Live on Facebook about to get started on the show, got Annette with me. So here's the opening music.

Not Lisa.

: John: All right, here we go.

: Welcome to "Aging Insight" everybody, this is your host John Ross, here Live in the studio. You are listening to the number one place to get information on your health, housing, financial, and legal needs. I'm John Ross, and I'm your host, normally here in studio with my co-host Lisa Schoalmire who apparently just likes to go off and do things on the weekends. So once again, I am here not with Lisa Schoalmire, but I have brought in a guest. So today joining me is Annette Mugno with Dierksen Memorial Hospice.

Who has no life and nothing to do on the weekends.

Clearly.

There you go.

So there you go, and you have been on the show before.

Been a long time. Glad to be back.

Excellent, so lots of good stuff going on out there. I spent quite a bit of last week out running my mouth. I think I was in Camden one day, I was in Marshall one day, I was in Carthage one day because we like to get out there and get you all the information that we need. And as far as that goes, coming up on the 23rd which will be in about two weeks, we'll be back with our Eggs and Issues Breakfast over at Trinity Church. It's free breakfast about 0830 in the morning over at Trinity, right there off the interstate. And it's a great program. Topic, I believe is going to be, scams on seniors. Particularly, we're gonna be talking about some of the more modern takes on it because we're seeing them get more and more advanced as they go along.

I did not. So I'm sitting here doing the walk of shame, I promised you I would. Unfortunately, I got a call that said I was gonna be in Charleston, South Carolina, so I'm not gonna be there.

Surely there's somebody with Dierksen that needs to go over the edge.

There's a lot of them I can think of that need to go.

Well, we're gonna have to pick us one, we're gonna pick us one with Dierksen because...

But it is work that's taking us there so a lot of us are gonna be going.

Because you know one of the things that we have…and this goes to all the listeners'. Maybe you work at a shop or whatever, you got your job. We have a thing that we're calling Toss the Boss. So sign up the boss, get all the staff people to throw in the money, hit that $1,000 mark, and they're going over unless they match it.

Gotcha.

And if the boss matches it, then they can pick somebody else to do it. So maybe...

But all the bosses are gonna be there, so none of us are gonna

Come on, we are gonna figure something out. Somebody's gonna do it. All right, so that's coming up. It's gonna be a great program. And like I said, if you're not interested in doing it yourself, we've got lots of edgers, that's what we're calling them, lots of edgers out there who would love to have your support. And of course, all the money goes to the Tri-State Alzheimer's Alliance right here in Texarkana, and it's local. All the funds stay here local, and provides a great support. Particularly, those funds help keep the Our Place Day Respite Centre running.

Am I? I thought I was just her as a sidekick.

Yeah, just somebody...

Just hanging out.

Just somebody for me to have in the studio with me today. So what's your background here? You're a nurse, right?

I'm a nurse, I've been a nurse for... You know, do I really need to say how long? It's been a long time I've been a nurse.

Let's just say that you've done it long enough to be somewhat of an expert in the field.

Right. In some areas you could say I've been grandfathered in. I've been doing it that long.

There you go.

And then I've got over 15 years of experience strictly in hospice.

All right, so definitely know what you doing out there, and of course, you work for Dierksen Hospice.

I do work for Dierksen.

Is it Dierken or Dierksen?

It's Dierksen.

Dierksen?

: Yeah.

: Everybody mispronounces that.

Yes, well because there's Derek's Arkansas and so it's Dierksen. And sometimes it's spelt with an e, sometimes its spelt with an o, sometimes it's Diorksen. I mean…

Well, of course, everything in Arkansas is mispronounced too.

I don't care how you say it as long as you call us.

That's right, all right. So, fair enough. All right, so I was reading an article this morning and this was in "The Washington Post," and it was talking about how living wills, DNRs, things like that are misinterpreted often by medical staff. And anybody who's listening to the show before has heard Lisa and I say over, and over, and over that there are four things everybody walking around over 18 in the United States should have in place. That would be a financial power of attorney, a medical power of attorney, a HIPAA release, and a living will.

That's right.

