A family finishes a difficult conversation. The person at the center of it has explained what matters, chosen someone they trust to speak for them if necessary, and signed the appropriate papers. Everyone feels a little more prepared.

Then comes a question that can seem almost too ordinary to ask: Where will those papers be when someone actually needs them?

Not merely where they were placed or whether somebody remembers a PDF. I mean the current document, accessible to the appropriate people, in the setting where a decision may have to be made.

That is an entirely different kind of preparation.

We celebrate the signature and overlook the delivery

An advance directive is not merely a form to file away. Depending on the document and state law, it can record treatment preferences, identify an authorized health care decision-maker, or do both. They deserve thoughtful conversations, not a hurried checkbox exercise.

But even a carefully prepared directive can be difficult to use if a hospital has an older copy, a specialist has none, the designated agent cannot locate the signed version, or the person has since changed their wishes.

This is not an argument against advance care planning. It is an argument for finishing the practical work that makes planning useful.

The National Institute on Aging recommends sharing copies of advance directives and proxy contact information with the people involved in care. MedlinePlus similarly advises giving copies to family, providers, and the health care agent — and telling them when the documents change. The instructions are sensible. The problem is that someone still has to carry them out.

That work rarely receives the same attention as completing the form.

I have called the broader problem a completion gap. Here, the missing step is document delivery.

One question I couldn’t leave alone

During a November 5, 2026, discussion about health care planning led by Honoring Choices Massachusetts, I raised a practical question: when several providers and family members are involved, who makes sure an updated document reaches all the places it needs to go?

The discussion reinforced an uncomfortable reality: having a plan does not establish that every relevant care team can retrieve it. In Massachusetts, as the presenter described, people and families may still need to distribute copies and check whether they are actually in the medical record. That observation was about a particular setting, not a claim that every health system everywhere operates the same way.

There are good planning tools, patient portals, electronic records, registries, and ways to exchange information. We should use them. We should also resist mistaking the presence of technology for proof of a completed handoff.

A file uploaded is not necessarily a file available to the next clinician. A document sent is not necessarily a document received. And a document received is not proof that anyone has discussed how it applies.

Those distinctions matter most at the very moment when nobody has time to chase another copy.

Consider what happens when the version changes

Imagine an illustrative family situation. An older adult names her son as her health care agent, discusses her preferences with him, and gives a copy of her directive to her primary care practice. A year later, after further conversations, she updates the document and chooses her daughter instead. The revised copy goes into a household folder and onto her daughter’s phone.

Everyone in the family believes the matter is settled.

But what does the primary care practice have? What does the specialist have? If she arrives at a different hospital, which version will appear? Does the former agent know the change was made? Does the newly named agent know where the current document is and what the person actually wanted to communicate?

The issue is not that a family member failed to care. It is that the process had no reliable way to distinguish created, shared, received, and available for use.

We have become accustomed to tracking a package through delivery. Yet for decisions that may affect a person’s care, we often rely on a vague assurance that “everybody has it.”

A simple distribution plan, not another complicated system

One reliable process beats a dashboard nobody maintains.

Start with the person whose choices the document is supposed to represent. Ask what they want shared, with whom, and why. If someone is helping them understand or organize the process, that supportive role should not be confused with the legal authority of a designated health care agent. Capacity, authorization, and document requirements depend on the circumstances and applicable law.

Then give the plan five practical parts:

1. Identify the current document. Record its type, date, and where the signed version can be found. Clarify when a newer version replaces an older one, using appropriate legal guidance.
2. Name the intended recipients. Usually this includes the designated health care agent and relevant clinicians; other family members or caregivers receive information according to the person’s wishes and applicable permissions.
3. Agree on the route. Ask each office how to submit the document securely and how it will become part of the medical record. Do not assume that uploading to one portal makes it visible across organizations.
4. Confirm what actually happened. Keep a modest record of which recipient acknowledged receipt or confirmed that the current copy was filed. If confirmation is missing, say so rather than checking the task off.
5. Revisit the plan. Major changes in health, preferences, relationships, care teams, or the designated agent should prompt a review and, when appropriate, a new distribution round.

No special software is required. A sheet of paper, a well-maintained folder, or a secure shared method may be enough. The point is not the tool; it is knowing what remains unfinished.

The person is not an attachment to the form

There is an ethical risk in talking only about document circulation. We can become so focused on getting paperwork to every destination that we forget who owns the decisions.

An older adult should not lose their voice because relatives are efficient, anxious, or physically closer to the doctor’s office. A person who needs support to understand options may still be able to express preferences or make decisions. A supportive companion is not automatically a substitute decision-maker. And the existence of an advance directive should not be used to silence someone who can still participate in the decision at hand.

