Sunday, October 23, 2011

A Note From Israel

Below is a commentary that I have permission to pass on from Dr. Leibovich. It points out to me that the issue of forcing the dying patient into the hospital may be an international problem, especially in the more developed countries.

"Today I found your blog on End of Life issues. I spent several hours reading all your posts, and I wanted to thank you for writing.

I want to apologize for my basic English, but I hope you'll understand. I wish I could write like you do…

I am a family physician in a Kibbutz in Israel and I take care of almost all the people in the Kibbutz, from birth to death. I am faced with end of life issues quite often, and I feel that I have the exact same views on this like you. I am fortunate to be able to help many patients and families to avoid futile hospital care, and this is one of the things I am very proud of.

A few months ago I took care of my stepfather who lived in a fancy place for old people who can take care of themselves and live alone in a nice flat, but they have a restaurant, have cultural activities etc, in a big city. (I don't know what this kind of place is called in English – here it's called something like "sheltered living"). At the age of 89 he started getting weaker and needed more and more help with his daily activities, until finally he needed constant care. Cancer was diagnosed. We got someone to take care of him 24 hours a day. When he got to the stage where he needed a wheelchair the management of this place did whatever they could to get him to leave – to a nursing home (with four people in a hospital bed in a room), a hospital or whatever. He had already sold his previous home, and he expected to live in this place for the rest of his life. He was alert and understood they wanted to get rid of him, as this spoiled their nice place for "the young at heart". They referred me to the contract where it says that this is a place for independent people. I managed to take care of him in his flat and refused to take him to the hospital, as this was his explicit wish, and we all knew that there was nothing they could do better in the hospital than we could do in his own home and bed. In the last week of his life I was there most of the time, gave him medications against pain, and he passed away in his bed surrounded by those who loved him. I was very happy to have been able to do this for him. I was very sad that this had to be done fighting the management all the way. They threatened me that I was denying him adequate care in a hospital, where he should be in his situation. I ignored them as I knew his time was getting short, and I didn't believe they would try to evacuate him forcefully in his situation. He passed away a day before another meeting they set up to tell me I had to take him somewhere else.

So I am glad to read your stories that show me that I am not alone in the thought that if there is nothing more medicine can do the best place for a person to finish his life is in his own home, if this is what he wants.

All the best, Mira Leibovich, MD - Israel"

Thursday, October 6, 2011

Honor the Advance Directive - or Not?

I gave a lunch time talk at a retirement home today to a group of about 60 pretty bright folks including judges, chaplains, professors, etc. The subject was "Your Life Your Choices", a program oriented toward educating families about the value of advance planning and how to make their values and wishes known. The discussion was dynamic and lively.

One consistent point about advance directives is to preserve the patient's autonomy for decision making by having a person "close to their heart" act in their behalf when the patient is no longer competent.

After the session and discussion, a lady quietly approached me and asked if she could have a moment of my time. She said, "My husband has worsening Alzheimer's and can no longer care for himself reliably. He's been transferred to the Memory Care Unit. The doctors say he is no longer competent to make any health care or financial decisions so the burden is entirely on me, but I have a problem. My husband said a few years ago and signed the papers that he would want full life support including fluid and nutrition to sustain him. But I don't know if that's the right thing to do now."

My first thought was to advise her to meet with her doctor and a palliative care or hospice provider to look at all the options with their benefits and burdens. Also I advised meeting with a social worker and/or a spiritual counselor to explore the difficult decisions and to meet as an entire family unit. Then I asked her, "Do you think if your husband's heart stops that CPR would benefit him?"

"No," she replied. "But I'm not sure what his wishes in his present situation would really be. He never talked about quality of life issues much."

I tried to reassure her that there were no clear guidelines in this situation. To try to take the burden off a bit, I told her that doctors in general didn't feel obligated to provide treatments to patients that are not beneficial. She gave me a sad smile saying, "thanks, but I still don't know what to do."

Comment: It can at times be very difficult for a surrogate to truly know the wishes of the patient who is ill and can't further discuss their status. That's why I encourage patients to write an addendum to the Living Will giving their overview of "quality of life." What are the biggest hopes and biggest fears about the end of life? What would be acceptable or when to "pull the plug"? The more we can let our surrogate know our true feelings, the better the decision will be, but it's hardly ever easy in the gray zone such as with this patient.

An example of fear is the story of Chopin's heart. His great fear was being buried alive so he had his physician promise to remove his heart at death, thus ensuring he was dead! Chopin is buried in France but the heart is enshrined in a church in Poland, a significant tourist draw. Chopin's wishes were honored. May we all have surrogates that know our own hearts.

Wednesday, October 5, 2011

Saving Health Care Costs the Easy Way

How would you like to have physicians in the USA cut health care costs by more than 6 billion dollars a year in a rather simple non-painful way? A recent study in the Archives of Internal Medicine looked at rather commonly done tests and prescribed medications.

The National Physicians Alliance (NPA) initiated a project called “Promoting Good Stewardship in Clinical Practice.” They have published lists of the “top 5” activities in primary care (family medicine, internal medicine, and pediatrics) that could improve both care and the use of clinical resources. After testing showed physician support for these evidence-based, cost-saving, easy-to-implement activities, the group published their lists with simple guidelines like:

1. Don’t do imaging for low back pain within the first six weeks unless red flags are present.
2. Don’t obtain blood chemistry panels or urinalyses for screening in asymptomatic, healthy adults.
3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.
4. Don’t use bone-density screening for osteoporosis in women under 65 or men under 70 with no risk factors.
5. Do use only generic statins when starting lipid-lowering drug therapy.

The biggest savings was by the use of generic statins, but all of these five steps were well supported by medical evidence and had peer group support.

If medicine were a large business with careful accounting and accountability, these five steps would be implemented (or the manager fired). But we have a large messy expensive system with little accountability.

Can we step up to evidence based peer supported medical practice? Otherwise I fear the cuts (which are coming) will be painful and illogical.

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