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Physician executive Joseph Pepe discusses his article, “A doctor’s guide to preparing for your death.” He shares practical and compassionate advice on planning for life’s inevitable end, from organizing essential documents and creating a “death folder” to protecting loved ones through wills, trusts, and life insurance. Joseph explains why facing mortality head-on allows people to live more freely and meaningfully. Viewers will learn how thoughtful preparation transforms fear into peace and why readiness is the greatest gift you can leave behind.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Joseph Pepe. He’s a physician executive. Today’s KevinMD article is “A doctor’s guide to preparing for your death.” Joseph, welcome to the show.

Joseph Pepe: Thank you. Thank you very much, Kevin.

Kevin Pho: All right, let’s start by briefly sharing your story and jumping into the KevinMD article that you wrote for us today.

Joseph Pepe: Sure. My story is that I’m retired now. However, I feel it’s been a lifelong process of being what I like to say is on all sides of the bed. When I was 17, I was in a car accident and fractured my neck. I was paralyzed from the neck down temporarily. But I learned a lot of lessons through that.

Then I went on to school at college, and I was a biology major. During that time, I also picked up a lot of ethics and moral values, which helped me later on in life as a physician.

I then went on to attend Tufts University School of Medicine. In the summers of college and medical school, I was a home health aide. I was an orderly in a nursing home. I was an O.R. technician. I was an orderly in a hospital. I got a lot of experience with all sides of the bed, so to speak.

Eventually, I became an internist and practiced in New Hampshire, where you are located now.

After a while, I gradually got into health care administration and became the vice president, senior vice president, and chief medical officer of a 330-bed hospital. After that, reluctantly, I would say, I became the CEO of that 330-bed hospital with 3,000 employees.

During that time, I was on the board of many hospitals. I was even on the board of an insurance company, and I became a patient several times. Two of which I had life-threatening illnesses myself. Then my wife got some very difficult news that she had a terminal illness. I then became a caretaker as well.

When you look at all of this, you can see why I say that I feel like I’ve been on all sides of the bed. Now that I’m retired, I started doing some other things, such as writing and giving back.

Kevin Pho: And your KevinMD article talks about “A doctor’s guide to preparing for your death.” I’m interested in hearing your perspectives from all sides of the bed on this topic. For those who didn’t get a chance to read your article, tell us what it’s about.

Joseph Pepe: Yes, it’s about how we need to prepare for our death. It sounds morbid, but it is a practical thing to do. People don’t like to talk about it. I think as clinicians, we need to get people to talk about it because 60 percent of adults do not have advanced directives, and only 31 percent even have a will. That leaves your loved ones scrambling. What I’ve learned is that it’s best to prepare so that they can grieve without having to go through all the chaos that surrounds documents and what needs to be done after someone passes.

It’s things like coming up with a list, a checklist, and everyone’s will be different because it’s different based on who you are and your age and circumstances change. But it’s important to have that to-do list so that your loved ones can go to that list and get things like your passwords in all your digital, financial aspects, and everything from websites to all your bank accounts, things that they will be scrambling for if it’s not done.

I think it’s more than advanced directives. I like to say that: People should be looking at estate planning. With estate planning, it’s about revocable trusts. Anyone that has a net worth over $250,000 should really consider a revocable trust.

That deals with the assets and distributions afterward. But in that packet of estate planning, you would have a living will or advanced directives, you would have a health care proxy or the medical power of attorney, so to speak, as well as a DPOA for financial reasons, HIPAA releases, all the things that your loved ones will need after you pass, and optionally even a DNR status or a POLST.

It is very important to make your wishes known because it takes the pressure off your loved ones. The idea of the article was everyone wants to be like a turtle and put their head, legs, and arms in, but the situation is still there. You have to take care of it. I do believe that it’s difficult, but it’s all about minimizing the overwhelming tasks that your loved ones will have to do when you pass on, and that’s the best gift that you can give.

Kevin Pho: When we’re talking about the health care aspects of preparing for your death, you went through a lot of terms: advanced directives, living wills, POLST. Go through some of these terms for those who may not be familiar with some of the nuanced differences between them all. Tell us about these terms, what they mean, and how they should be prioritized.

Joseph Pepe: Sure. For example, an advanced directive will talk about your medical treatments, what your wishes would be, and your preferences. So many times I’ve been at the bedside of a patient, and the family is sitting around saying, “I want to do what they would want. But I don’t know what they would want. We never discussed this. They never wrote it down.”

That’s what advanced directives are all about. It’s truly about what your wishes would be if you should become unable to tell us. Whereas something like a POLST is more of a physician order for treatment, and that’s about orders.

When I talk about POLST or orders like that, or DNR, everyone has to go by the state because not all states will go by a POLST or a do-not-resuscitate order. Florida is different than New Hampshire, which is different than North Carolina.

The advanced directives are about your wishes. DPOA, durable power of attorney, has to do with finances. HIPAA has to do with the ability of your loved ones to be able to talk to your doctors and obtain records so they can make informed decisions. It’s all about making informed decisions.

