Tag Archives: Advance Directives

The Trouble With Advance Directives: Doctors Often Miss Them

“This is not how it was supposed to happen…First there was a cancer diagnosis, too far gone for cure, then surgery…The elderly man had been found there earlier that evening, pale, feverish and too confused to communicate. There’s no family around. We’re probably going to have to intubate, the emergency room doctor told me… one of the doctors in training tapped me on the shoulder and pointed urgently at the computer screen. There was something important there at the very end of a progress note from the patient’s outpatient oncologist…Facing a prognosis on the order of months, the elderly man had requested that when things got worse, there would be no breathing tubes or chest compressions. Only comfort and quiet.” Dr. D. Lamas, The New York Times

ESL Voices Lesson Plan for this post with Answer Key

Image- Stuart Bradford

Excerpt: You’ve Detailed Your Last Wishes, but Doctors May Not See Them-By Daniella Lamas, M.D., The New York Times

“But now he was unable to speak for himself. Too busy with X-rays and ultrasounds and medications, the emergency team hadn’t seen the note. I sent a page off to the attending taking care of the patient to alert him to the patient’s wishes, and my resident gathered his papers to run down to the emergency room.

This patient had done everything we could have asked. He’d been brave enough to talk with his doctors about his cancer and acknowledge that time was short. He had designated a health care proxy. But there he was, surrounded by strangers, the intubation he never would have wanted looming and the record of that conversation buried in his electronic record.

Something had gone wrong. And though it would be easy to blame the oncologist for not sending the patient home with a legally binding directive documenting his end-of-life wishes, or the emergency doctors for not searching harder in the chart, it’s not that simple. As it usually is with a surgery performed on the wrong side of the patient’s body or a medication that’s prescribed despite a known allergy, the problem here is not about individuals, but instead about a system that doesn’t sufficiently protect patients from getting care they do not want.

 Increasingly, doctors like me are trained to have frank, hard conversations with our patients about prognosis and care goals. Outside the hospital, people with serious illnesses are encouraged to discuss these issues with their friends and family.

But what happens after? As a doctor working in the I.C.U., I knew firsthand the frustrations of searching the electronic record for notes and scanned documents. But I had no idea how common this problem was…Through my interviews, I heard stories of patients who had been transferred to nursing facilities without their advance directives and returned to the hospital intubated when that was explicitly not what they wanted. Others told me about patients of theirs who’d grown ill on vacation only to end up in a hospital they’d never been to, with an entirely different electronic medical record, where no one was able to access any prior documentation… In the absence of nationwide standards, there’s significant variability among hospitals and among electronic records. Some have worked to make end-of-life documentation more easily accessible.

At my hospital, for example, clicking on an ‘Advance Care Planning’ tab will bring you to a record of all advance care planning notes, health care proxy forms, scanned directives and code status orders.

This is a start, but it wasn’t enough for that elderly man in the emergency room. Habits are hard to break, and without a clear set of incentives, training and ongoing education, doctors (myself included) continue to record information about end-of-life conversations in progress notes, where they are not readily available, particularly when they are urgently needed.”

ESL Voices Lesson Plan for this post

NOTE: Lessons can also be used with native English speakers.

Level: Intermediate – Advanced


Language Skills: Reading, writing, and speaking. Vocabulary and grammar activities are included.


Time: Approximately 2 hours.


Materials: Student handout (from this lesson) and access to news article.


Objective: Students will read and discuss the article
with a focus on improving reading comprehension and learning new vocabulary. At the end of the lesson students will express their personal views on the topic through group work and writing.

I. Pre-Reading Activities

Stimulating background knowledge: Brainstorming

Directions: Place students in groups, ask students to think about what they already know about  the topic.  Next, have students look at the pictures in the text and generate ideas or words that may be connected to the article.  Regroup as a class and list these ideas on the board. Students can use a brainstorming chart for assistance.

 

Brainstorming chart by UIE

 

II. While Reading Activities

Word Inference

Directions: Students are to infer the meanings of the words in bold taken from the article. They may use a dictionary, thesaurus, and Word Chart for assistance.

  1. Many patients do not have advance directives.
  2. I was working  in the intensive care unit.
  3. The patient finally had  a discharge to go home.
  4. There was a note from the patient’s oncologist.
  5. Doctors gave him ultrasounds and medications.
  6. There was the intubation he never would have wanted looming.
  7. Increasingly, doctors are trained to have frank conversations with patients about prognosis and care goals.
  8. Some have worked to make end-of-life documentation more easily accessible.
  9. Doctors and health care workers need a clear set of incentives and training.
  10. Just imagine, your E.D. doctor is fumbling to find your information in your chart.

Word Chart By Education Oasis

 

Reading Comprehension

Sentence Match

Directions: Students  are to complete the sentences from the article by selecting the correct words or phrases.

  1. This ___ had done everything we could have asked.
  2. It’s tempting to assume that if you tell one ___ what you want at the end of your life, that’s enough.
  3. For the past year, I delved into the unexpectedly interesting world of advance ___planning.
  4. Recently, a ___ of start-ups have stepped in, trying to offer a solution.
  5. There’s software and ___patient apps that work outside the electronic record.
  6. Just imagine, your doctor is fumbling to find your ___in your chart, but you have an advance directive that was safely uploaded onto your smartphone.
  7. This most likely could have helped my ___ that day.
  8. At least, all related advance care planning documentation should be in one place in the ___.
  9. Beyond that, maybe all ___could require identification of a health care proxy for all patients.
  10. Yet as it is, we’re___.

WORDS/PHRASES: a-care, b-playing catch-up, c-clever, d-patient,  e-medical record,  f-handful,  g-information,  h-health systems,  i-patient,  j-doctor

 

Grammar Focus: Word -Recognition

Directions: Students choose the correct word to complete the sentences taken from the article. They are to choose from the options presented.

When the resident/reside arrived outside my patient’s room, he was relieved/relive to see that the elderly/elder man was still breathe/breathing on his own. The E.D. attending had held off. The patient’s family was on the way. Up in the I.C.U., we treated/trotted him gentle/gently with fluids and antibiotics and oxygen. He never did get strong/strength enough to make it back home, but I think he was quite/quiet and comfortable in the end, as he had wanted.

III. Post Reading Activities

WH-How Questions

Directions: Have students use the  WH-question format to discuss or to write the main points from the article.

Who or What is the article about?

Where does the action/event take place?

When does the action/event take place?

Why did the action/event occur?

How did the action/event occur?

Discussion for Comprehension /Writing

Directions: Place students in groups  and  have each group read the following statements from Dr. Lamas. Then see if each group can think of solutions to this problem. Share ideas as a class.

“As a doctor working in the I.C.U., I knew firsthand the frustrations of searching the electronic record for notes and scanned documents. But I had no idea how common this problem was… Through my interviews, I heard stories of patients who had been transferred to nursing facilities without their advance directives and returned to the hospital intubated when that was explicitly not what they wanted. Others told me about patients of theirs who’d grown ill on vacation only to end up in a hospital they’d never been to, with an entirely different electronic medical record, where no one was able to access any prior documentation.”

1-Minute Free Writing Exercise

Directions: Allow students 1 minute to write down one new idea they’ve learned from the reading. Ask them to write down one thing they did not understand in the reading.  Review the responses as a class. Note: For the lower levels allow more time for this writing activity.

ANSWER KEY

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