End of Life Planning with Dr. Daren Heyland | E052

Planning ahead to ensure better outcomes.

In this episode of Financial Planning for Canadian Business Owners, Jason Pereira, award–winning financial planner, university lecturer, and writer, interviews Dr. Daren Heyland, a former critical care doctor who now assists people in appointing a decision-maker and planning ahead in the case of serious illness!

Episode Highlights:

  • 1:07 – Dr. Daren Heyland introduces himself and his profession.

  • 2:18 – Jason and Dr. Heyland discuss the stress of making life or death decisions.

  • 3:36 – What are both the industry and the layperson doing wrong?

  • 6:51 – How have Dr. Heyland and his colleagues taken action to make change?

  • 9:10 – What is Dr. Heyland educating his patients about through his Plan Well Guide process?

  • 12:25 – Dr. Heyland discusses how oftentimes, the personal directive of the power of attorney becomes an afterthought.

  • 15:00 – Has Dr. Heyland ever received a Dear Doctor letter?

  • 16:22 – What is the level of resistance to this conversation that Dr. Heyland faces?

  • 19:10 – Dr. Heyland expands on the toolkits that are available on Plan Well Guide.

  • 21:10 – Jason emphasizes the downside to not taking action on time.

3 Key Points

  1. Dr. Daren and Jason believe that the estate planning process is a great time to plan ahead and appoint decision-makers, should the time come, in order to avoid the stress of being named the decision–maker in a stressful moment.

  2. Through his online platform, Plan Well Guide, Dr. Heyland helps his clients determine their authentic values and preferred treatment processes.

  3. More emphasis needs to be placed on naming the power of attorney as well as making everyone involved aware of what the game plan is if the estate owner is to die.

 

 Tweetable Quotes:

  • “When you’re already stressed because you’ve got a loved one lying there in a bed, critically ill, and we add stress to the experience by making them a substitute decision-maker.” – Dr. Daren Heyland

  • “Let’s educate them to capacitate their substitute decision-maker with values and preferences that will be expressed in a way that is helpful to me as a critical care doctor.” – Dr. Daren Heyland

  • “Unfortunately, a lot of people and a lot of doctors go about that process of talking about values in a very loose irreproducible way.” – Dr. Daren Heyland

  • “It’s a much more acceptable and understandable concept to plan for serious illness than to plan for death.” – Dr. Daren Heyland

Resources Mentioned:

Transcript:

Producer: Welcome to the Financial Planning for Canadian Business Owners podcast. You will hear about industry  insights with award-winning financial planner and entrepreneur Jason Pereira. Through the interviews  with different experts, with their stories and advice, you will learn how you can navigate the challenges  of being an entrepreneur, plan for success, and make the most of your business and life. And now, your  host, Jason Pereira. 

Jason Pereira: Hello, and welcome. Today on the show I have Dr. Daren Heyland. He is a doctor who focuses on critical  care medicine. And specifically on the show today to talk about substitute decision-making and who gets  appointed to those roles; and specifically about what professionals and individuals get wrong about this and how we all need to take a different view as to how we should be appointing people and preparing  them in advance for these types of roles. And with that, here's my interview with Dr. Heyland. Daren,  nice to have you on. 

Dr. Daren Heyland: Thank you for having me, Jason. 

Jason Pereira: So Dr. Daren Heyland, please tell us about what it is you do. 

Dr. Daren Heyland: I'm a critical care doctor and I work with very complex sick patients who have life-threatening illnesses,  where we're making life and death decisions. And as you can appreciate Jason, when you're that sick,  you're not able to participate in your own decision-making. And so we're often grabbing a family  member or a substitute decision-maker to help us. 

Dr. Daren Heyland: So imagine this scenario when you're already stressed because you've got a loved one line there in a  bed, critically ill, and we add stress to the experience by making them a substitute decision-maker. And  it led me to wonder, "Surely we can do this better. Surely we can prepare people better for that  decision-making when seriously ill." 

