Real Intentions for Life

Make Peace with Physician

Mindful Considerations Raised by Netflix’s “Extremis” – Part 2

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The gut reaction to Netflix’s new documentary “Extremis” is the ICU is a hellhole.  No one wants to end up there.  Patients enter this purgatory after becoming sick and requiring a higher level of care.  Patients enter the ICU from the ER, the hospital ward, or after surgery.

Donna, one of the two patients featured in the film, has myotonic muscular dystrophy.  Her muscle weakness caused respiratory failure, and she needed a breathing machine.  Donna has to choose between having the tube removed and having a permanent tracheotomy.  The tracheotomy requires Donna has to live in an extended-care facility. Removing the tube means that she will die.

Mindful considerations identify upsets before they happen. The purpose of advance care planning is to avoid the pitfall that Donna had encountered.  Muscular dystrophy has no cure.  What Donna had to endure was unnecessary and torturous.  Donna was competent so she had to fend for herself against the physicians and her doting family.

3 Mindful Considerations for advance care planning include:

Avoid the bridge too far.

To what extreme is it necessary to keep you alive? At what age would you avoid admission to the ICU? Do you understand that you will be in the ICU following surgery?  Do you understand that calling 911 could lead to an ICU admission?  Is your medical condition expected to get better?  What quality of life will you enjoy after leaving the ICU?  “We’ll cross that bridge when we get there,” seems to be the best copout for advance care planning.

These are questions that you prefer not to think about ahead of time and are often left open-ended. Advance care planning that is open-ended will likely cause you to cross a bridge too far and take you into the ICU.  Elderly patients who are reluctant to sign a Do Not Resuscitate (DNR) often die in extremis in the ER or ICU.

Refuse nonviable options.

“I can’t live like this” becomes a personal proclamation for advance care planning. “I do not want _______” becomes a matter of choice.  You might begin to fill in the blank by refusing certain medical procedures:

Heart transplant      Colostomy bag      Breathing Tube      Feeding tube      Cardiac resuscitation     Needle sticks       Medical Specialist           Dialysis Extended-care          Chemotherapy          Antibiotics          Blood Transfusions

Would any doctor in Donna’s situation choose to have a tracheotomy?  Should doctors offer nonviable options to every patient as a matter of choice?  Who determines if a particular patient can live with a tracheotomy?  Is living with the prospect of dying ever a viable option?  How do patients get the inner strength to give up on hope and to refuse medical intervention?

Donna was looking at a longer course of pain and suffering with no hope of recovery.  Sadly, this seems to be the best practice of medicine today.  Patient-centered care calls for advance care planning that focuses on personal dignity. Nonviable options lead to patient indignation.

Put your promises in writing.

The quality of your death is a matter of choice with no guarantee. Those who rely on good faith often die in extremis.  We all know the importance of getting our guarantees in writing, yet many people fail to do so.  They trust in God and the healthcare system.   Advance care planning provides the means for you to maintain control over the decision-making process. Being mindful requires taking responsibility for both your life and death.

Mindful considerations help you balance refusing and receiving medical intervention.  Entitlements are what you receive.  Empowerment allows you gain dignity through refusing intervention.  Donna had to choose between entitlement and empowerment- suffering and freedom.  Had she made a promise to herself about this choice? Were others aware of it?

How did Donna feel about corporal punishment?  Was the breathing tube necessary?  Was a permanent tracheotomy acceptable?  Does the prospect of corporal punishment prompt you to get things in writing?

“Give me liberty or give me death” are the immortal words of Patrick Henry. Is it important to include these words in your advance directive? “Give me extremis,” as in inhumane treatment, is absurd.

Be mindful of what you wish for and put it in writing. If you do not wish to suffer in extremis, plan ahead.  Be mindful that withholding life support supports personal freedom and everlasting peace.

 


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Caregivers often suffer in silence while looking after loved ones and grieve in the aftermath of their death.

These twice a month email tips help caregivers understand that pain and suffering are inevitable – grieving is optional through better advance care planning.

Let’s start developing a community that creates and grows understanding, knowledge and support for compassionate end-of-life care.

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3 Issues Raised by Netflix’s “Extremis” – the Overview

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“Extremis” means the crucial point before death.

