作为道德顾问, Constance Holden at Boulder Community Hospital and Jean Abbott at University Hospital in Aurora are often called on to help resolve conflicts that arise when family members disagree on how to care for their loved ones who are nearing the end of life.
“I have witnessed many difficult situations that might have been averted or been less difficult if the patient had had a conversation with family about their wishes,霍尔顿说。, 她是一名退休注册护士，也是博尔德县“对话项目”的联合创始人, 谁的使命是促进十大菠菜靠谱老平台临终关怀的有意义和有效的对话.
根据医学研究所, many people may not be able to physically or mentally communicate their wishes regarding care when they are nearing the end of life. 82%的美国人认为把临终愿望写下来很重要, 只有23%的人真正做到了. 此外，病人在医院里常常遇到一个他们从未见过的医生.
Designating a medical durable power of attorney before a crisis – choosing an agent who is locatable and can speak on the patient’s behalf at those crucial moments – can eliminate these conflicts. “这个人是关键，因为医疗保健系统支离破碎,艾伯特说。, 他是一位退休医生，也是博尔德县“对话项目”的联合创始人.
与社区基金会合作，为博尔德县服务, 对话项目鼓励人们思考, 文档和, 最重要的是, 与家庭成员谈谈他们对临终关怀的价值观和愿望. 一个入门工具包(可在conversationprojectinboulder获得).Org)中包含了一些情绪性的问题, 医学和实际问题来帮助指导人们进行这些对话.
州和国家外展
The Conversation Project in Boulder County is based on the work of Pulitzer-prize winning journalist Ellen Goodman, 谁在她年迈的母亲去世后，于2012年创立了这个组织. 对话项目由医疗保健改善研究所支持.
“珍让我注意到了艾伦·古德曼的作品. 我们都看着对方说，‘这就是人们应该做的，’”霍尔顿说.
They believed similar programs across Colorado could improve end-of-life care for people in many communities and prevent the types of conflicts they often deal with as ethics consultants. They asked Goodman if they could use “The Conversation Project” name for their local endeavor.
古德曼同意, 要求博尔德项目成为其他社区的典范, 它已经做到了. 在维尔德县和拉里默县以及丹佛市区的几个团体也有类似的努力, 阿伯特说. She and Holden regularly hear from people from across the country seeking information about what’s happening in Boulder County.
我们希望这将成为一个全州范围的倡议，”霍尔顿说. “我们愿意分享我们拥有的一切.”
在博尔德县, Abbott and Holden along with a dozen trained volunteers have given nearly 200 presentations about The Conversation Project. 他们估计至少有2人死亡,200人在扶轮社演讲, 库, 老年人中心和其他场所.
在Grand Junction, Rocky Mountain Health Plans Foundation has twice invited Abbott to speak on the Western Slope to groups that include clergy, 社会工作者, hospice employees and other community members about how to start their own Conversation Project. “我们的基金会正在考虑将对话项目带入工作场所,RMHPF执行董事Lisa Fenton Free说. “从秋天开始，我们的(450)名员工, 我们将在工作时间和工作前后在工作场所举行会议.”
7月, RMHPF会见了协调协调员委员会, 一个致力于协调医生对病人护理的大枢纽组织, 机构和案例经理, 并把“对话项目”带到他们不同的工作场所. RMHPF also plans to reach out to the Mesa County Health Department to learn about other places in the community where they might introduce The Conversation Project. “我们对促进这些对话感到兴奋, 比起以恐惧的方式结束生命，哪个会给生命增添更多的意义,芬顿·弗里说.
开始对话
在过去的二十年里, 梅萨县预先指示特遣部队, 由大枢纽的两家医院代表, 县公共服务部, RMHPF和其他组织, 是否试图教育社区成员十大菠菜靠谱老平台预先指示, 工作组主席玛丽·沃森说. “This year we focused our attention on The Conversation Project” by giving presentations at HopeWest hospice, 辅助生活中心, 疗养院和蒙特罗斯纪念医院.