And what happens if that adult person becomes incapacitated. What if they get in a car wreck down there in Waco? And I've had many parents find out the hard way that just because they're the parent, doesn't mean they have any say so whatsoever on that adult person.

That's correct.

So we talk about all of those things, and the last one of those being the living will. And I mentioned I was speaking in Marshall, and my topic in Marshall was actually related to how to save a house from Medicaid. But as it always happens, I get folks asking questions at the end, and somebody in there said something about a DNR. And I said... Well, I think they asked about you know, any documents. I said, yeah you know, medical power of attorney, financial power of attorney, HIPPA release, living will, and they were like, "Yeah, living will, same thing as that DNR, right?"

No.

No. Right. Unfortunately, as common as that misconception is in the general population, what's really concerning is if that same misconception is in the medical community. And I have found that to be the case in some situations.

It absolutely is. And the other thing that's really confusing to the medical community is we are very unique in being in this Tri-State area. And with each state, the law changes a little. So some of our physicians that are from Texarkana may have trained in Arkansas, and then they come and practice in Texas and vice versa. Some of them go to LSU and then they come up to Texarkana, and all of the regulations regarding the state change.

Right, because all of these rules are state-based rules. There's no federal rules related to these documents, other than the HIPPA, I guess. But when we're talking about these end-of-life type decisions, yeah, it's all based on state law, and the interpretations are based on state law, and they can get really complicated. There's a whole semester-long course in law school that's called, "Conflicts of Law," and it's a whole class in law school on what do you do when you've got different states doing different things and... So if I'm a Texas resident but I'm in a hospital in Arkansas, then which a law applies? Is it Texas law or is it Arkansas law?

Exactly.

And there's a whole… Like I said, there's a whole complicated semester on this in law school, which kills many law students because it's so complicated. So even the people that are trained in legal stuff have a hard time with this issue. So you certainly get with the medical. But anyway, so this Washington Post article had had this...it opened...the thing opened with this scene from a hospital. And they've got this person in, they're unconscious, they're maybe having a heart attack or whatever it is. And the nurse yells over at the doctor and says, "Don't resuscitate. They've got a living will in place." And you're laughing because to us, that's funny because it's so wrong.

It's bad wrong.

It's so wrong. So we're gonna talk about a lot of the sort of things today, and just kind of the differences between the two, and maybe some things that y'all can do out there. So let's start with the living will, right? So in your... I can talk about it from what it is as a legal document, but tell me in your medical opinion, what is a living will?

A living will is what the patient themselves execute, that just kinda has what they would like to have done at the end-of-life, okay. So there's a will like you would deal with every single day, "When I die, I want so and so to have this."

Yeah. "Little Timmy gets the car."

That's exactly right, but a living will is exactly what it says it is, it's what is your wish while you're alive? But unless it's been executed into a formal document, and the power of attorney is there, and then you have DNRs, and all of these other things that have to roll along with it, it really isn't substantial. And let me just give you a word of advice when it comes to physicians and nurses and all the people who are actually putting hands on them. And I know this is terrible. But we're in a very...our society is to a point now where we'll sue each other because we dropped coffee. And it's our fault but you were there and you laughed and so now I'm gonna sue you because you humiliated me.

That's right.

So people who are no longer alive can no longer sue you, but family members absolutely can. And even if they knew that was the wish of the patient, they're gonna sue you just because they're in mourning and you're liable.

Yeah, and the doctors know this, the hospital's know this.

Yes.

The rest of the medical professionals know this. So yeah, you know, from the legal standpoint, that living will is you saying, "Here's what I either want or do not want once I have gotten into a certain particular situation." And that certain particular situation is that you have an irreversible or incurable condition that will cause death without continuing medical intervention. Or you are in a persistent vegetative state.

Yeah, seems simple

It's seems simple. And I think, you know, a lot of times people say...at least when I'm talking to them, they often say, "Yeah, John, just pull the plug. You know, if I get in that spot, I'll just pull the plug."