It’s measured by the level of stress and the length of time patients suffer as they die.  You often hear people express consolation to the family with the kind words “at least he didn’t suffer” or “she died with dignity.”

In the short-film “Extremis,” Dan Krauss brilliantly depicts how patients endure tremendous suffering and loss of dignity through the efforts of well-intentioned physicians and family members.

The documentary begins with Dr. Jessica Zitter, an intensive care and palliative physician, who is trying to determine a patient’s wishes. The anonymous patient can’t speak and appears to be incompetent.  Dr. Zitter’s creative attempts include having the patient scribble answers on a clipboard and spell out words in the air. These efforts are futile and border on being cruel.  Is it ethical to question patients in extremis?  Why ask a patient anything when the physician knows the appropriate answer?

The documentary allows the viewer to peek in on several ICU patients at Highland Hospital in Oakland, Calif.  Two are on life support with family members at their bedsides.

The ICU is often described as a place of limbo.  Strong doubts exist as to whether any of these patients will recover, yet hope abounds.  Hope, however, comes at a cost – the amount and time a patient has to suffer and the increasing risk that a patient’s dignity will not be respected. Subjecting terminal patients to this level of care appears more like punishment than palliative medicine.  Yet, this has become standard practice for end-of-life care. The documentary should leave viewers frightened and shaking their heads – saying, “ain’t it a shame – someone ought to do something.”

Dr. ZItter offers a resounding story about a nurse who challenged her practice of medicine. Dr. Zitter was inserting a large IV into the neck of a critical patient when the nurse standing in the doorway looked her straight in the eyes and shouted, “Call the police.  The doctor is torturing the patient.” The bombshell that saving certain lives is criminal gives viewers a wake-up call. The ignorance and bullying that exists in the healthcare care system is overshadowed by the claim that “This is for your own good.”

Patient autonomy and self-determination allow patients to formulate a personal statement, “Someone ought to do the right thing for my own good.”  A self-respecting person completes an advance directive.  An intuitive husband understands how to love his wife as he does himself. An astute physician has the wisdom to know the difference between torture and respect.

Having to contend with God, physicians, and family members in the moment of extremis raises issues the patient needs to address well before admission to the ICU.

A person who wants to be responsible for their own their end-of-life care must do so when they are of sound mind, body and spirit. What to think, do, and feel after watching “Extremis” can leave you feeling helpless. But consider it a valuable lesson.

In this four-part series over the next three issues of Dr. H’s Clipboard weeks, I’ll discuss a holistic approach to “Extremis.” You’ll learn about mindful considerations, practical considerations and spiritual considerations that dictate how the patient should be treated, or left to die.

Being of sound mind, body, and spirit insists that you are prepared for the inevitable.  Believing that you are invincible is foolhardy and adds to pain and suffering.  Only you can guard against the loss of dignity that so often occurs during extremis.  Take the steps necessary to make sure that you receive compassionate end-of-life care through advance care planning.

 


Subscribe to Dr. H’s Clipboard
Caregivers often suffer in silence while looking after loved ones and grieve in the aftermath of their death.

These twice a month email tips help caregivers understand that pain and suffering are inevitable – grieving is optional through better advance care planning.

Let’s start developing a community that creates and grows understanding, knowledge and support for compassionate end-of-life care.

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I Can’t Get No Patient Satisfaction

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Ruth was a spry, but frail 98-year-old woman who was stiff and sore following the 6-hour drive from California to Arizona. She had suffered a recent wrist injury and was not recovering well after spending three weeks in a rehabilitation center. She was in the midst of upheaval and discontent – in the throes of relocated to an assisted-living residence closer to her son. The facility’s coordinator had begun to evaluate Ruth’s aptitude and appropriateness for assisted living, but thought it best to have Ruth seen in the emergency department.

Ruth was hungry, but did not wish to eat. She felt like her bowels needed to move, but did not wish to use the bedside commode. While still engaging, Ruth wished to be left alone. Ruth had explained that she used to be able to tell herself not to be sick, but her higher power seemed to be failing her now. When a patient feels abandoned by a higher power, what hope is there for patient satisfaction? When patients are uncertain of what is in their best interest, how can physicians succeed at meeting their expectations?  Does it become the physician’s duty to tell Ruth that she is not doing well and further deflate her self-image?

