Category Archives: Medical Decision Making

Happy-Man-Jumping

By now you’ve surely heard that Medicare is going to pay doctors and other qualified healthcare providers for advance care planning with patients in 2016.

Aren’t you excited?!?

Ok, so if you are not utterly thrilled or even if you are nonplussed about the whole issue, then let me give you a different perspective on why you should rush into your friendly local doctor’s office to make a living will and chat about your future.

Here are 8 unorthodox reasons to create your own advanced care plan in 2016:

 1. You don’t want your Aunt Bertha changing your diapers.

Maybe your Aunt Bertha did change your diapers when you were 6 months old, but do you really want her cleaning your feeding tube and wiping up your poop stains when you are 60? I mean heaven forbid that you end up in a chronically dependent or even vegetative state at such a youthful age, but what if…??? Did you even want to be kept alive in such a state at all…??? Certainly something to think about. Maybe you should give Aunt Bertha a call?

2. The loudest person in your family may not have your best interest in mind.

Oftentimes the loudest relative “runs the show” in the hospital- by guilt, intimidation, and a host of other aggressive or passive-aggressive strategies. If you don’t want “you-know-who” making decisions for you or bullying around your other relatives, while you lie helplessly in the hospital bed, then for Pete’s sake, choose and document your own healthcare proxy today! Make sure they know EXACTLY what’s acceptable and not for you.

3. I’ll bet you know who you DON’T want making decisions for you.

Simply put, some people can handle this kind of pressure and some people can’t. The people who would wilt under life and death decisions on your behalf should NOT become decision makers for you, either by intention or default.

4. Hell hath no fury like your family fighting over your fate or your fortune!

I’ve seen feuds break out around a deathbed that would make the Hatfields and the McCoys cringe. I always want to scream, “What the hell are you people doing? Can’t you see that your loved one is dying here?” (Of course that kind of outburst is never good for the physician professionalism scorecard, so I usually manage to translate the sentiment into something a bit more PC.) So, please, please I beg you to have your fate and your fortunes pre-determined before that fateful and inevitable moment arrives!

5. Grudges can come back to bite you.  

One time the closest available relative to my unresponsive patient on full life support was his estranged wife. She had carried a grudge for 20 years. When we finally tracked her down to make a decision for my patient, with glee she whispered evilly, “Pull the plug.” (YIKES!) I’m pretty sure that guy would have had someone else in mind to make this decision, but IT WAS TOO LATE! No advance care plan was in place with his doctor. (I sense that you are getting my drift…)

6. No one knows your secret priorities.  

During one of my traveling lecture series last year I met a gerontologist who shared some of the idiosyncrasies of his advance care plan with me. He had in writing, that should he become demented and placed in a nursing home: 1) Under no circumstances should he ever be physically or chemically restrained, and 2) He should be allowed to have sex with anyone who is willing to engage him :)

7. No one knows you like you… and you deserve a fitting exit. 

I would like to die on a blanket under the oak tree at bottom of my field. My dad would like to be buried in a bright red racecar motif casket. My husband wants a Viking funeral pyre. I’m sure you have some pretty unique idea about your final goodbye as well… do you have the plan in place?

8. Embracing death will allow you to embrace life. 

Is this too much for you? Think it’s too morbid? Let me tell you the great secret… when you embrace death in its inevitability, then each moment of life itself becomes more precious. Now will never come again. Planning for the end-of-life awakens you to the gift of this very moment of life, this very second. What a gift.

“The doctor will see you now…”

I was at the end of a long shift. I had already seen too many patients to have any common sense left and it felt as though there were no remaining neurons firing in any agreeable pattern in my brain. And here came my last patient. I peeked into her room before I showed my own face. She was 78 years old with long gray curls piled way atop her head. Her chest seemingly rose and fell too rapidly for comfort. The sounds of bubbles in her airway were audible even outside of the room.

“Uh oh,” I thought…fate has saved the toughest patient for last. Tough because at first glance I could already tell that I would need to have an end-of-life planning conversation with this little lady. She was already triggering my mental screening tool: Would I be surprised if this patient died within the next year?
The answer was a resounding “no.”

I pulled back the curtain.

“Hi Toots!” She called out to greet me as I made my way into her room. (This was a first…and I liked it!)

This spunky little lady was in the ER for shortness of breath. Again.

As we talked it became clear that she had entered her end-of-life pathway. The last six months she had multiple hospitalizations for pneumonia. She now only routinely walked to the restroom or to the dinner table. She was beginning sleep a lot and there was about 20 lbs. weight-loss.

Despite my fatigue it was my duty to have “the conversation” with this patient and her husband, regardless of the physical and mental energy costs to myself.

