My grandparents have always seemed young. They would come for Grandparent's Day in elementary and middle school, without canes, glasses, or oxygen tanks, and everyone was in awe. High school graduation was the same way-my grandparents and their 13 grandchildren. Grandpa went to work every single day, with no foreseeable plans to retire. Grandma and grandpa have always looked great for their age, and seemed to have everything figured out.

Two years ago, grandpa was diagnosed with cancer. He was an older gentleman in his 70s going through chemotherapy, so it was difficult at times. He had made advance directives with his healthcare team at a well-known cancer institute (or so I had assumed), and most treatments went according to plan. To the best of my knowledge, the biggest scare was when his team wanted to intubate him for a pneumonia that was making it difficult for him to breath. I heard all of this second hand, from a family of bakers. That is not a typo, they actually all make bread. So, when my parents first called to update me, they kept repeating "Grandpa is going to be incubated!!" This made me second guess my original assumption about grandpa having made advance directives. Family drama heightened as big decisions were discussed. I kept out, I was in nursing school several hours away and my parents said I shouldn't get involved because the family drama was too much. I would ask a couple of questions on the phone, searching for any useful information about grandpa's status. But the bakers didn't really understand what was happening, and as a result... neither did I. Long story short, he didn't get intubated and he beat cancer. He is okay, still weak. Chemotherapy took a toll on him.

Just before grandpa got sick, grandma started struggling with her memory. Her problems got pushed to the wayside, and my family just went with the assumption that dementia was suppose to happen to older adults. It is not. After 3 years, her memory had gotten progressively worse, and she was diagnosed with Alzheimer's disease. She doesn't cook anymore, she doesn't leave the house unless someone is with her. With six children, my grandparents go to a different child's house for dinner every night-my house on Tuesday nights.

I am most concerned about the potentially missed opportunity to discuss her advance directives and end-of-life wishes. Her disease progressed quickly while grandpa was fighting cancer. His hospital healthcare team discussed his end-of-life wishes, and helped him to create his advance directives. But what about hers? Is it too late to have a meaningful discussion with her about what she wants? Would she be able to comprehend the gravity of the conversation and make a decision?

I have been through a lot of nursing school. Four years for a Bachelor's in Nursing, and now 3 more years to become a family nurse practitioner. Classes and experiences have taught me how important it is to have these conversations early, before anything happens. "Perfect world" stuff. Home healthcare and primary care settings are ideal places to start these conversations. Working as a nurse has exposed the true difficulty of having these conversations in the hospital, when it may be too late.

Does being sick change one's perspective on what they would and wouldn't accept as a "good quality of life?" I wish the conversations for both of my grandparents would have happened sooner, but I believe we can't waste time thinking about what could have been. Not having discussed end-of-life wishes with my grandparents early on was a missed opportunity in a way. However, it has helped me to know that as nurses, we have a wonderful opportunity to start these kinds of conversations early, before the crisis. And what better venue to do that in, than in a person's own home, where they are surrounded by the people they love and trust?