The breakdown in patient satisfaction often occurs when physicians cannot view the situation from the patient’s perspective. When the ED staff does not see the emergency, misunderstandings and missed opportunities frequently happen. There is a propensity for ED personnel to become defensive and stand their ground regarding standards of care and appropriate patient conduct. The parental cry resounds: do things my way or else. Coercion and entitlement rarely lead to patient satisfaction.

Having the right to care for others is risky business – particularly when patients might be on the fence as to their desired care. Rather than healthcare personnel digging in their heels of righteousness, these types of situations often call for personnel to dig deeper into self-awareness and question, “What would Jesus do?” The healer of all healers would show compassion and treat people with kindness, similar to how those with special needs are treated. Ruth was in delicate position and needed to be treated with kid gloves rather than sterile gloves. Given her stage in life, there was little hope of making her situation better.   Doing more would most likely worsen her state of mind and lessen her satisfaction.

As situations often spin out of control in the ED, physicians are often called upon to soften their tone and maintain professionalism without authoritarianism. Through reassuring patients that we are in this together rather than working in opposition, hope springs eternal regarding patient satisfaction. Ruth simply needed to be reminded that she had the inner strength to weather the storm front at the end of life and that there was nothing really wrong with her. Nevertheless, she remained indifferent to the whole life-and-death conundrum. While this might be the best anyone hopes for, Ruth’s ED experience remained less than satisfying.

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Heart-Based Healthcare Decisions Day – April 16

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Javier was a heavyset 78-year-old man, remarkably edematous and exhausted, suffering from congestive heart failure. He had been seen by his primary care physician and sent to the emergency department for his difficulty breathing and hypotension. His vigilant son provided the history of the 3-month battle Javier had been waging between heart failure and fluid retention. His son was well versed in the treatment regimen and intended diuresis, but had little awareness that this best practice of medicine was inflicting undue suffering on Javier. Sadly, the son was not prepared for any discussion regarding appropriate end-of-life care for his father. Obviously, Javier’s physician had been ill-prepared to address these matters of the heart pertaining to life and death.

Most physicians simply do not know how to talk with patients about dying. Those dying are more likely to be sent to the emergency department and subsequently admitted to the hospital or ICU. Essentially, patients have to figure out for themselves how or when to die due to physicians’ ignorance. Patients are encouraged to fill out advance directives and Medicare now pays physicians to assist in the process. However, Javier’s all-too-familiar predicament is not typically addressed in these documents until he becomes incompetent or experiences cardiac arrest.  Truly, these documents are never a substitute for having heart-to-heart conversations between patients and their caregivers about crossing the finish line long before exhaustion or sudden death ensues.

Lack of medical education has been cited as the reason for physicians’ mismanagement of end-of-life care. However, the end-of-life journey is a spiritual undertaking for patients and this has been overshadowed by the use of fearful medical terminology like “terminal sedation” or “death through starvation” – used to describe heartfelt provisions of compassion, dignity and unconditional love.  Physicians need much more spiritual training and guidance in these matters, but not through curriculums. They need to listen to their own hearts – the voice of humility. Through an evidence-based perspective, humility is weakness. While as a quality of respect for others, humility is a heart-based initiative.

Physicians are more likely to tell patients what to do and rarely have patients actually think from their hearts. Near the end of life, a physician might ask, “What are your wishes?” Panic-stricken, most patients and their caregivers call for everything to be done to sustain their lives. Many physicians feel this is wrong, yet are less inclined to disagree with their patients’ wishes and provide opposing insights from their own hearts. Physicians and patients have one-track minds toward measures of hope that promise little or no improvement. When the medical condition has a poor prognosis, a spiritual connection between physicians and patients is needed to address these heart-wrenching, life-and-death concerns.

Wishes To Die For is a personal example of a physician who has examined the heart of his patients, contemplated his own wishes and shared these matters with other caregivers to ponder.  The medical school model of “See one, Do one, Teach one” is how physicians learn to practice medicine. The same methodology could be used to incorporate this physician’s self-prescribed version of humility into the purposeful intention to do no harm. Being true to the heart in matters of spirituality is not an intellectual practice, but enlists the necessary virtues of integrity and intuition. The certainty of being right, described as dignity in this book, instills a profound truth and intuitive reasoning which aid the decision-making process.

