I have found the discussions within my community to elicit rich conversations about what matters to people as they approach the end of their lives.  Likewise, the ethics consults I am part of are complex and thoughtful.  Two contrasting dilemmas are seen pretty regularly.  There is the distraught family in the waiting room with little insight into what mom, critical in the ICU, would want as she struggles on a ventilator, near the end of life.  There is also the family who holds in their hands documents written 5 years before which say their father would want “everything” done to prolong his life.  Sometimes it feels like “I don’t know” versus the “I know too much.”

Because of these two ends of the spectrum, I spend spent a lot of time encouraging people to tell their loved ones what matters to them.  I do this knowing how those goals may well change over time -- in response to progressive disease, life events and such specific (but unforeseen) situations as a COVID-19 pandemic.  In a recent essay, Dr. R Sean Morrison challenged the whole notion that advance care planning (ACP) “works.”  He questions whether any of our professional or public efforts to encourage ACP has led to improvement in providing “goal-concordant” care at the end of life.  We providers aren’t very good at prognosticating or recognizing when a downturn is terminal.  Our patients aren’t very good at predicting what they would want in a future “peering into the abyss.” They adapt, their fears may be worse than the reality of serious chronic diseases.  Choices are complex.  They require the skills of palliative care specialists trained in guiding people through the situations they find themselves in. It takes special skills to keep us and our patients from making decisions in the abstract that, when written in stone, may not represent wishes at the time of crisis and may confuse providers and family further.  We need to be humble about how our futures may unfold but somehow keep breaking the taboos around reflecting on death and dying.  Advance care talking is certainly a worthy value.