The legal rules vary. A directive, a health care power of attorney, and medical orders such as POLST or DNR forms may serve different purposes and follow different requirements. Families should confirm the relevant state rules and discuss clinical orders with qualified professionals rather than treating every health-related document as interchangeable.

Sometimes the most important step is not sending another copy. It is asking, “Is this still what you want?”

The final question is not “Did we upload it?”

As a physician and someone interested in how people move through fragmented care systems, I see a broader design challenge here. We routinely measure whether an activity was recorded. We are less consistent about checking whether the next person could actually use the information.

Technology can help organize authorized tasks, versions, recipients, and reminders. It cannot honestly claim that a physician reviewed a document unless that was confirmed. It cannot determine legal authority by guessing from family relationships. And no application should quietly turn a caregiver’s convenience into permission to share someone’s private information.

Human judgment remains essential. So does plain language about what has — and has not — been verified.

A worthwhile test for any household or care team is this: if the person needed care somewhere unfamiliar tomorrow, could the right people locate the current document, identify the authorized decision-maker, and know whom to contact when something is unclear?

If the answer is “probably,” there is still a small piece of work to do.

The signature matters. The conversation matters. The work is unfinished until the person’s wishes have a realistic path to the people responsible for honoring them.

What part of sharing or updating care-planning documents has proved harder than expected in your family or organization? Please share general experiences, not personal medical details.

Sources and further reading

• National Institute on Aging — Advance Care Planning and Health Care Decisions.
• National Institute on Aging
• MedlinePlus — Advance care directives.
• medlineplus.gov
• PREPARE for Your Care — Questions About Advance Directives.
• prepareforyourcare.org
• CaringInfo — Storing and Retrieving Your Advance Directive.
• CaringInfo
• Honoring Choices Massachusetts — Health Care Planning Tools.
• Honoring Choices Massachusetts

Healthcare has spent years improving access to information. That work matters. But access is not continuity.

A care plan can be documented perfectly and still fail in the space between an order and everyday life.

Physical therapy was recommended — but was it scheduled? A medication was changed — but was it collected, understood, and tolerated? Transportation was arranged — but did the ride arrive? A referral was placed — but did anyone close the loop?

This is the completion gap.

The burden of closing it often falls to families. AARP estimates that 59 million adult family caregivers provided 49.5 billion hours of care in 2024, valued at $1.01 trillion.

Much of that contribution is not a single task. It is invisible integration: calling, reminding, relaying, checking, escalating, and carrying context between systems.

The technology conversation is beginning to notice. ONC’s 2026 EHIgnite Challenge selected early-stage concepts focused on dropped threads, missed follow-ups, structured tasks, reminders, transition support, and shared caregiver hubs.

These are developing concepts, not proven outcomes. But the direction matters: the problem is no longer only whether people can access data. It is whether they can act on what matters next.

A continuity layer therefore needs more than a shared inbox. For each responsibility, the authorized circle should be able to see:

1. What was intended?
2. 2. Who owns it?
3. 3. Did it happen?
4. 4. Was there an exception?
5. 5. What changed, and what comes next?

“Completed” should not be confused with “clinically effective.” It should prompt observation, follow-up, or escalation when appropriate.

The goal is not to monitor families. It is to stop making them reconstruct the care journey from phone calls, texts, portals, and memory.

A chart can close the encounter.

Continuity closes the loop.

If the usual caregiver became unavailable for 48 hours, which mission would fail first — and would anyone else understand why it mattered?

Our theme is: “Proximity is not consent.”

As we review family-care workflows, look for responsibilities silently assigned to whoever happens to be nearby: scheduling, medication follow-up, transportation, documents, monitoring, or escalation.

Reply with one commonly hidden task and one way its ownership could be made explicit. Please use general examples only — no personal or clinical details.

Before labeling a missed follow-up as “nonadherence,” ask whether the care plan exceeded the household’s actual capacity.

A clinically sound plan can still be operationally impossible.

What is the most important caregiver-capacity signal teams should capture — time, understanding, transportation, authority, backup, emotional load or something else?

I’m particularly interested in signals that could trigger support before a task is missed.

When Iranian President Masoud Pezeshkian abruptly canceled his in-person attendance at the 2025 BRICS summit in Brazil — citing U.S. airstrikes and regional instability — it underscored the fragile fault lines within the bloc’s newest expansion. Yet beyond the headlines and diplomatic choreography, BRICS+ is quietly staging something far more consequential: a challenge to the entrenched monopoly of Western-led financial systems. For all its internal contradictions — state-heavy economies, geopolitical rivalries, and ideological dissonance — this expanded coalition is inching toward a more decentralized global order. It’s not a libertarian utopia, but it may be the most significant market disruption we’ve seen in decades.