Yeah, and I mean I have this conversation, I have this conversation daily with patients and families, and I have this conversation pretty frequently with my spouse, my children, and my family. And we as people tend to say, "Do we want it?" and actually there's a lot of studies out there that have been done that says you know, when we went out and we did a perception survey, how many people said, "Do you wanna live in a constant vegetative state?" Well, almost 100% of them said, "Absolutely not." But then they ask, "What have you done? What have you put in place to prevent that from happening?" And almost 100% of them said "Nothing."

Yeah, and that's pretty much right. All right, we're gonna take our first break of the day. So stick around until after this. We're gonna get into a lot of the other details: the differences between the living will and DNR, and some things like that. So lots of good information today.Stick around, we'll be back.

I'm gonna stand up and let the...

Let the blood.

Blood come back to my legs. You all are gonna get to see what happens whenever I choose to stand.

Yeah. So just disappear below the...

Yeah

There is a height difference between Annette and I, slightly.

There's kind of a height difference between me and everybody.

Slight height difference between the two of us. All right. Here you go, pop quiz, right? So you're at the hospital, right, you're in the ER, they have brought in this unconscious person that is, as you and the hospital people like to say, actively dying, right, which to me is the weirdest phrase ever.

There's more phases than just active even, there's transitional, there's...sometimes it's even circling the drain.

So we got this person that's actively dying, you got them in there, you pull their shirt off and this is what you see.

What am I looking at?

Oh that's cute. It's not effective.

Very good. This is true. That is not effective. This was actually... This is a real picture from a homeless person that was picked up off the streets in Chicago who...

A tattoo across the chest that says, "Do Not Resuscitate."

Is a great idea, and I wish it were. I wish it were a legal document. I mean, I can't imagine anything more permanent than taking the time to ink it on yourself. That's exactly how, you know, you think you can...when I can't talk, you can still read me.

Right, see here.

That's exactly right, but it's absolutely not effective.

Yeah, so the hospital in Chicago, they did go ahead and administer life-saving procedures and saved the guy. And there was some discussion as to whether or not they had done the right thing. I actually say that they did the wrong thing for the right reasons.

Well, I started to say, the question isn't really did they do the right thing? It's like, did they do the right thing, or did they do the legal thing? And sadly, that's what it's come down to, and you can hear me say that over and over and revert back to legal things. Look at malpractice insurance nowadays, and it will exactly explain why I put so much focus on it. It's not the right thing in any way. It is, however, unfortunately, the legal thing.

Yeah, the interesting thing on that would have been what if he would have had two witnesses, and his treating physician also tattoo their signatures onto his chest?

Now, that would have been okay.

I think it might have been.

: Annette: I think it would have worked actually.

: John: It just might have been.

Nobody said the paper or the parchment had to be of any particular matter. It just said you had to have those things.

Yeah, you just have to have those basic things. Anyway, I just always thought that was interesting. I did a whole show on just that one a while back.

Yeah, you're gonna get to watch me climb up. It's like a ladder.

All right, we are going back to live in four seconds.

I'll take the earphones off.

What?

I have to take the earphones off with the short in it.

Okay.

All right, here we go. Welcome back to "Aging Insight" everybody, this is your host John Ross here Live in the studio today with Annette Mugno. I have to... Mugno.

Okay, I'm gonna have to say.

I have to... Every time I say it, because I've known you for so long that I have to remember that you have a different last name.

I do.

So that I stumble every time because I don't wanna mess it up and I mess it up anyway.

Everybody messes it.

Yes, so today we're talking about living wills, DNRs, and this sort of stuff. So we were been talking about the living will, which is you saying what you want there at the end-of-life or don't want there at the end-of-life. And I think one of the things that a lot of people don't necessarily understand is, what exactly is a life-continuing procedure?

That really varies. I mean...and there are documents that can break it down into very, very, very specific things, and that's where we get into some issues. Is because the average Joe on the street doesn't know what constitutes a life-sustaining device. And then some life-sustaining devices can be used strictly for comfort. An IV could be considered a life-sustaining device, even if it's just putting fluid in because if we don't have fluid we die.

: John: Exactly.