Dr. Daren Heyland: Either for the person themselves, if they're able to voice and find their voice. Or more commonly, that  substitute decision-maker. And we better prepare them in advance. And of course, most people go  through that will and estate planning process where they're filling out a will, naming a substitute  decision-makers. So is that not an opportunity to insert a better planning process as people are thinking  ahead and planning ahead from a will and estate point of view? 

Jason Pereira: So like all things in life, if you prepare for success, it's all going to basically be more successful. And I  completely agree with you. I can't imagine a more stressful situation having a loved one, critically ill, not  able to make a decision. And in that moment of grief... My situation is different, I will have had this  conversation countless time. So I will know to expect what's going to be next.

Jason Pereira: But you have that moment where you're there and you're like, "Oh my God, what's going to happen to  this person?" And doctor's like, "Okay, so what do want us to do?" Not in that tone. But it's like, "Oh my  God, what a position to put someone in." 

Jason Pereira: I'll go back to the... not quite a joke, but a piece of advice of never appoint your mother. Having to make  the end-of-life decisions for a child for a parent is difficult enough, as one female lawyer said to me  once. Was like, "I don't want to do that for my kids. So I always tell people never to do it to their  mothers." 

Jason Pereira: So anyway, let's talk about besides the mom shouldn't be picked up for it. I'm just being tongue in cheek  there. Absolutely they can, if they're ready for it. Tell me about it from your viewpoint, what are we  doing wrong as an industry? Or the laypeople doing wrong? Because some people will arbitrarily pick a  power of attorney without much consideration because it's this add-on document to the will. Right? 

Dr. Daren Heyland: Yeah. 

Jason Pereira: Other people like advisors would take their time will try to coach you through who we think the ideal  person might be, but we're still not getting it right necessarily from your frame or from your point of  view. Tell us where we're dropping the ball. 

Dr. Daren Heyland: Sure. Great. Again, this is a really important conversation we're having. I would say the majority of  substitute decision-makers, when put into that space where they have to interact with doctors, lack the  awareness. Number one, that, "Oh, I didn't know that my dad named me his substitute decision or  power of attorney or agent," whatever the legal term is in your province. Or some say, "Yeah, I knew  that I was named on this form, but we never talked about this. I don't know what his wishes and values  and preferences would be." 

Dr. Daren Heyland: So that's the missed opportunity, is when we're preparing people in there in that space of thinking  ahead, planning ahead, filling out these forms, let's educate them to capacitate their substitute decision maker with values and preferences that will be expressed in a way that's helpful to me as a critical care  doctor or any other emergency room critical care doctor. But the main problem there is that historically  and traditionally we focus on having people predefine their end-of-life wishes. And so we do see a lot of  legal documents where there are instructions in them that say things like, "If I am dying, I do or I do not  want X, Y, or Zed." 

Jason Pereira: Define dying. We're all dying from birth. Right?

Dr. Daren Heyland: Exactly. And that's exactly the point, is I don't know when you are dying. You present to me short of  breath or you present to me in shock, and you've got a possibility that this could be your dying episode,  but there's also the possibility that you could recover from this. 

Dr. Daren Heyland: And so plans laid under the certainty of "I'm dying, or when I am dying, this is what I want or this is what  I don't want" or "If I am in this state, say a persistent vegetative state, this is what I want, this is what I  don't want," isn't helpful to me because I'm upstream here working with a very sick patient where I'm  uncertain about their outcome. 

Dr. Daren Heyland: So we have to think about, "Well, how do we make decisions under conditions of uncertainty?" In fact,  it's actually not the paradigm. The paradigm is, "How do I prepare you or your substitute to interact with  doctors at that point when they're seriously ill and express their values and preferences in a way that we  can make the best decision for them?" 

Dr. Daren Heyland: So we're trying to move away from end-of-life planning. We're trying to move away from instructional  directives, making decisions in advance. But rather, naming of that substitute decision-maker and  capacitating them to express authentic values and informed treatment preferences. So that when  serious illness arrives... And gosh, with COVID around. It could be tomorrow or it could be whenever. But  when serious illness arrives, we've got a plan in place. We're able to verbalize authentic values and  informed treatment preference. 

