Case Study: Facilitating Medication Preferences
Facilitator: Now we’re at the part of the advance directive where we talk about medications. In your advance directive, you can list medications that you would like for doctors to give you and you can also list ones that you do not want them to give you. Let’s talk about the ones that you would like first.
Client: Great. This is the thing that’s the most important to me. I have a whole list of medicines that I want my doctors to know about.
Facilitator: All right, but before we start writing them down, I want to make sure that you understand that this doesn’t mean that your doctors have to give you these medications. It just means that you are telling them that these are the medicines you would like for them to try first.
Client: But I thought that if I said that I wanted these medicines, those were the ones that they would have to give me.
Facilitator: Not exactly. They’re your preferred medications, but, for instance, you might be having a problem that needed a different kind of medication than any of the ones you listed. Basically, you can give a list of medications that you would like for the doctors to try first, but you can’t force the doctors to use those medications.
Client: Well, I guess I’ll have to live with it. But the doctors would be willing to try these first if I list them, right?
Facilitator: That’s right. Usually, if you list the medicines and explain why you want them, doctors are willing to use those first.
Client: Okay, that’s great. I have this list of medicines I want to make sure that we put on there.
Facilitator: How many medicines do you have on your list?
Client: 15.
Facilitator: Well, okay. We can put all of those medicines on your advance directive, but here on the front of the page there’s only space for three of them – the three that are the most important to you. That’s because if a doctor just sees a long list of that many medications, it’s hard for them to know what you want, or what’s most important to you. What we can do is have you choose your top three medications and put them on the front of this document.
Client: But I really think these medicines are all important.
Facilitator: I understand. We can put the rest of these medicines on the back of the form. Or we can attach another piece of paper with the whole list on it. But it really is a good idea to give your top three on the front of the page, so the doctors will know what’s especially important to you.
Client: I don’t mind doing that as long as you’re sure that all these other medicines will get listed too.
Facilitator: Don’t worry; we’ll put them all on. What’s the very most important medicine that you want doctors to know about?
Client: I think that the most important one would be Risperdal.
Facilitator OK, I’m writing that medication down here. What would that medicine be used for?
Client: That’s the medicine that helps me if I start to feel paranoid. And also if I’m hearing voices it helps. I take it every day. Also it helps me sleep.
Facilitator: Okay, I’m going to put that down in this blank that asks what this medicine is used for.
Client: That’s fine.
Facilitator: Why do you prefer this particular medication?
Client: Because it works best for all that stuff I just told you.
Facilitator: Okay. I’m going to put that in the blank that asks the reason that you want this medication. Now, what’s another medicine that you want to be sure that doctors know about?
Client: It’s really important for doctors to know that I use medical marijuana. I use it every day, because otherwise I get really anxious.
Facilitator: Hmmm. Well, the problem is that marijuana is illegal.
Client: I know, but I have a prescription from when I was living in Colorado, so it’s legal for me to have it.
Facilitator: I understand what you’re saying, but do you really think that doctors will be willing to give you marijuana in the hospital?
Client: It’s the only thing that helps my anxiety.
Facilitator: If you really want me to, I can write down marijuana as your second medicine choice. Like I said before, this is your document. On the other hand, I have to tell you that personally I don’t think that a doctor in Virginia would ever be willing to give you marijuana in the hospital. They could get arrested for that. I know you might have a prescription from Colorado, but here in Virginia it’s illegal. Is there any other medicine that’s helped you with anxiety that a doctor might be more willing to give you?
Client: Marijuana really works the best. I guess I used to take Ativan before I got my prescription when I was living in Colorado. That worked ok, but not great.
Facilitator: Do you think it might be a better idea to put Ativan at the front of this list and maybe just put marijuana at the end of the list?
Client: I guess I’d be okay with that. You’re right that doctors don’t usually like that I smoke it. I did have one doctor who told me it was safer than most medicines, but my doctor now wants me to stop using it at all. I know she wouldn’t give it to me if I was in the hospital!
Facilitator: Okay, I’m going to put Ativan in here in the second line for medicine. I’m going to say that you use it for anxiety. Right?
Client: Right.
Facilitator: Why would you want Ativan in particular? Is there a reason that I should let doctors know why you prefer it?
Client: Because the only other thing that works is marijuana, and you just told me that they probably wouldn’t give me that.
Facilitator: Right. OK, what I’m going to write is that Ativan helps your anxiety better than anything other than marijuana. Is that okay to put as the reason you prefer it?
Client: Yeah. And you should say, “…better than anything except marijuana, but doctors won’t give me that.”
Facilitator: Okay, I’ll add that. Now, what’s the next medicine you want to put as your number three medicine?
Client: The other medicine that’s really important to me is Valerian root.
Facilitator: Valerian? How come?
Client: I’ve read a lot about it. It’s natural, and it helps calm your nerves.
Facilitator: Are you sure there isn’t another medicine that’s more important to list?
Client: Nope.