You can't go more than about three days without hydration. So in that circumstance, absolutely is considered a life-sustaining device. Oxygen absolutely a life-sustaining device, although if you are actively dying and you are truly terminal neither of those will save you independently.

Okay, yeah, and others that are...something as common as antibiotics.

Absolutely, absolutely, and lay people tend to think of what is a life-sustaining device, we wanna get really technical and go those are things like ventilators, and being intubated, and CPR, and they are. Those are a more aggressive life-sustaining devices, but there are lesser aggressive life-sustaining devices as well.

Yeah, and I think this is where a lot of people...again, they don't necessarily know, and I have...although I will say that the vast majority of people once I explain to them where they would be at this point, right, how far down the road of bad health they are, before this becomes an issue.

Actually yeah. The question for most people, the way I tend to put it, and I wrote it down so I get it right because, you know, this is what happens, is do you want a long lifespan or a long health span? And those aren't necessarily the same. We all tend to think, "Yeah, I'd love to be 110," would you though? What if you couldn't communicate? What if you were in a vegetative state? If you were in a bed, contracted, and you were in constant need of all of your ideals or activities of daily living. You had to be fed by a tube, you had to be changed by someone else for your incontinent care, is that a life that you want? So in that case, do you wanna be 105, or do you want to be whatever age that you stop sustaining yourself with quality to yourself, what you consider quality?

Exactly, and then the other thing that I think a lot of people have some misconceptions on beyond just that, you know, one they don't know where they're gonna be in this position. And once it's explained, look...like you said, you know, you're gone basically, right? Your body's there but all the other things are gone, and then now would you still want these things? The other thing I see a lot is people have a misunderstanding of essentially how death works. And so, for example, I had somebody just the other day that... They had a big issue with artificial hydration, right? They said, "I want the living will, no artificial means whatsoever except artificial hydration."

Right, and so then it comes down to semantics, and really a lot of study. And this, honestly guys, is still a real controversial thing even in the healthcare industry. Because I know some healthcare professionals who've said, "I've been really, really, really sick and I was thirsty and I wanted hydration." Yeah, but it's hard to know what happens when you're actively dying, or you're terminally ill. Without getting too religious, I always say there's a way we were made to come in this world, and there's a way we are made to go out of this world.

Good stuff. We'll be right back after this break. Sorry.

Sorry. I was like, "What are you doing with your fingers, man?"

I was trying to count you down.

You're used to playing with Lisa and you all know this thing, I'm just like.

Yeah, I forgot to warn you our bottom of the hour, we have to take a news break, Fox News starts…

The things you should tell me to begin with.

Fox News starts at 12:30 whether you're still talking or not, so all right...

All right, so we learn or I learn, who knows.

Well, Arwen did give you a thumbs up.

Sweet. I love Arwen.

So there you go. You know, I had a...and I may mention this, but I had a case years ago where a gentleman was at that point, had two daughters and he was a silent aspirator.

Yes/ Does everybody know what that is?

:John: Meh, probably not.

So sometimes...and I always wanna make sure I'm not talking over anybody, and I'm also not wanting to offend anybody by you know, making...or assuming that you don't know what we're talking about. But a silent aspirator is a person who when they drink or eat food, rather than swallowing it down their digestive tract as they should, part of that goes into their lungs. And they will develop what is called an aspiration pneumonia where the fluid collects in the lungs.

Right. But they're so paralyzed that they don't cough or choke?

Right.

They...

And sometimes even if they do choke or cough, it doesn't matter, it's too late. I mean, I've literally looked at X-rays with patients that had bacon and eggs in their chest, yeah.

Okay. That's nasty.

It is, but again it is 100% accurate. And so one of the things that I was talking to my husband about this morning, I said you know, I just want people...the reason why we do these shows are to make people understand what you see on television isn't accurate. A lot of what you hear is people who are semi-educated on it and a lot of times isn't accurate. And so I just wanna break it down into a regular conversation to where we're putting accurate information out there. So when you make these informed decisions, they're informed based off of something that's actually accurate.