Jason Pereira: Interesting. So, it's not so much that we're dropping the ball by not having these conversations. We're  dropping the ball by not going deep enough in these conversations. 

Dr. Daren Heyland: Right. 

Jason Pereira: And talking about not just, "Okay, well, you're close to death. So, therefore, no heroic measures," or  whatever term we're going to use. But there is a large degree of interpretation as to both those terms,  from close to death to no heroic measures. So you've been on a [inaudible 00:06:43] one-man campaign  to improve the conversation around this. Tell me what you've done to date to help raise awareness of  this and guide people through it. 

Dr. Daren Heyland: Yeah. Actually, it's not been a one-man campaign. I've been part of a national 

Jason Pereira: I'm giving you credit. Take credit. No, I'm kidding. Okay, good. Credit were credit is due. There we go.

Dr. Daren Heyland: But for 20 years, my colleagues and I have been researching this space trying to understand how to  improve communication and decision-making in the context of serious illness. And I was part of the  founding development of what we call the Speak Up Campaign, which is a national advanced care  planning process, many, many years ago; trying to create that awareness of thinking ahead and planning  ahead. 

Dr. Daren Heyland: But as of late, I've evolved this concept, again, informed by the research that we need to shift this  paradigm. It's not about end-of-life. It's about serious illness. It's not about making decisions in advance.  It's about preparing people for future decision-making. And then, so what that led to was the evolution  of what I call Plan Well Guide. So online virtual educational process, where I work a person through  determining what their authentic values are and their informed treatment preferences. 

Dr. Daren Heyland: They go through that process. They come away with that with a three-page "Dear Doctor" letter, we call  it. But it's the output of their planning process. And it basically says things like, "Dear Doctor, I've been  through this planning process. I understand the difference between serious illness and terminal illness.  Here are my authentic values. Here are my informed treatment preferences. Here are my open  questions and any further issues I'd like to discuss with you." 

Dr. Daren Heyland: So that document then serves as a script for them when they interact with doctors, so that they give me  meaningful information about things that are important that will make better medical decisions, but it  also serves as a script for their substitutes. So it's going to decrease the stress and anxiety that  substitute experiences if and when they're called up to represent that person. So that's what I'm about.  And I'm looking for opportunities such as with financial planners and lawyers to help get that message  out when they're meeting with their clients in that space of thinking ahead and planning ahead. 

Jason Pereira: Well, that's part of the reason for the interview. So let's go through that list. I want to talk about the  specific topics that you cover as part this process. So you're taking us through this journey to make sure  that we end up with something that is as fully informed and as understandable by the people around  you to eliminate that stress and that question. Tell me what it is you're educating them about. What are  the action items you're trying to drive from this? 

Dr. Daren Heyland: Yeah, I think it's important that people realize that these are complex decisions where errors are being  made, and we've documented that and published it in the literature. So you can't be a passive vessel  when you get sick. You've got to be as much as you can actively managing your health, your healthcare  decision-making. If you can't because you're so sick, you have to empower your advocate, your family  member, your substitute decision-maker. 

Dr. Daren Heyland: So the first thing I explain is the nature of decision-making and how that works and what's important  that we hear as doctors to make better or the best decisions for you. And that comes back to this issue  of authentic values. Unfortunately, a lot of people and a lot of doctors go about that process of talking  about values in a very loose, irreproducible way. And so part of what we do with Plan Well Guide is we  educate people on how to express those values in a very transparent, reliable, valid way that then can  lead to better decision-making. 

Dr. Daren Heyland: The other assumption we make in healthcare is that it can be as simple as, "Hey, Jason. If your heart  stops, what do you want us to do?" So as if you are an informed consumer and you know the difference  between CPR or ICU or comfort measures and all we have to do is ask you. Whereas, again, our  research-informed by surveying hundreds of people in scores of hospitals, tells us differently. That you  are not an informed consumer. And I don't say that in a derogatory way. I say that in a descriptive, real  situation that you don't 

Jason Pereira: Anyone who isn't suffering from serious issues of hubris and isn't in a medical practitioner will agree that  they don't know. As much as I spent time around doctors and all these issues, I don't know. 

