but so hopefully I covered what you came here to hear and answered your questions but health care directives are and I'm not sure what you're asking by legally binding because people sometimes mean a different thing by that so maybe I better ask what a lot of times that does happen now if you write in your health care directive what you would want about CPR and then appointed a health care agent and that health care agent was carrying out your wishes so then it yes it's legally binding now if you write we'll just use this as an example say you write that you do not want CPR you're taken in to the hospital and there is a need for CPR and the health care agent who has been appointed as the health care agent is disagreeing with the directive they would sit down with you and say okay what's going on here your mother did not want CPR and you're telling us to do CPR so there would be a discussion and they would a lot of times it does happen though with families where you may have people on opposite sides and if you've written that health care directive the health care institution needs to follow it yeah then you know many times there's lots of different scenarios because our health is complicated and the health care provide institution needs to follow out follow what a health care directive says if there is family that's really disagreeing about it the physicians team of individuals will sit down and really help the family work through that so that everybody to can kind of come together and honor mom or dad's wishes yeah yes sure yeah but thank you for saying that so through honoring choices and you will see it says honoring choices Minnesota at the bottom soon these will say honoring choices North Dakota it's just I mean it is just like in the last probably six weeks that honoring choices North Dakota became a 501 3C and so they couldn't really put that on everything but anyway maybe didn't need to know all that but so there is going to be all the in North Dakota and Minnesota they will be using this form okay and now at the sentia or trying to think what some other anyway they'll probably have their own logo right there but it will be honored at all the institutions across North Dakota Minnesota and so you know it starts out where you will say your name your date of birth your address all of that now if your address should change it you don't necessarily have to redo this you don't unless your wishes have changed but we really do that to really identify you know if you have a name like Barb Hansen there's lots of us out there and so really to identify who's directive it is and then the first thing you're addressing is my health care agent and and it does show there that you know in North Dakota you have to sign off and it has kind of the different states that are right in this region what the requirements are on the second page that is where you will identify who your agent is and who your alternate agent is and that kind of goes with that question about if your if you name like your spouse and you're both in the same accident yes that's for someone who doesn't speak English yeah it's not the facilitator who yeah but great question and then we will you know when we sit down we will really take into account what is going on with you as far as your health and then what decisions maybe that you would want and not want and we'll explain each of these individually what you know if you mark like on the third page where it says my initials below indicate I authorized my health care agent to make decisions about the care of my body after death we'll we'll tell you kind of what would happen with that you know if I live in North Dakota Minnesota my initials below indicate I also authorized my health care agent to you know continue this is where that addendum you know continue as my health care agent even if our marriage or domestic partnership is legally ending or has been ended so you know we'll really try to individualize it to what you might be going through and then we will address those things that I that slide that I had about CPR and there's you know you may some people would maybe want CPR no matter what that may be a decision that they might make some people might make the decision I don't want CPR ever you know so kind of those two extremes now some people and we I think it's important well I know I'm saying what I kind of think myself but you know kind of to say a statement to based on what is going on with your health you know I would maybe want CPR in this situation but maybe not in this situation and we'll really help you discern that and help you address it and then treatments about prolonging your life and that's where dialysis and artificial feedings would come into place and then about organ donation any questions so far about the document okay and we do have a statement about having an autopsy a lot of people don't know this but an autopsy is not covered by your health insurance and maybe you did know that in this room but it is not because your health insurance is for when you are living an autopsy is done after you die health insurance does not cover an autopsy isn't that interesting now if if you have a autopsy that is ordered because there's been an unattended death then it is like they can do kind of a there's kind of degrees of autopsies too and that can be covered by it is discovered if it's ordered legally then it's just covered by the legal system but you can't so many times you know and I've been with families where there's been a sudden death and the and you do want an autopsy so that the family knows but you need to know that it it will cost several thousand dollars then for the family to know but sometimes that is just very important if it's if you want to know if it's something that maybe a child could possibly die up to or children so but we don't always hear that so and then let's see here I put autopsy and then my hopes and my wishes and that's really where you know we do time so we do kind of have what was on that slide but things that you know make life worth living to you you know your beliefs your thoughts about medical treatments and some people really write quite a bit in there some people really don't write anything you do need to have something in each blank even if you don't have if you don't want to put anything you just can put any there too but you do need to have something in each blank okay and we do have there is about religious affiliation and then the last part on page 8 is about having it notarized all of the health systems have several notaries on staff so it can be notarized when you go in for a clinic appointment we can do that as part of the facilitation process or you can go to a bank and have it notarized you can also have two witnesses and it goes into there the requirements of the witness it can't be your health care provider and it can't be somebody you know who would benefit from your death too so any questions and then it's part of the form to it does encourage you to review it and and then give copies to many people and has a place there to really document who you've given copies to any questions about the form that I maybe didn't answer yes okay I they probably did just yes if they requested it yep yeah yeah so that might be a situation too but Jane yes right I'll address that first you can fill this out on your own you don't need somebody that is going to tell you to fill in each blank just know that you do need to fill in each blank you do need to have it notarized and you do need if you are a North Dakota resident you do need to have your health care agent sign off on it and then it is on page it's turns the back this I should know this right it is no there's a place yes on page nine thank you I accept I accept this appointment agree to serve as the agent yep yep it is yes yeah so yes you can do this by yourself you don't need to have a facilitator walk you through it but the importance of having it notarized and having your health care agent sign off if you would like to have a facilitated discussion we can set that up when it's convenient for you and you just called to at Sanford it's two three four six nine eight zero essentials three six four four eight two eight and then Hospice of the Red River Valley will also do home visits and we will also go out to the home if someone cannot come into our office and and they will help with that facilitation process we do encourage you to bring your health care agent I think somebody asked about that if that's not possible that's okay a good facilitated conversation usually lasts about an hour and a half to really walk through all of the pieces and if sometimes you just need to kind of mull it around and you have to think about it we'll do two appointments three appointments we also try to make it very convenient to if you have an appointment with a health care provider we can a lot of times piggyback alongside that too and then just to let you know to that we're really trying to get a process where we have facilitators in each of like the clinics like if you are a patient in at North Port we're trying to get a facilitator there at South Point and internal medicine in cardiology and nephrology we're trying to really have facilitators where it's convenient for the people so for many of us we work out of spiritual care at Sanford and so that is at the hospital downtown did I answer that okay you know some of when you work with it so much you're just kind of like oh yeah but yes it would be especially if the people like say you say your spouse is going to be your agent but you just didn't get it notarized but you came in with it and your spouse is there and he's agreeing with what you've written down yeah yeah and it really is I do really want to say how important that conversation is because even if you don't even bring the document with but you know your children are there your spouse are there and everybody's agreeing they're going to carry out your wishes they are yes yep and what I would do it you know I don't think it's on honoring choices North Dakota yet that's great question but you can just write in health care directive and I would do the honoring choices because it is a lot easier just so the languages I think a lot easier so but yes you can get it online and you can we can send out these packets if you call the Sanford number two and we can send them out to anybody too that might need them yeah please take them because it's we just want the information out