Right, well, and of course, this was one of those situations where we had two daughters, they did not like each other. And so you can imagine that they had a difference of opinion when it came to the care. And the doctors had said, "This is a done deal, this is permanent. There's no going back from here." So it's either feeding tube or not, and my client said, "Dad wouldn't wanna live like that, let him go." The other daughter said, "This is cruel because you're starving him to death," is that starving him to death? No.

No, again back to what...

And so explain it, so why isn't it?

Well, okay. First of all, can we withhold nutrition? Absolutely. Should we withhold nutrition? That's up to the person that we're withholding nutrition from, okay. So it's their perception as to what they wanna do as to what you really consider it. So is it keeping them comfortable or is it forcing nutrition on them? Because it's just as wrong to force something on someone who doesn't want it. And like I said before, a lot of times when you're in a terminal state, you aren't hungry. So you will offer food and they will often times tell you no.

Well, and in this particular case, one thing we did have was he did have a living will in place and it specifically mentioned no artificial nutrition. Whether or not he really had thought all of that through, or whether or not he had just signed something that somebody had put in front of him, I don't know. But what we did have was we had what was on paper which was no artificial nutrition. Unfortunately, we had to go and have a judge confirm that, and then get an order sent back to the hospital and everything.

For them to not give him artificial nutrition.

For them to not do it.

And that's exactly right.

All right. Going back live. Welcome back to "Aging Insight" everybody, this is your host John Ross here in the studio with Annette Mugno of Dierksen Hospice. Is it Dierksen Hospice, Dierksen Memorial Hospice or…?

We'll just call it Dierksen Hospice.

Dierksen. I still messed up, didn't I?

It's okay.

That's fine.

Actually, just so we put it out there, it is actually a long name. It is Lester Dierksen Memorial Hospice because that's exactly what it is. It's a memorial hospice based off of Mr. Lester Dierksen.

Got you.

But for that for all of us out there, it's just Dierksen.

All right, if you're listening to the radio, you can also login to Facebook, as we've been doing for about a year now. We're doing all the radio shows on Facebook Live. So if you'd like to see how to spell Dierksen, I have put it on the Facebook, so that you can see it. And you can also get on Facebook and see the height difference between John Ross and Annette.

This is on an elevated stool.

John this is on an elevated stool. All right, so we're obviously... You know, the thing is, you know, you're in the hospice business, so you get to talk to people about...

Death and dying, absolutely.

Death and dying on a daily basis. I'm in the estate planning business, which means I get to talk to people about getting old, getting sick, then dying on a daily basis. And so people that are listening may seem...maybe it seems a little squeamish to them that you and I are laughing and joking, while at the same time having this conversation. But that's the way it should be, right?

Right, and that's what I was laughing about this morning. I said, "This outfit isn't..." because John gave me an hour's notice that, "Hey, I could use you to come in here and sit with me if you want." I'm gonna say this was done intentionally to take on a comfort level because that's the level we should present it at any time we have that conversation. I really wish people wouldn't wait until the last minute, until someone is actively dying or very sick, terminally ill, before they have that conversation. Have that conversation over coffee, just sit down and start talking about it one day.

Yeah, and again, you confront this stuff head on. At least that's my personal philosophy. I have a friend of mine that was in my Marine unit, he's actually I think a year younger than me, and he has pancreatic cancer.

There you go.

And I found out a couple months ago, and when I found out I gave him a call and I said, "Hey man, I hear you're doomed."

Exactly.

And you know what, that immediately broke the ice, it got us past the big elephant, and then we could go on and have a two-hour long phone conversation about old times, and it was great. You know, so yeah, so we do, we joke about it but it's serious stuff but you gotta just face it, and go head on.

It happens and sometimes people… Nobody knows better than a terminally ill person that they're terminally ill, and they get accustomed to people. Everybody that comes in and talks to them about being sick. Please don't ever forget that they're still human, they're still the same person who you knew six months ago, or a year ago, or two years ago, that wanna have companionship last time with someone who wants to talk to them something about other than being sick. And if you do talk about being sick, make it funny. One of my really good friends that passed away, she had liver cancer, her eyes turned very, very yellow, and so when she took her sunglasses off one day, I looked at her. I said, "Oh my God. Is there a superpower that comes with those?" you know, "Do you have x-ray vision? I just need to know."