Dr. Daren Heyland: Yeah. And therefore, a part of what we do in Plan Well Guide is we educate people at a high level, not in  a way that I hope we're not overwhelming people. But we help them have a general understanding of  the risks and benefits and possible outcomes of CPR, cardiopulmonary resuscitation, of going to the ICU,  of going to the hospital ward and just getting medical care, or of comfort care. So you can gain an  appreciation by going through Plan Well Guide of these different buckets of care. 

Dr. Daren Heyland: And we work you through a process to try to help you get a sense of what might be right for you. And I  emphasize the word "might". Because, again, we're not coaching you to make a medical decision today  about some future care that you're going to receive, which is the current paradigm. We're coaching you  on understanding what future decision-making looks like and what you need to say and in the way you  need to say it that will then come together in that moment with your illness, with your doctor to make  the best decision for you. 

Jason Pereira: Excellent. So basically, taking them through this journey, making sure that they've got it all planned out.  This is very much in the planner's realm of what we and so many other things. But now we're going  deeper on a document that was also... I have to say, it's almost like, "Do you want fries with that option  that comes with it?" 

Jason Pereira: Because you're going to get the, "Hey, let's get the power of attorney down at the same time." And it's  vital. You need those things, but they're almost afterthoughts to the complex cases we sometimes deal  with the wills, but incredibly important.

Jason Pereira: So basically, people go through this journey, they end up with this directive document, which is fantastic  because now we have a much more realistic view of how things should be handled. What are the next  steps? Are you advocating for family meetings to basically pass this onto the people responsible for this? 

Dr. Daren Heyland: Yeah. Can I just back up a little bit and 

Jason Pereira: Absolutely. 

Dr. Daren Heyland: ... [crosstalk 00:12:29] to how oftentimes the personal director or the power of attorney is more of an  afterthought? And that's exactly what happens in practice today, where their focus is on something else.  The focus is on the will or the focus is on the broader financial planning point of view. And I really hope  that changes because that's where we need help in partnership with lawyers and financial planners, is to  really beef that up a little bit. 

Dr. Daren Heyland: Because you're capacitating somebody to make decisions for you. Not only these life and death medical  decisions, but imagine you have a serious illness and you survive, but now you're alive and in an  incapacitated state, where there's more decisions being made for you about your personal care. And  you want that power of attorney or that representative to really be acting in your best interests and  supporting you through that difficult stage of life. 

Dr. Daren Heyland: And so we need to put more emphasis on the naming of said individual, their qualifications, their ability  to communicate, to coordinate, to collaborate. And the more we make this transparent about what the  person's wishes were in the context of the family. So not just that one person who's named the agent,  but the whole family culture is aware of mum and dad's wishes. It'll be a smoother journey if and when  that serious illness comes or if and when that being alive and incapacitated state comes. 

Dr. Daren Heyland: So yeah, visit Plan Well Guide, do your planning, but then there has to be a process whereby you're  communicating that to your substitute decision-maker and to the broader family culture that you live in.  So everybody knows what the game plan is if mom or dad or whoever become seriously ill and either  dies in the one instance, or they recover and they could be fine and regain their own capacity, or they  could recover and be still living in an incapacitated state. 

Jason Pereira: It goes back to the need for these meetings in the first place. And I find many people are often reluctant  to do so. People who've been reluctant, I've said, "Look, we can talk about what happens without  getting into the numbers. I don't have to tell you about numbers, but it's important that you  understand, people understand the reasoning and understand the wishes."

Jason Pereira: And this falls right into that category. Right? The more we can communicate with people in advance of  this being an issue, the better. Because the last thing that I always say, "Do you really want them  opening up an envelope after you're gone, or when you're in a bad position, and then reading it and  being like, 'What the heck? Dad wanted this?'" Right? 

Jason Pereira: This is how problems start in families, is the lack communication. So I'm a big advocate of that. So talk to  me about from... You've been advocating for this. I'm curious if you've ever been a doctor who's  received one of these when the time came for someone else? 