Advance care directives offer little insight into how to best address patients’ end-of-life care. These documents do not pose the right questions or address the inherent conflicts between a patient’s mind, body and spirit. Reconciling these conflicts is both a personal and professional dilemma for physicians, requiring empathy and enlightenment. Achieving resolution in life-and-death discussions involves the distinction between quality of life and quality of death. Having patients consider their quality of death may actually begin with physicians coming to terms with the essential message of the Serenity Prayer. The wisdom to know the difference between acceptance and courage is fundamental to end-of-life care.

Most physicians do not know how to properly treat patients at the end of life due to primarily focusing on them as diseased human beings. The end of life is not a medical condition – it’s a spiritual journey. Patients at the end of life need to be respected as spiritual beings. Wishes To Die For is the personal diary and outcry of one physician to other caregivers to treat others as they would treat themselves – as a gift from God. The collective duty of caregivers is to return this gift to God unharmed. Spiritual beings have a light that shines through them and healthcare decisions need to surely be illuminated by compassionate physicians who practice medicine from the heart.

 

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Another Opening Day

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Once upon a time Martin Simpson was playing little league and had hopes and dreams. At the age of 89 he was falling frequently due to weakness brought on by urinary tract infections. Before his son could arrive at the residential group home, Mr. Simpson had been loaded onto the EMS gurney for the obligatory trip to the emergency department after he fell again. This vicious cycle was becoming out of control and Simpson’s son needed to find a solution to this conundrum – a presumed opening day that would close off the option of returning to the ED.

Opening Day in Major League Baseball is a time-honored tradition that symbolizes new beginnings. The prior season is one for the books while the present scoreboard displays 0-0. There is a great anticipation with the ceremonial first pitch along with the collective chorus of root, root, root for the home team. If they don’t win it’s a shame. For its one-two-three strikes you’re out – in this game called life. Patients near the end of life might be given similar permission to swing and miss three times, but the third time’s a charm. Hope changes from improving a batting average to seceding from the batter’s box with both good sportsmanship and personal dignity.

Emergency department use in the last six months of life is common and ominous. ED’s are designed for advance care, not end-of-life care. Most patients prefer to receive end-of-life care at home. Notwithstanding, 77% of ED patients near the end of life are admitted to the hospital and 68% of them die there. Patients enrolled in hospice or palliative care rarely visited an ED during the last month of life.[i] Game rules or policies need to encourage patients and families to “warm-up” to these services rather than attempt swinging aimlessly and having to run the bases out of necessity. Patients need to plant their feet firmly on home plate and maintain an appropriate stance for end-of-life care.

Having an opening day at the end of life with the prospect of winning is unthinkable. Obliging patients to repeatedly return to the emergency department near the end of life seems unconscionable. Patients, caregivers and healthcare providers alike need to agree on the merits of advance care planning and reconcile that when patients fall for the third time, the gates of heaven are immediately opened by the “key factor” of palliative care. Opening day must become anticipated after the second fall and recurrent encounter with emergency services.

As patients become ill, they are determined to have something wrong. When patients are seen as dying, there is nothing wrong with them. With nothing to gain, there is nothing to lose – like any opening day the score resets to 0-0. From a personal wish list – Buy me some peanuts and Cracker Jacks, I don’t care if I never get back – to the ED.   From a professional perspective – If they don’t win it’s not a shame. Home base at the end of life is where patients are declared Safe! Having slid into home plate, this safe zone needs to be free of expectation and intervention without the repeated bellowing cry of Batter Up!

Thomas Boswell wrote Time Begins on Opening Day. More likely, time stands still when the gates of heaven open. Both experiences wrap nostalgia and wonder with awe and anticipation. When opening day coincides with closing time, what comes to mind is the lyric – every new beginning comes from some other beginning’s end. The dawn of a new day is nature’s unconditional promise of many happy returns. When the sun sets on advance care for those dying, the sun rises on end-of-life care along with the invitation for a brand new prospect of the best interest of these patients. Take me out to the ballgame rather than to the ED becomes both a wish to die for and a grand opening to the ultimate field of dreams.

 

[i] Damian McNamara, “ED Utilization High During Last Months of Life,” Elsevier Global News, August 2010,http://www.acep.org/Clinical—Practice-Management/ED-Utilization-High-During-Last-Months-of-Life/.

