1. Gurpreet K. Padam, MD Planning Ahead & A Graceful Exit

2. Why Talk About This? We like to plan Short term – dinner with friends, samagams, keertans, Long term - retirement, college, mortgage, family planning  Plan A and Plan B We don’t like to take about it It’s not the most pleasant of topics Fear of the unknown Suffering and lingering  The possibility of a good death?

3. Benjamin Franklin “…in this world nothing can be said to be certain, except death and taxes.” http://www.notable-quotes.com/f/franklin_benjamin.html

4. Guru Granth Sahib 1430 Angs/Pages 26852 lines 29445 words “Hari” appears 9388 times Reference to death (jam, kaal, mareh etc.) appears at least 1,000 times > 1000 times Ref: Sikher and Sikhi to the max website search

5. Objective Identify tools you need to plan ahead for: 1. The unforeseen circumstances 2. Plan for the stages at the end of life

6. - AD - surrogate decision maker - POLST - Palliative care - Hospice Show of hands - familiarity

7. Imagine a good death -You do not have to participate -Close your eyes -Imagine your last days -Choose your surrounding -Choose who surrounds you -What are your wearing -Imagine the music/shabad in the background How many people imagined the last days in the hospital? How many people imagined last days at home or surrounded by loved ones?

8. · Nearly half of all Americans die in a hospital. · Nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility. · 7 out of 10 Americans say they would prefer to die at home. · Only 25 percent of Americans actually die at home. · More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying. How We Die Ref: http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-and-figures/

9. imRg iqRsnw ijau jg rcnw Xh dyKhu irdY ibcwir ] mrig thrisanaa jio jag rachanaa yeh dhaekhahu ridhai bichaar || The created world is like an illusion, a mirage - see this, and reflect upon it in your mind. Guru Tegh Bahaadur Ji Raag Dayv Gandhaaree 536 The Illusion of Control Ref

10. When the unforseen happens, there seems to be sense of loss of control Natural disaster Accident Rapid progression of a disease despite maximum medical treatment What is the right treatment for you, who will make your decisions, what is important to you? CPR or DNR, Aggressive tx something else, tube feeding What can we control?

11. Advance Directive Your wishes in writing Who is your spokes person? 1

12. 2 POLST – physician’s order for life sustaining treatment. Your doctor has to sign it too. A copy of the original is also valid http://capolst.org

13. 3 Share Your AD + POLST - Your Doctor - Your Family Out of sight, out of mind. Keep documents visible to the paramedics, your doctor, your family

14. Document Your Goals and Directives Review every couple of years and update 1 Advance Directive 2POLST 3Share

15. Advance Care Planning is in place Illness progresses Maximum treatment has been tried i.e. asthma, copd, heart failure, complications of diabetes, cancer, kidney disease, dementia, liver diease, dementia ”How much time do I have” ”6 months”

16. Goal: Comfort at the end of life -- focus on managing symptoms and treating suffering rather than seeking a cure --Medicare benefit for those with a terminal illness and 6 month prognosis. Hospice.

17. What’s Your Message? Know Your Options… Empowerment through awareness