Dr. Daren Heyland: No. You mean the "Dear Doctor" letter or the current practice of living wills? 

Jason Pereira: The "Dear Doctor" letter. 

Dr. Daren Heyland: No, I'm not actively practicing anymore. So I'm not at the receiving end of my own tools. But I'm  collaborating with a number of doctors, both in primary care and acute care. We've had tremendous  positive feedback from doctors on the receiving end of these "Dear Doctor" letters. Not only does it  increase the quality of the conversation they're having with patients, but it reduces the time that they  have to spend with the patient on said conversation because they've now got an informed person or  they have to spend less time educating and more time just getting to gold, getting to that bottom line.  So tremendous positive feedback from doctors. 

Jason Pereira: Excellent. Well, doctors aren't exactly suffering from an abundance of time when they're on shifts, right?  So anything that takes away from the cognitive burden or the stress or the role of having to play  counselor in these situations must be a welcome a change of pace. 

Jason Pereira: So basically, this can be a thorny issue for some people. Have you found much resistance to people  you've approached to on this, on how to have this conversation? Or are they like, "You know what? I  really should have this conversation or should go through these steps." 

Jason Pereira: Because it's hard enough to get people to think about what happens when they die, because of the fear  of death. The fear of we'll call morbidity or near death, I got to think is almost more frightening thing for  some people. So has that been a hard conversation starter? 

Dr. Daren Heyland: No. In fact, my sense is the level of interest in this serious illness planning has escalated tremendously  with the help of COVID, unfortunately, right? Because COVID is an example of a serious illness where  there's a probability that people can die, but there's also a probability that they can recover. 

Jason Pereira: Yeah. Fortunately, and unfortunately, there's always a spike in the activity for state lawyers when  there's some sort of crisis or event. Whether it's 9/11 or COVID or whatever it is, something that  reminds us all that we're human. Suddenly it's like, "We should get our wills redone." It's like, "Yeah. You  didn't need a disaster to make it happen," that's all I'm saying. 

Dr. Daren Heyland: I think the changing of the language from end-of-life. Like we have 80-year-olds say to us, "Oh, I don't  want to do my advance medical care planning because I'm not sick enough. I'm not near death yet." So  we can get rid of that excuse by saying, "Well, no, no, no. We're not talking about planning your death.  We're talking about serious illness. You could cross the street today and get hit by a car and we would  need to activate these serious illness plans, or you could catch COVID." And so, it's a much more  acceptable and understandable concept to plan for serious illness than to plan for death. 

Dr. Daren Heyland: And the other thing that I think is a message that I keep pounding that I think is being heard, is if you  ignore or deny leaning into this space, there will be consequences. You will more likely to get wrong  medical care, which will then add to your personal suffering. And you're adding to your family suffering  as they journey with you through the serious illness. 

Dr. Daren Heyland: So the failure to engage has negative consequences for you and your family. So why not? Why not spend  20 minutes of your time, lean into this space, have a few conversations, and then you can buy that piece  by? It's a free tool, but you're buying with your time, a peace of mind that you're more likely to get the  medical care that's right for you. And you will have done your family a favor. 

Jason Pereira: Absolutely. Massive favor. I always say, "If you want to see a family fall apart, go ahead and leave an  estate that's not organized." And I had to think, "This is probably the first step of how bad that goes,  right?" 

Jason Pereira: It's the end-of-life decisions that they put the stress under. It's like they just get through that. Then it  turns around and it's like, "Oh, in addition to that, dad or mom didn't organize themselves and now  we're left fighting over everything." 

Jason Pereira: So, yeah, it's funny. If we had met earlier, I would have included you in my four-part series on estate  planning as the last piece. But nevertheless, I'm glad we did get in contact. So in terms of where to get  started, you have a website, the Plan Well Guide. And that is... Can you give me the URL for that?  Planwellguide.com, is it?

Dr. Daren Heyland: Planwell guide, all one word, .com. Yeah. 