So I took a deep, tired, ragged breath and started my usual condensed ED-goals of care conversation:

“Do you have a living will?”

Her husband quickly responded, “What’s a living will?”

Secretly, in the recesses of my imagination, I slapped my forehead, yelled out “Oh brother!” and rolled my eyes. As I sat motionless, fake-smiling at the gentleman, I hoped that none of my true sentiments had shone through in my facial expressions or demeanor.

Before I could continue my spiel with this fake-smiling expression plastered on my face the husband asked, “Does that mean that we ask about her wishes?”

Oh wow!

Suddenly I felt as refreshed as after a good nights sleep! “Why yes!” I gushed to
him, my fake-smile now genuine and deep.

“Well, let’s just ask her then,” he said turning to her as my smile turned to an expression of near-astonishment. This had never happened before.

“Honey,” he leaned over her bed rail, “This nice doctor wants to know your wishes like whether or not you want life support and things like that.” He looked toward me as he spoke to her searching my face for confirmation.

Boy, did he get it! I was shaking my head vigorously, “YES!”

Her response?

“Well, I don’t want all of that. You see, I only want to die once.” She said impishly.

We all burst into laughter.

She apparently took this as her cue. So, she continued, “I mean who in their right mind would want to die twice? Right?”

(She began to remind me of Joan Rivers on stage.)

She kept going…”Why break my ribs just so I can come back to do it all over again? And who came up with that plan anyway, doctor ?!?”

#LOL #ROFL were understatements!

Observing my uncontrolled laughter she said, “At least you’ve got a sense of humor kid. But let’s get on with this admission, I’m hungry….”

So, we did.

—–

Lesson 1- Things are not always as they first appear. Sometimes we are pleasantly surprised.

Lesson 2- Fatigue is no excuse for skipping what could be the most important healthcare planning conversation in a patient’s whole life.

Lesson 3- Always find a reason to smile or laugh with your patients (even if it’s a choice :) )

I have a very wise nurse-friend, we call her “Coop.” I have always thought that she double-dipped from the fountain of compassion. This paper, which she wrote for a Nursing 403 class, proves my suspicions true and gives us all a clue on how to become more like her. This lesson is applicable to ALL of us who care for and serve others, not just those called to nursing: Continue reading

It’s Personal… by Michael Fratkin, MD

Friday, 21 Nov 2014 20:13

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When we hear that we have a terrible illness that will shorten our life, it’s personal.  When we learn about the benefits and trade-offs of the tests and procedures that will decide what treatments and medicines may help us, it’s personal.   As we make our way through side effects, complications, insurance plans, phone calls, waiting rooms, pharmacies, labs, radiology departments, billing departments, emergency rooms, intensive care units, medical jargon, bad news, good news, family conflict, family meetings, caregivers, nursing homes, physical therapy, occupational therapy, speech therapy, psychotherapy, medication lists, medication interactions, medication errors, advance directives, wills, and the many losses, it’s personal. Continue reading

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“If you don’t want to deal with death and dying, then you need to quit medicine now and become an accountant…because this is what we have signed up for and we’ve got to do a better job at it.”  Continue reading

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I love hospitalists, they are some of my favorite people. Like me, they come into the hospital and work their butts off for 10-12 hours with very little food or water. We are essentially kinfolk, and we take care of the same patients.

Because we are comrades, I make sure to meet and greet with hospitalists each time I see them. (Some of us even hug!)

One of my favorite hospitalist was in the ER today when I arrived, and somehow (of course) we got on the subject of advanced directives. He told me that his own living will says that when he cannot wipe his own ass, then doesn’t want to be kept alive by any medical interventions. (Excuse his “French”)

We both laughed knowingly.

He said that when he shared his living will with his wife, she freaked out. In her distress, she asked, “Don’t you love me? Don’t you love the children?”

He said, “Of course I do, however my definition of life meaning means being able to actually live.”

Pensively, I remarked, “We’ve seen too much haven’t we?”

We both nodded in agreement. Then, we both smiled and he admitted my next patient-an hundred-year-old man who could no longer wipe his own ass.

Recent articles suggest that doctors typically do not want aggressive measures for themselves at the end of their own lives.

And why is that? It’s because we’ve seen too much haven’t we?

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(photo credit: www.mdsalaries.com)

First, click here to watch my video recount of the “Hospice” ER Shift

Ok, well I am neither a good actor, nor producer but don’t let that stand in your way of receiving my message…Hospice care can be activated ANYWHERE within the healthcare system (and even outside of it) when the patient is ready!