 

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Doctor Recommended, Patient and Sister Approved

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Finding balance between over-treating and withholding medical intervention at the end of life remains problematic when patients are not afforded palliative care. John was one of my patients – another victim of this predicament.  He had recently retired and been diagnosed with advanced lung cancer. While never really liking doctors, he had his share of them while hospitalized for the diagnostic workup, chest tube insertion to drain fluid from his lung cavity and his first round of chemotherapy. John was discharged home, but returned to the ED the following day, experiencing difficulty breathing and his heart racing. IV fluids and sedation seemed to ease his symptoms and he pleaded to return home. I was uncertain if this was in his best interest and whether he had the appropriate necessary resources.

While I questioned his treatment goals, his wife insisted that they were realistic. John and Betty hoped to “even things out” – get the cancer under control and give him a little more time to live. John was pleased that he had great health insurance, but was well-aware that the co-pays were piling up and that Betty could eventually end up destitute. I admired John’s conscientiousness and quipped, “Yeah, you don’t want to get stupid about this.” I struck a nerve with John and essentially fired him up. I expressed sympathy for John and Betty being caught between a rock and a hard place.  I was on the side of him receiving medical intervention, but who was on the other side of the gurney? Who would give him permission to defer being admitted to the hospital?

If patients and family members have the intention to “even things out,” palliative care needs to be offered to patients enduring end-stage disease. John and Betty were both very receptive to this proposal. When people claim to take the good with the bad and the yin with the yang – peace, harmony and personal empowerment are possible.  I gladly arranged palliative care services for John and he was released from the ED. With her husband receiving palliative care, Betty had another emergency number to call besides 911.  If John took a turn for the worse at home, Betty would have the option to simply hold his hand and comfort him without being considered negligent. Palliative care promotes much hand holding aside medical care and opposes aggressive medical intervention that is often outside the bounds of compassionate end-of-life.

The newfound insight provided by my experience with John prompted me to think about my dad.  Dad does not wish to be perceived as stupid regarding his end-of-life predicament and is adamant about not being transferred to the hospital from his assisted-living residence.  My sister works for a hospice corporation and I questioned if it had palliative services available for Dad in Illinois. We had a simultaneous reaction of embarrassment, realizing that we both have an ethical duty as healthcare providers to promote patient autonomy and choice. However, we had not offered Dad the dignity inherent to free will, essentially limiting his choices. As his medical power of attorney, she explored options and found a local nurse practitioner who frequents Dad’s assisted-care facility, providing palliative medicine for the residents. He now has palliative care as a choice.  My sister and the entire family have agreed, all’s well that ends well if Dad’s wish for never returning to the hospital is honored.

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THE DISCOVERY PERIOD REGARDING THE EXISTENCE OF LIFE

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What do I need to know as I age?  While scientists ponder the questions of water existing on Mars and if it can essentially sustain life, my duty it to assess if there is life left in Oliver – a nursing home patient transferred to the ER. Oliver was not oxygenating well, but appeared to be resting comfortably. Reportedly, Oliver had fallen that day and EMS discovered a sizeable bruise on his chest.   Did Oliver have a collapsed lung or did his underlying congestive heart failure worsen? With age, my need to know about other planets and disease processes in patients approaching the end of life has become more selective and less enterprising.

My need to know seems to waver between being perceived as apathetic and/or negligent and having values and/or priorities. Hospital staff was already preparing to save Oliver’s life while I resisted the need to take immediate action until speaking with Oliver’s out-of-state daughter. I initiated the dreaded phone call from the ED at 2:00 a.m. Groggy and incoherent, his daughter needed to know all details about her father’s condition prior to making the decision to allow Oliver to rest in peace. By her command, there was no rest to be given to this wretched diapered man with dementia, Parkinson’s and heart disease, along with the new finding of a dusky blue foot.

This unrelenting need to know often works against one’s better nature to leave well enough alone.   In general, society is wrought with anxiety and increasing fear around death. Will our celestial body end up like Mars, seemingly lifeless and dehydrated?  Presumably, we need to know if Earth is following the path of demise similar to both that of Mars and Oliver. This overwhelming concern intensifies the plea, “Don’t let the sun go down on me.” On a more personal level, Oliver’s daughter mandated that I not allow her father to die. One day Oliver’s daughter will come face-to-face with her own end of life. Has she designated an advocate who will need to know everything wrong with her body as disease overtakes her life and death becomes imminent?