Jason Pereira: Okay. And even for it professionals and advisors who are listening, there is a toolkit that can be  downloaded, which I finally got around to doing while we're on this call. And that basically will provide  tools that will help facilitate those conversations and actually go through the checklist. Is that correct? 

Dr. Daren Heyland: Yeah. And if I may just expand on that a little bit, Jason. Like if you're a lawyer, this means you work in  that way in the estate planning space, when you're having that conversation with your client about wills,  estates, power of attorneys, personal directive, whatever, we've got some language up there on our  website and some tools that you can download. We're asking you to stop making instructional directives  and codify the person's values and preferences using that "Dear Doctor" letter that can be included in  your planning documents for them within the financial planner. 

Dr. Daren Heyland: Obviously, you're still recommending to your client to do their will and estate planning. So this health  conversation, this serious illness conversation, it's there for you as a financial planner. But probably,  you're also speaking to them about serious illness or contingency funds or emergency funds or critical  illness insurance or disability insurance. This is under that broader serious illness planning conversation  that you're having with your clients. And planning for the medical care part fits well. So make a referral  to Plan Well Guide. And again, there's tools in there, all virtual and hard copy that you can download  and print to enable that easy referral to Plan Well Guide for people to use it. 

Jason Pereira: Excellent. No, honestly, this is a incredibly valuable message. Anything that alleviates a family stress in a  time of need and discomfort and great emotional pain is incredibly valuable. And I would say in addition  to that, having gone the extra mile that you've done about putting together online resources for  consumers, online resources for professionals expanding and trying to reach out to us, you're doing  some great work out there and I sincerely thank you for it. 

Jason Pereira: We're going to link to the website in the show notes as well. And I highly encourage everyone to take a  look at the website as well as if you're in this space; lawyer, advisor, whatever it is; to download the  toolkit and definitely make use of it. Because frankly, there is no downside for you, but there's a  tremendous amount of downside for the average Canadian who doesn't have something like this. 

Jason Pereira: And I'll also say it's not too far from some of the other stuff we'll have, like sometimes clients will want  to put in some, "I want to tell my kids this story of whatever it was" or "why I came to these conclusions  and everything else," in the will. And it's like, "That's not for the will." 

Jason Pereira:Sometimes we'll just do an addendum letter where they just write a letter to the family after they're  gone that they can post on top of it. And this is no different. It's just that it's before they're gone and  when that decision needs to be made. So it's not like this is a foreign concept. It's just a different  application of it. 

Jason Pereira: So, Daren, I sincerely thank you for this. Again, this has been great. And I hope that everyone takes the  time to go check this out. And I hope your message gets up there more and I'm going to do what I can to  help. So appreciate it. 

Dr. Daren Heyland: And I thank you for helping me get the message out, Jason. And I want your listeners to realize that this  is a work in progress. If you have better ideas on how I can communicate, what I'm communicating on  the website, or there's different tools that you think I can create to enable you as a planning  professional to be more effective in messaging this to your class, reach out to me. My email is all over  the website. So please don't hesitate to reach out. It's a free tool. It's funded through the research that  I've been doing, and I'm just keen to help people think ahead and plan ahead so we alleviate human  suffering. 

Jason Pereira: Fantastic. Well, thank you yet again for joining us for Financial Planning for Canadian Business Owners.  This was a particularly important message, I think, specifically because this is all about alleviating pain  and discomfort in the worst of times. So hope you took this all to heart, and please do take up Dr.  Heyland's resources online because it's definitely a paramount importance. As always, if you enjoyed  this podcast, please leave a review on iTunes, Stitcher, or wherever you get your podcast. Until next  time, take care. 

Producer: This podcast was brought to you by Woodgate Financial, an award-winning financial planning firm  catering to high net worth individuals, business owners, and their families. To learn more, go to  woodgate.com. You can subscribe to this podcast on Apple Podcast, Stitcher, Google Play, and Spotify.  Or, find more episodes@jasonpereira.ca. You can even ask Siri, Alexa, or Google Home to subscribe for  you.

FPCBOJason PereiraCritical care