自从医疗保险中心以来，对话项目尤其及时 & Medicaid Services recently announced a new policy: The government will reimburse doctors for having voluntary conversations with their patients regarding values and preferences for end-of-life care. 该政策将在60天的公众意见征询期后于2016年1月1日生效. A similar provision was initially included in the Affordable Care Act until opponents likened it to “death panels,“声称, 错误的, 政府将对实际的医疗保健实行定量配给.
“坦率地说, the majority of people who come to our presentations fear they’re going to get too much medical care – life-prolonging procedures they may not want,霍尔顿说。. “默认情况是，如果你不告诉任何人你的想法, 你会得到一切的(复苏), 呼吸机, 喂食管)不管之后的生活质量.“对话项目帮助人们确定他们想要什么, 这是否具有侵略性, “竭尽全力”进行医疗救治或签署禁止复苏令.
The Patient Self-Determination Act requires physicians and hospitals to ask patients if they have advance directives or would like information about making end-of-life decisions. “它本应该引发这些对话, 但这种情况并没有发生，“因为医生们通常不愿意提起这个话题。, 霍尔顿说. “We want the public to have these conversations with family, and then go and talk to their doctor. 我们正在为人们做准备.”
坦率地说, the majority of people who come to our presentations fear they’re going to get too much medical care – life-prolonging procedures they may not want.
桑迪·扬汉斯在她的弟弟杰夫被诊断出患有一种罕见的癌症后下载了这个入门工具包, 退行性脑病. The retired Boulder attorney initiated the conversation with her brother by using the starter kit questions to help Jeff identify his goals and wishes for his approaching end of life.
扬汉斯说:“他非常明确地表示不想要任何喂食管。. 她发现哥哥最大的恐惧是失去行动能力, which explained his plans for knee replacement surgery – a high-risk procedure that would have still left him with tremors, 言语障碍及容易跌倒以及康复期较长. 在与他的妹妹和姑息治疗专家交谈后, 杰夫能够确定对他来说最重要的是什么——与家人共度时光. 他取消了手术. The conversation with his sister paved the way for subsequent conversations with his wife and daughters.
Retired Boulder physician Carolyn Shepherd learned about The Conversation Project when she heard Goodman speak at an Institute for Healthcare Improvement conference on the East Coast. 谢泼德和她的丈夫下载了入门工具包，并分别回答了问题. 尽管他们发现大多数人的回答并不令人惊讶, 有些问题“对我们俩来说都变得更清楚了——如果我们曾经处于那种境地的话,谢泼德说.
“例如, 我丈夫坚持要他所爱的人完全按照他的意愿行事, 即使这会让他们不舒服,谢泼德说. 作为一名医生, she said she expected to make some decisions about his care; but her husband was most comfortable with her promising to not deviate from his wishes. “The degree of importance of this to him surprised me and was something that was critical for me to understand,谢泼德说.
接下来，这对夫妇和谢泼德的妹妹进行了交谈. 第三次谈话是和家里的两个孩子.
“One daughter is very uncomfortable (with the topic), but she’s going to do it,谢泼德说. “有一个小的对话模板是很有帮助的. (入门工具包)是一个有用的工具.”
谈话可能需要重复，因为计划可能会改变, 被选中的代理人也可能经历转换, 霍尔顿说. She emphasizes the importance of having the conversation “upstream” – before a new diagnosis or other medical crisis, 当这个话题可能更难与所爱的人谈论时.
"以我们各自医院道德顾问的身份, we are often called upon when families are in conflict about the course of action to take when their loved one is unable to participate in decision-making,霍尔顿说。. “Too often we hear, ‘We really don’t know what Dad would want; we never talked about such things.“以价值观为基础的讨论可以在床边为家庭提供关键的指导. 避免困惑、冲突和心痛是对话项目的目标."
本文最初发表于2015年秋季期的《十大菠菜靠谱平台》杂志.