By Richard B. Stuart (MSW'60, DSW'65)
As a passionate advocate of planning end-of-life care, I encourage social workers and other healthcare professionals to consider careers in geriatric services. The proportion of the US population 65 and older will double in the next 30 years and most people will endure three or more major illnesses at the end of their lives.
Since the default approach is full treatment, few will receive the kind of end-of-life care that they want, and the Medicare and personal budgets will be strained to meet the cost of services, many of which the patients would prefer not to undergo.
Great creativity will be needed to develop cost-effective services to meet this exploding need, which creates huge opportunities for social workers.
My own path into the geriatric field
I was not always interested in geriatrics. After graduating from Columbia University’s School of Social Work with an MSW in 1960 and a DSW in 1965, I moved to the University of Michigan where, as luck would have it, my first patients were overweight adults and delinquent adolescents. Since the psychodynamic psychotherapy training I had in New York did not meet the needs of my Ann Arbor clientele, I had to learn a different approach. I undertook additional training in what was then the fledgling behavior therapy approach, after which I published a series of papers and books that progressively focused on behavioral medicine and led to employment in departments of family medicine and psychiatry.
As part of my work as a hospital clinician and member of hospital ethics committees, I have been called upon to help make decisions about treatment options for seriously ill patients who had no advanced directive. Occasionally I would also get involved in helping to negotiate plans of action for patients whose relatives had conflicting ideas about what the patient would have chosen.
As we all do eventually, I encountered end-of-life decision-making quandaries with close friends and relatives, watching helplessly as the people I cared about suffered through lives they considered worse than death and hoped for a peaceful death that would end to their suffering.
Most of these people had little information about geriatric and end-of-life care before they became ill, and what little information they had was too vague or too complex to be useful. Just about everyone denied the inevitable until it was too late to do anything about it.
Consistent with national trends, even when people named surrogates to speak for them, many of their representatives did not know they were chosen and/or lacked the information they needed to meet their responsibility adequately.
What is different about 6stepslivingwill.org
Many advance-care planning documents are available, but all offer a narrow range of options and most lack the information needed for informed decision making.
To reach the largest possible number of people, I decided to develop an online tool that includes the facts needed to help people decide whether to attempt to prolong life or experience a natural death. Launched in April 2015 as a free public service, the 6-Steps Living Will site (www.6stepslivingwill.org) guides users through six basic steps, from clarifying values and articulating wishes to telling surrogates and providers about preferences and making sure documents are available when needed.
The site aims to dispel myths about end-of-life care—such as the notion that patients who choose palliative care die sooner, that CPR miraculously restores health, or that people in comas cannot experience pain. It addresses issues that virtually all other protocols avoid—such as the cost of care, the downside of dying at home, and the implications of hastening death. It also prompts collaboration with surrogates and family members to increase the likelihood that patients’ requests will be understood and respected.
I plan to continue refining the “6 Steps Living Will” site and toward that end would welcome your feedback. All adults, but particularly healthcare professionals, should have complete advance directives: by completing my proposed six steps, you can have the best possible documents and increase your ability to help others to do the same.
If you have any suggestions about how to expand the site, make it easier to navigate, and or promote it, please send them to me at rbstuart88@gmail.com. I hope you will join me in thinking about how to mobilize the resources needed to help everyone get the compassionate end-of-life care they deserve.
Richard B. Stuart is Clinical Professor Emeritus in the Department of Psychiatry at the University of Washington in Seattle. He has fifty years of experience working in hospitals and community settings and has authored more than a hundred papers on topics ranging from behavioral contracting with delinquents, ethics and behavioral self-management, to multiculturalism and the treatment of domestic violence. His books include Trick or Treatment (1971), Slim Chace in a Fat World (1972), and Helping Couples Change (1980). Among his public service activities, he currently serves on the board of the Linehan Institute, which is chaired by CCSW Professor André Ivanoff, and is a first responder in a rural volunteer fire department.