The ER (besides the ICU and Surgery Suite) may be one of the most aggressive, intervention-focused areas in the house of medicine. So, if WE can do it, then ANYONE can do it (meaning, transition patients to hospice care when appropriate.)

Here are some tips from my Emergency Department:

1- Signage

ER docs like to look at algorithms. It’s the way we are trained, just open up any ACLS guideline and you will see what I mean. So, in our emergency department we have a sign at each doctor workstation which reads:

“Signs that a person may be ready for hospice care”

  • Weight Loss
  • Increased pain, nausea, fatigue or other symptoms
  • Increased need for assistance
  • Decreased alertness
  • Increased hospitalizations
  • Family exhausted from care-giving demands

(At the bottom of the sign are directions on how to make a referral).

2. Train your staff to screen for hospice readiness

My nurses ask all kinds of questions to patients during their initial screening:

“Do you have any religious, or cultural preferences that might affect your care today?

“Do you feel safe at home?”

“Would you accept blood products to save your life?”

So, you see, we are accustomed to asking deeply probing questions from the get-go, so why not also ask end-of-life screening questions:

“How many times have you been to the ER or hospitalized in the last 6 months?”

“Do you feel like your health is steadily failing with worsening symptoms?”

“Are you feeling tired from the amount of care-giving required for your loved one?”

Identifying the potential hospice-appropriate population goes along way toward getting them the care they need in a more timely manner.

3. Build relationships with local hospice providers

Our hospital has an affiliate relationship with a local not-for-profit hospice who serves as our preferred provider. RNs from this hospice have affiliate hospital privileges at our institution. So, if we call… they come. This takes a huge burden off of the ER staff in transitioning care– our role just becomes one of “screener”- we “screen” the patient and family for physical and emotional “hospice readiness” and then can simply call for a consultation.

OR, if we have a patient who desires another hospice who doesn’t have affiliate privileges, OR if we have a clear-cut, “I want to go home on hospice” patient, then we can simply call the hospice service of choice (make sure their numbers are readily available to the secretary) and have the hospice RN meet them at their home or home facility for intake.

NOT COMPLICATED!

So, the bottom line here is, if we can do it, anyone can do it.

How does your department or institution make hospice referrals easier? Please share!

 

 

My step-father likes to tease a lot. One of his favorite sayings is, “Even a blind bird sometimes gets a worm!” That’s what I feel like with this BIG tip that I am about to share with you…

You see, I serve on the Board of Directors for two non-for-profit hospices (Hospice Family Care and the Los Angeles Hospice at Anam Cara), so I know how hospices are always strenuously brainstorming on how to get more market-share and how to get more referrals. I have on occasion offered a few weak suggestions to which everyone responds in a polite but we’ve-already-tried-that-one kind of way. Let me assure you, this idea is different. This idea is one whose power I learned first-hand as a physician…

So, here it is…

Are you ready?

You’ll never believe you didn’t think of this yourself!

So, simple…

Just have the hospice patient and/or family write a personalized thank-you letter to the referring doctor!!!

Here is why this works. You see, as a doctor, and I know what it’s like to have drug reps and service marketers come up to me and try to get me to use the “best and newest” medication or the “best” service. Do you know what my brain does in response to these requests?

(Yawn…..) Then I think, “Hmm, did you bring donuts?”

OK. Now this is why my recommendation is so radically different…

You see, on the rare occasion that I get a “thank you letter” (and even more, rarely, a “thank you visit”) from a former patient or their families, something totally amazing happens to me.

I feel warmth in my heart. I smile. I forget that I am tired or hungry. For a moment, I think that I have the best job in the whole world… and most importantly, Whatever I did to make that patient or family “thank me”… whatever I did, well I want to do that OVER AND OVER AGAIN!! It’s like hitting the Jackpot in the physician’s heart! He or she will want to do “that” (ie. make that hospice referral) over and over again!

So, when the time is right, bring a pre-addressed stamped envelope bearing the referring physician’s name and office address to your hospice patients and their families. Say something along the lines of this: “If you are grateful for our services, please send your doctor a little thank you note so that he/she will know that he/she made a good decision by referring you to our care. We will even drop it in the mail for you.”

“Ah ha!” you are saying, “Why didn’t I think of that?” :)

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–Again, doctors listen to two groups of people primarily, patients and other doctors. I am happy to be the “other doctor” who makes the argument for hospice as the way to best serve our patients at the end of life! I do this in the easy-to-read book, It’s OK to Die. Give it as a “thank-you” gift to your doctors! For bulk purchases of 10 books or more, the price drops to $8 per book with only $1 shipping per book (in the Continental US). Email me if you are interested in this discount: DrMurphy@oktodie.com

(Photo credit: businessnewsdaily.com)