A Summit of Absences — and Signals

Held in Rio de Janeiro under the theme “Strengthening Global South Cooperation,” the 2025 BRICS summit was already shaping up to be diplomatically delicate. Pezeshkian’s absence, following a 12-day conflict with Israel and subsequent U.S. strikes on Iranian territory, added another layer of complexity. He will participate virtually, but the symbolism is clear: Iran, newly admitted to BRICS+, is under siege — militarily and economically — and is looking to the bloc not just for solidarity, but for systemic alternatives.

He’s not alone in his absence. Chinese President Xi Jinping and Russian President Vladimir Putin are also skipping the summit in person, opting for virtual participation. Their decisions reflect both logistical caution and a shared understanding: BRICS+ is no longer just a diplomatic club — it’s a geopolitical counterweight.

The BRICS+ Expansion: Power in Numbers, Not Yet in Principles

With the addition of Iran, Saudi Arabia, UAE, Egypt, Ethiopia, and Indonesia, BRICS+ now represents over 46% of the world’s population and more than 35% of global GDP. It includes some of the world’s largest energy producers, fastest-growing economies, and most vocal critics of U.S. foreign policy. But it also includes regimes with vastly different visions of governance, trade, and sovereignty.

From a libertarian standpoint, this is no dream team. Iran’s theocracy, China’s surveillance capitalism, and Russia’s oligarchic statecraft are hardly models of free enterprise. Even Brazil and South Africa, democratic as they are, lean heavily on state intervention. Yet the bloc’s very existence — and its growing momentum — signals a shift away from the Bretton Woods consensus that has long tethered global trade to Western institutions and the U.S. dollar.

One of the summit’s most anticipated agenda items is the push for de-dollarization. BRICS+ members are exploring mechanisms to settle trade in local currencies, develop alternative payment systems, and eventually launch a shared digital currency. Critics call it premature. Libertarians should call it overdue.

The dollar’s dominance has long enabled U.S. monetary policy to distort global markets, inflate asset bubbles, and weaponize sanctions. A multipolar currency landscape — however messy — would introduce competition, discipline, and optionality. It’s not about replacing one hegemon with another; it’s about breaking the monopoly.

Iran’s Role: Pariah or Pioneer?

Iran’s entry into BRICS+ is both strategic and symbolic. Isolated by decades of sanctions, Tehran sees the bloc as a lifeline — a way to bypass SWIFT, trade in non-dollar currencies, and gain legitimacy on the world stage. But Iran also brings ideological baggage. Its calls for anti-Western solidarity risk alienating more pragmatic members like India, Brazil, and the Gulf states, who prefer reform over revolution.

Still, Iran’s presence forces the bloc to confront the very question libertarians have long asked: Should access to global markets be contingent on political alignment with Washington? If BRICS+ can answer “no” and build the infrastructure to support that answer, it will have done more for economic freedom than any G7 summit in recent memory.

A Bloc of Rivals, Not Allies

Let’s be clear: BRICS+ is not a unified front. India and China remain locked in border disputes. Saudi Arabia and Iran are historical adversaries. Egypt and Ethiopia are at odds over the Nile. These aren’t allies — they’re rivals with overlapping interests. But that’s precisely what makes the bloc interesting.

Unlike NATO or the EU, BRICS+ isn’t built on ideological conformity. It’s a transactional platform — one that, paradoxically, may be more resilient because it doesn’t require consensus on values. For libertarians, that’s a feature, not a bug. Voluntary cooperation among diverse actors is the essence of market logic.

The Road Ahead: Imperfect Progress

BRICS+ will not usher in a global free market overnight. Its members are too statist, too fragmented, and too cautious. But it is creating space — space for alternative trade routes, alternative currencies, and alternative alliances. In a world where economic access is increasingly politicized, that space is invaluable.

President Pezeshkian’s absence may dominate the headlines, but the real story is what BRICS+ represents: not a perfect solution, but a necessary disruption. And in a world starved for decentralization, that’s a step worth watching.

If you believe global trade should be freer, not just fairer — and that no single power should control the rules of the game — consider following for more analysis at the intersection of geopolitics, markets, and liberty. Let’s keep the conversation going:

💬 What do you think — can BRICS+ evolve into a true force for economic decentralization, or is it just another cartel in disguise?

Pezeshkian Skips BRICS: A Flawed Bloc’s Bold Step Toward Market Decentralization was originally published in The Political Pulse on Medium, where people are continuing the conversation by highlighting and responding to this story.