Facilitator: Okay. This is your list of important medicines so if Valerian root is important to you, I’m going to put it down. What should I fill in for what it is treating?
Client: Nerves.
Facilitator: Okay. I’m going to put down that Valerian root is for treating nerves. Is that right?
Client: That’s exactly right.
Facilitator: Okay. Do you have that list of medicines that you made?
Client: Yeah, I have a right here.
Facilitator: Would it be allright if we stapled that list to your document and then I wrote, “Please see attached list for additional preferred medications?”
Client: That sounds good. That would be fine with me.
Facilitator: OK, let me do that. Now, we need to talk about the medicines that you don’t want.
Client: Good. I have a list of those medicines also.
Facilitator: This works the same way as the ones we just did. We can put your top three medicines that you don’t want on this page and then we’ll attach your list so that doctors have all of your medicines listed. How many medicines do you have on your list?
Client: I have seven.
Facilitator: All right. Now, first, I want to make sure that you understand that if you list medicines here, by law, doctors usually cannot give them to you. So, you want to be sure not to put any medicines on here that would actually be okay with you, because it means that you won’t be able to get those medicines.
Client: I don’t understand what you mean.
Facilitator: What I mean is, if you have a medicine that you don’t really like but that you would be willing to take if you absolutely had to, you don’t want to put that medicine on your list. You only want to put medicines on your list that you do not want in any circumstance.
Client: OK, I get it. I know what you mean, but I don’t want any of these medicines.
Facilitator: Okay, that’s fine. I just wanted to make sure that you understood that. The other thing I want to make sure that we’re clear about is that, although in most cases doctors cannot give you these medicines, there are a few situations where a doctor could give you a medicine even if you put it on this list.
Client: What’s the point of the list then? That’s pretty annoying.
Facilitator: I understand that could be frustrating. Unfortunately, there are some situations where a doctor can “override” your preferences. For example, if it was an emergency, and the doctors thought that you might die if you didn’t get a particular medication, they might be able to give it to you even if it’s on your refusal list. Like, say you were having a seizure. They could give you a medicine to stop the seizure even if your advance directive said you didn’t want that medicine.
Client: So that rule is mostly for an emergency like a seizure or if you were dying or something?
Facilitator: Yes, that’s right.
Client: I guess that’s okay then.
Facilitator: All right, now that I’ve explained that, we can go ahead. What medicine is most important for you to let doctors know that you do not want?
Client: Definitely Zyprexa.
Facilitator: Okay. I’ll put that as the first medicine that you do not want. Do you want to tell the doctors the reason that you don’t want this medicine? You don’t have to, but if you give a reason, it helps them understand why they shouldn’t give you the medicine.
Client: That’s easy. It made me get really fat. I’ve been trying to lose weight ever since then, and I still haven’t gotten down to the way I used to be.
Facilitator: Okay. I’m going to put that it makes you gain weight, and that is why you don’t want it.
Client: Great. The next medicine I don’t want for sure is Haldol.
Facilitator: All right, I can put that next. How come you don’t want that medicine?
Client: They gave me that in the hospital a couple of times. They gave me a shot. It was awful.
Facilitator: Was it the medicine you didn’t like or was it the shot part?
Client: Both.
Facilitator: I can put Haldol down as a medicine you don’t want and put the reason that you didn’t like it is because it was a shot. Is there another reason you don’t want it?
Client: It made me feel terrible. All zoned out.
Facilitator: Okay, I’ll put that it made you feel terrible and zoned out. Also, I’m glad you mentioned that you didn’t like getting a shot. A little bit later, we’ll complete a section in the advance directive about what things you would or wouldn’t want in an emergency like if you got violent. So we can keep that in mind for later.
Client: Okay. Good. I’d rather have to go to seclusion than get a shot. I’m afraid of needles.
Facilitator: That’s good to know, and we’ll come back to that in a little while. Right now, is there another medicine that you want to put that you do not want?
Client: Lithium.
Facilitator: How come you don’t want that one?
Client: I had to take it for a long time, and it started to damage my kidneys. My doctor told me I could never take it again. I want to make sure that they know not to give me that medicine, because it could hurt my kidneys again.
Facilitator: I’m going to put down lithium and put that the reason you don’t want it is because it damaged your kidneys. Now, if you have your list of other medicines, we can attach that to your document, and I’ll write, “Please see attached list for additional refused medications.” You should have four other medications on that list. Is that right?
Client: Umm, if we already put the first three on the front. Then I guess that’s only four left. You’re right.
Facilitator: Okay. The last part in this section asks if there is anything else you want your doctors to know about medications.
Client: Like what?
Facilitator: Like anything. Like, maybe if you have an allergy to a medicine or something like that.
Client: I’m allergic to penicillin. I don’t think I’m allergic to anything else.
Facilitator: All right. I’ll just put, “Allergic to penicillin,” in that space. Is that okay?
Client: Sure.
Facilitator: Okay. That’s everything for this section.