It took less than a minute to realize that Oliver was dying. There was nothing more I needed to discover about Oliver’s medical condition that would justify attempting to prolong his life and sacrifice his dignity. When the discovery period ends, the grace period begins. In my practice of emergency medicine, the demarcation between discovery and grace – intervention and mercy – establishes a clear boundary between treating a patient like a guinea pig or a human being. The medical power of attorney rarely allows for a loved one to have a grace period at the end of life. Grace periods stop interest from accruing, but love holds no bounds to medical intervention at the end of life. Nevertheless, having nothing to do might actually turn out to be amazing – like an unexpected day off work. For many patients, having nothing further done is often the beginning of the end – the end of suffering.

The discovery period encompasses advance care planning, physician counseling regarding end-of-life care and patients yearning for a grace period. The need to know how to care with dignity and grace for people at the end of life does not occur through looking outside oneself, but more so from looking within the universal soul of intuitive understanding. Planet-gazing is most useful if it leads to soul-searching. Advance care planning that incorporates soul-searching provides a means to envision storybook endings. I believe life ends happily ever after through the proverbial assertion that ignorance is bliss. The grace period of feeling blissful upends the discovery period of needing to know about the existence of life.

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HIGH MARK FOR HEALING A GREAT DIVIDE

20150611_093403-300x169I cared for a 48-year-old Bosnian woman whose constant chest pain had worsened that day. Her evaluation in the Emergency Department did not reveal any evidence of heart disease. In broken English, with the help of her son translating, she admitted that stress could be causing her chest pain. Moreover, she quickly mentioned that her stress was justified. Ten years prior, two of her teenage sons were tragically killed in a car accident while driving to school. Stunned, I paused in condolence and consideration. Even though she failed me for not truly knowing the depth of her pain, I was not content to fail her in an opportunity to heal.

Aside from language, cultural and emotional divide, human beings rarely see eye-to-eye amid the limitations of the mind. With the additional concerns regarding her sciatica pain, I suggested she participate in stretching classes, in particular, the practice of yoga. She seemed receptive; I kept talking. Yoga denotes union and in this practice students yoke with the divine. Having experienced this transcendent feeling at the end of yoga classes and knowing a friend who cherishes this time to communicate with his deceased partner, I encouraged her to explore the practice of yoga and perhaps rekindle the bond with her sons. She was right about my not understanding her situation and it truly being outside the scope of my medical practice, but not out of my awareness.

The value of shutting off the mind and opening up the heart generally goes unrecognized. There are certain expectations placed upon physicians to heal everything; and many times we fail. Most patients enter the Emergency Department in anticipation of a prescription. I make certain they leave with a dose of awareness. Oftentimes, I might query if the patient learned a lesson. The art of medicine is the ability to have a heart-to-heart conversation even when tensions flare. The mere suggestion that her sons could not rest easy while their mother was still in pain gave my patient pause in her heartache and consideration. There was a nod and a smile in her demeanor that revealed a shift in her mindset. She may not have recognized me as an inner wounded child, but she knew I was speaking for her sons who longed for her to rest easy.

Despite making the effort to not fail patients, I rarely receive positive feedback from patients who take the time to write letters on my behalf. Through an uplifting stroke of thanksgiving on her discharge instructions, this woman sent my spirit soaring with a high mark for healing a great divide. The nurse who witnessed the entire conversation with this patient made certain I was aware of the grade I earned for having shared my yoga that day.

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GOOD FAITH, FALSE HOPE AND BAD MEDICINE

separatism-300x150Cancer has a way of spreading separatism insidiously which shields patients from knowing the truth.  In good faith, many patients with terminal cancer maintain a one-track mind toward survival. Doctors tend to appease this mindset by both providing false hope and practicing bad medicine. They enroll cancer patients in separate prognoses for their conditions, but provide equal opportunities for survival. Those with terminal cancer and good faith are often given the benefit of the doubt along with the booster shot of false hope, pretense and bad medicine.