They came in the dark of early June: precision drones that penetrated deep into Iranian territory, striking missile silos and air defenses with surgical accuracy. Intelligence and diplomatic sources now strongly suggest Israel, with covert assistance from Britain’s MI6, established an underground Mossad-operated drone base near Tehran. This was no routine espionage — it aimed to dismantle Iran’s response capabilities in preparation for a broader air campaign known as Operation Rising Lion .

That plan rapidly unraveled. On June 13, between five waves of airstrikes from over 200 Israeli aircraft and coordinated drone sabotage, Tehran’s critical missile infrastructure was hit hard. But Iran’s response was swift and furious . Within hours, it launched hundreds of ballistic and hypersonic missiles, along with drone strikes, directly at Israeli cities including Tel Aviv, Haifa, and Jerusalem . Iran even deployed its new “Haj Qassem” missile — the first operational use of this weaponial warning fire and a bold demonstration of its strategic reach .

Today marks Day Four of the conflict. Iranian strikes have killed dozens of Israelis; on June 16 alone, at least eight civilians died in Haifa, and five more perished elsewhere . Israel’s retaliatory moves have been equally brutal — 10 Quds Force command centers in Tehran targeted, leaving over 224 Iranians dead, many civilians . Iran reports over 400 fatalities with widespread devastation .

This spiral highlights the limits of covert drone warfare. The Israeli-MI6 strategy sought to negate Iran’s air defenses and unhinge its command structure. Instead, it signaled to Tehran that a shadow war had become an overt military confrontation. Drone strikes that were meant to paralyze Iran instead triggered a counteroffensive of unprecedented scale.

Diplomats and world leaders are sounding the alarm. At the G7 in Canada, European heads urged urgent de-escalation as oil markets tremble . Even U.S. President Trump — according to reports — vetoed a proposed Israeli assassination attempt on Ayatollah Khamenei, signaling a ceiling on Western alignment . The UN is convening; the EU calls for restraint.

This episode echoes past patterns. The U.S. drone strike that killed General Qassem Soleimani in 2020 unleashed missile volleys in Iraq and accelerated Iran’s drone-missile investments . Similarly, the Stuxnet cyber campaign delayed Iran’s enrichment program — but didn’t staunch its ambitions . Sneak attacks may offer tactical advantages, but strategic resilience is built underground, decentralized, and far from cameras.

The inclusion of MI6 marks a darker turning point. Without parliamentary oversight, Britain may have abetted a major act of war. Democratic legitimacy demands scrutiny. The U.K. public must know: did we covertly sanction an undeclared aggression that ignited a region-wide crisis?

Covert drone bases and untraceable strikes might feel like the future of surgical warfare — but their aftermath is anything but quiet. They invite retaliation, civilian suffering, diplomatic breakdown, and economic shockwaves. What begins in the shadows ends in explosions heard by civilians and diplomats alike.

If Western powers truly want to protect global stability and prevent nuclear proliferation, they must abandon the mirage of deniable conflicts. Instead, they need transparent, legally grounded diplomacy — and openness about the trade-offs of coercion.

This crisis is still unfolding. Iran has offered a ceasefire if Israel ceases its own strikes — but Tehran’s Revolutionary Guard has vowed to intensify attacks if the campaign continues. Both sides appear locked in a tit-for-tat spiral that risks engulfing the region — and dragging the democratic West into a war few citizens understand or support.

We must ask ourselves: can covert aggression ever be justified when it becomes the spark for open war? Covert strikes may silence an enemy for a moment — but they never silence the consequences. And right now, those consequences are roaring in the skies above Tel Aviv, Tehran, and beyond.

Citations:

1. Reuters. (2025, June 16). Israel says Tehran residents to ‘pay price’ after Tel Aviv, Haifa attacks. Reuters. https://www.reuters.com/world/americas/israel-iran-battle-escalates-will-be-high-agenda-world-leaders-meet-2025-06-16/

2. Associated Press. (2025, June 16). Iran renews missile attacks on Israel, killing 5 and wounding dozens. AP News. https://apnews.com/article/c98074e62ce5afd4c3f6d33edaffa069

3. The Guardian. (2025, June 15). Explosions heard over Tel Aviv — as it happened. The Guardian. https://www.theguardian.com/world/live/2025/jun/15/at-least-eight-killed-in-iranian-strikes-on-israel-while-israeli-attacks-set-tehran-oil-depot-on-fire-live-updates

4. BBC News. (2020, January 8). Iran missile strike: What we know so far. BBC. https://www.bbc.com/news/world-middle-east-51028954

5. Zetter, K. (2014). Countdown to Zero Day: Stuxnet and the launch of the world’s first digital weapon. Crown Publishing Group.

Drones Before Dawn: From Covert Sabotage to Full-Blown Conflict was originally published in The Political Pulse on Medium, where people are continuing the conversation by highlighting and responding to this story.