April 8, 2020

Princeton Medical Center Geriatric Physician Urges Advance Care Planning

By Anne Levin

As the Director of Palliative Medicine Services and Medical Director of the Acute Care for the Elderly Unit at Penn Medicine Princeton Medical Center, Dr. David Barile treats many patients who come to the hospital with no advance care planning in place. That lack of direction has never been more frustrating than it is now.

Barile notes that frail elderly patients who become seriously ill with the coronavirus and have no advance care directive to follow are often put on ventilators when it is unlikely that they will recover, only to die after a few painful days. This places extra stress on the medical staff and keeps ventilators from others who might benefit from them.

Barile wants people to know that there is a choice. Through April 24, his nonprofit Goals of Care Coalition of New Jersey is holding 30-minute Zoom webinars Mondays-Fridays at 1 p.m. The goal is to help educate the elderly, nursing home residents, their loved ones, and their authorized health care proxies about the importance of discussing and documenting wishes for medical care in either an advance directive or POLST (Practitioner Order for Life Sustaining Treatment).

POLST is a medical order and directs doctors by offering specific instructions related to a patient’s personal goals of care, artificial nutrition, resuscitation, and re-hospitalization. Barile urges family decision makers and authorized health care proxies for people living in nursing homes or other long-term care facilities to speak with their loved ones, when possible, to make decisions about future medical care, and to put them in writing.

“For years, through my whole career, I have been frustrated with the lack of advance care planning and physicians’ lack of the skill set to establish goals of care and align with available therapies,” Barile said last week. “I blame the medical educational establishment. It has always been my passion. The POLST form is built to structure the conversation.”

Barile regularly encounters situations where this kind of discussion has not been taken place.
“Now, for obvious reasons, its important to all of us because of the eventual allocation of resources and triage that we’re all going to have to do,” he said. “These decisions are going to happen in this country, and my feeling is that we could offload some of this pressure. If we could wave a magic wand across New Jersey and have this conversation with elders in a nursing home, most of them would choose ‘do not resuscitate.’ I’m seeing 80- and 90-year-olds getting intubated. We’re putting health care people at risk doing it, because they have to be right up to the patient’s face. The most important thing is that we get people the kind of care that they want and avoid care they don’t want. And as a secondary outcome, we protect health care workers.”

Barile said most people without pre-existing conditions who are careful about social isolation, washing their hands, and not touching their faces, will stay healthy. Those who do become ill should stay at home. “The most important thing is that of those who are relatively healthy and not elderly, who become so sick that they end up on a ventilator, many will get better. But if someone is frail or has a condition like metastatic cancer, and is entering the final years of life, they don’t have a reserve,” he said. “If they are put on a ventilator, they won’t survive. And it’s an awful death to have.”

To take part in one of the daily webinars, visit www.goalsofcare.org.

“We just need to get better at this,” said Barile. “And it has to happen now.”