I recently cared for a 72-year-old man suffocating from complications due to throat cancer.  He was now ready to have a tracheostomy tube inserted into his windpipe.  Five months previously, the throat tumor had been excised and he was currently receiving chemotherapy for metastatic disease to his lungs. Despite audibly high-pitched tones resonating from this man’s obstructed airway, his wife insisted that their hopes were high that chemotherapy would reverse the cancer. If all this were simple, why was this gentleman enduring so much suffering?

I immediately called the patient’s ENT surgeon. He grimly expressed that the patient’s medical condition was, indeed, terminal and palliative care was being provided. He stated that he would arrange that day for both an emergency tracheostomy and hospice consult. However, this line of thinking was in direct contradiction to the steadfast curative mentality of the oncologist, patient and his wife. In support of peace of mind and the practice of good medicine, I needed to clarify, reconcile and personalize these separate, but equally heroic game plans through the values of the patient and his wife.

The wife assured me that hospice had previously been consulted and her husband did not qualify. It was painfully obvious that he did qualify for hospice care. However, their good faith was not receptive to its resources or services. The false hope provided by the oncologist supported their good faith. The separatism between leaving this couple in the dark and shining a light on his mortality appeared to be acceptable to them, especially while being enrolled in the idea of terminal cancer achieving remission.  Seemingly, a bad disease provides the impetus to both practice and receive bad medicine.

Patients have the first right of refusal to accept any terminal diagnosis and potentially ineffective treatment through good faith. However, it is unacceptable for any physicians to capitalize on their patient’s good faith by adding false hope.  Treating patients by leaving them in the dark is contrary to the practice of good medicine. Best practice in medicine might be geared more toward having the patient prove the doctor’s prognosis wrong rather than have patients feel as though they had been wronged by the doctor more than the disease.

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DANGER OF TAKING TOO MANY PRECRIPTION MEDICATIONS

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It has become an unwritten rule that most patients who visit the Emergency department are to leave with a prescription. That is how emergency physicians practice defensive medicine. For instance, physicians rarely incur a lawsuits from prescribing antibiotics. Omission of any medication appears negligent. Therefore, temptation exists in treating most ear, nose and throat infections with antibiotics that are often unnecessary. In addition, the general perception is the doctor who prescribes the antibiotic is the better doctor than those who do not. When patients fail to receive “necessary prescriptions” from their personal doctor, they may obtain a second opinion from the EM physician and leave with a prescription. Strongly ingrained from early on is that medication makes us feel better.

Are all these medications’ necessary?

A recent study posted online in the journal Health Affair noted that over half of older Americans are taking four or more medications while roughly one-quarter of seniors in other countries take these many prescriptions.[i] Clearly, Americans have become more exceptional when it comes to taking medication in order to perhaps feel better. “Happy pills” that tend to be overused are narcotics, antidepressants and sleeping pills. These medication were intended for short-term use and as a stop gap measure until other therapeutics and coping strategies could be initiated. Health maintenance seems to gravitate to taking medication rather than disease prevention through lifestyle changes.

Does this medication have side effects?     

Any television commercial that advertises a prescription medication will rattle off a list of potential side effects. All medication has inherent unknowns for any given patient. Medications that initially appears to be the next best thing tend to be followed by a class-action lawsuit against the manufacturer. The most notorious side effect of medication becomes the loss of control over one’s health. Similar to a traffic citation, any medication can add points against a patient’s license. Patients lose their ability to be in control of the wheel when they no longer know what medications they take or what these treat.

Can medication mask a more serious illness?

When I inquire about patients’ medical illnesses, I am surprised when they answer “no,” yet respond with “yes” when asked about being on medications. Does this mean a patient who takes medication for diabetes is not considered diabetic and does not have to follow a diabetic diet? Medications have the potential to make patients delusional, similar to the alcoholic who perceives alcohol as the solution and not the problem. Medication can treat diseases or symptoms of illness. Unmasking the illness or issues underlying any disease process requires more of serious conversation with the physician, distinguishing the fixation on medication from the physiology of disease and the psychology of illness. Ultimately, conversations regarding self-restraint with prescription medication foreshadow end-of-life discussions that might necessitate other types of artificial life support.

[i] http://content.healthaffairs.org/content/early/2014/11/13/hlthaff.2014.0947

Copyrighted and published by Project HOPE/Health Affairs as [include the full citation: author name, article title, Health Aff (Millwood), year or original publication, volume number, issue number, pages]

 

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