: John: Exactly, that's exactly right.

So try to make light of a difficult situation if you can.

So we were talking about the living will which again, the living will kicks in once you...you know, this is you while you're alive and competent and thinking down the road, and saying, "Okay, if I've gotten to this end-of-life point, what kind of procedures would I want, would I not what?" One of the most common misconceptions is that the living will, which is also called a directive to physicians if you live in Texas. Because apparently, the Texas legislators had to give it a brand new name when everybody already knew what it was called.

And we can really confuse them with Texas.

So living will/directive to physicians, same document, different names, but people often confuse that with the Do Not Resuscitate order or DNR. These are not the same things, right?

I wanna watch a professional get stumbled up by this. I really do, because this is really difficult for everybody. So I'm just watching you trying to sort this out, if you can make it sound better than me.

So here's my DNR. The DNR is Do Not Resuscitate which basically, the way I often describe it is if the death process starts, don't stop it.

Pretty much, yeah.

That's how I describe it.

Okay. And, let me just also add, in the lovely side of Texas, there are two separate DNRs. And why this is, I'm not aware. So don't look at me. It's not my fault. I didn't do it. I'm just making sure you know ahead of time. You're gonna need two, if you find out you're dying in the hospital, there is a in-hospital Do Not Resuscitate. And then if you decide you wanna go home, and continue your dying process at home surrounded by people that love you in a comfortable environment, then you have to have another one that is an out-of-hospital Do Not Resuscitate.

This is also correct.

Yes, and you have to have it before you leave the hospital because if you only have the in-hospital, and you get on an ambulance and you get around the corner and you start dying, they're gonna code you and send you back to the hospital.

Right, so yeah. You do have... So yeah, in-hospital DNR, out-of-hospital DNR. They're basically, you know, from a medical standpoint, they're basically still the same thing.

They are.

So why do we need two?

There's no reason.

Go change that.

Unfortunately, I've got…well, I was gonna say something nasty about the Texas legislature. But since I'm live broadcasting on multimedia, I'll...

I've been thinking about saying something nasty about Texas legislature.

I'll just keep my mouth shut for a moment on that issue. So I got a call...actually, I think it was an email, but I got a call, email something. It might've even been a comment on Facebook at one point. But this was from a hospital nurse and they had a person in hospital with an in-hospital DNR, and they were they were feeding the person who basically choked on it. And the question was basically, you know, doing any sort of intubation or anything to clear that blocked passage, is that appropriate with the DNR or not? That's a tough one, isn't it?

Yes, so I wouldn't consider a finger sweep, if you were choking, to be resuscitative measures. Because...let me just throw this in there. For what we do on a daily basis, if a patient is on hospice and they have a Do Not Resuscitate order, I still give them antibiotics. I mean, we've already talked about it. Antibiotics could be life-sustaining in certain circumstances.

But it's not a DNR issue. That's a living will issue.

Right, so a finger sweep is not considered really a resuscitative measure in and of itself. Now, if the easiest modes of transportation in getting that out were not effective, then what would you do?

Right, and that was basically...that was my position on it, was essentially if a tool is involved. I mean basically...

Well I mean if you...because it's a hospital. So the patient has got a DNR, yadi-yada, so you're gonna have suction. Now, oral suction versus endotracheal suction down in your chest, there's even a difference in that. If I were to suction out your mouth, you do that at the dentist office. That's not really considered...

That's no big deal.

…life-sustaining. And I would do that if that could. You could see it. If you can see if you can visualize it, yes. But then if you're gonna start something super aggressive, is that what you wanna do? Is that what they want you to do is actually the question.

And the main thing I think people, the general population, particularly needs to understand is that there is a big difference between that living will and that DNR. I've had some folks that were very hesitant to take my recommendation of doing a living will because they had the impression that if they signed that document, and then had a heart attack, that everybody was gonna sit around and drink tea while they died.