The other thing that we don’t talk about a lot is a revocable trust. That’s one of those things. It doesn’t have to do with medical treatment, but it does have to do with managing your money and your assets, as well as distribution, and also helps your loved ones avoid probate, which will save them a lot.

This packet of estate planning is something we should be discussing with our patients. I think that we tend not to do that because there are so many things to talk about, but it’s just as important as some of the things we talk about, meaning: the stop smoking, the exercise, and all the other things that we educate patients on.

Kevin Pho: Now, what’s the best way to introduce end-of-life wishes or planning in the exam room in the context of a primary care 15- to 20-minute visit?

Joseph Pepe: Yes, sometimes it has to be done in more than one visit, certainly. But I think the biggest obstacle is that people do not believe that they’re going to have a sudden death. What they don’t know is that there are 320,000 unexpected sudden deaths a year in this country of those between the ages of 20 and 64.

Everyone thinks they’re going to have time to do these things, so I start off by saying, “You’re healthy now. You’re stable now. However, anything can happen, and it’s certainly something that we should discuss because it’s, if not for your sake, for your loved one’s sake.” Once they hear that, once they hear that it’s not about themselves, it’s about the people they love, they’re more open. They’re more receptive to listening to what we have to say.

Kevin Pho: Now, other than not planning for this at all, what do you see as some of the other big mistakes families make when it comes to end-of-life wishes and planning?

Joseph Pepe: I think some of the biggest mistakes that I’ve seen in my over three-decade career is that I’ve seen families struggle with what a patient would want, but instead of thinking about what the patient would want, they think of what they would want.

It’s a very common mistake. A daughter or a spouse would say, “I want this,” but they’re thinking about themselves. Not in a selfish way, but that’s the thinking that they process. What I do is I try to turn that on its head, and I say, “This isn’t about you or about your brother, or about your mother, or about your son. This is about, what do you think he or she would want?”

Then right away they have an answer. Sometimes they go, “Oh, they wouldn’t want this.” Or, “Oh, they would want X.” By reframing that question, I do believe we’ll be able to help patients and their family better.

Kevin Pho: One of the things that you wrote in your article is shifting their mindset from a fear of death to seeing preparation as an act of love.

Joseph Pepe: Exactly. I do think that there’s a common theme where everyone wants to avoid talking about this. They think that if you talk about it, you are inviting it. We know that superstition is not logical. It’s not scientific, but it’s out there.

It’s trying to allow people to think seriously about this. Sometimes it seems overwhelming, so I tell them, “You need to break it down. You have to do one step at a time, start small, and set a date on your calendar, on your smartphone, to say, ‘I’m going to start doing this.’ This isn’t about perfection; this is about progress.”

The list that I have for my loved ones is much better now than it was four years ago. It should be updated every six months. The first part is getting started.

Kevin Pho: Now, many of us in health care, especially new physicians, don’t get a lot of training in medical school and residency when it comes to talking about end-of-life care. What kind of tips could you share for physicians who may not be comfortable bringing it up in the exam room?

Joseph Pepe: Well, some tips I can share is that it all starts with that ethical decision-making. I do think that’s a huge lesson for all clinicians.

I used to have a statement that I lived by and it helped me, and it was, “If you do what’s right by the patient, you’ll always be right.”

We can’t predict outcomes, but if the intent is correct, if the intent is to do what’s best for the patient (not what’s best for me, not what’s best for my group or my hospital or my partner, but what’s best for the patient), then any outcome that occurs almost doesn’t matter. You can sleep at night, you’ll have no regrets.

I think people get lost. Clinicians get lost on decision-making because they haven’t been taught that. I know that you can have classes and courses on it, but I think that if you just take that statement, if you just do what’s right, you’ll always be right, I think that will help clinicians.

Kevin Pho: In a primary care practice, I sometimes find that there are cultural nuances when it comes to discussing end-of-life care, where some cultures may be more hesitant to talk about end-of-life wishes. How do you navigate some cultural barriers to discussing end-of-life care in the exam room?

Joseph Pepe: That’s a difficult one because there are a lot of different cultures in many cities, and our hospital happened to be in a city. A lot of it was self-learning. When you had to do a discussion that involved something like this, you know when it’s not landing.

You have to do your research. You have to find out what it means in this culture. Then the next time that comes around, you can take it from that. I don’t expect everyone. I certainly did not know every culture and how they thought of death and the dying process.

But I do know this, that when I did not land the conversation, and you can tell when you don’t land the conversation, then you end up having to back up and do your research.

Kevin Pho: We’re talking to Joseph Pepe, a physician executive. Today’s KevinMD article is “A doctor’s guide to preparing for your death.” Joseph, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Joseph Pepe: The take-home message is just this: Preparing for death isn’t morbid. It’s a gift. It’s a gift to your loved ones. It frees them from the chaos and the guesswork and allows them to focus on what truly matters: the grieving, the remembering, and the healing process. Do your work now so your loved ones can live better later.

Kevin Pho: Joseph, as always, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Joseph Pepe: Thank you, Kevin. Thank you very much.