Posts Tagged ‘Advance Directive’

Oct 25, 2012A Revolving Door to Avoid

by Judith Graham
The New York Times
October 25, 2012

Two weeks ago, Dr. Arif Nazir got a call from a colleague about a 79-year-old woman at an Indianapolis hospital. The cardiologist on the phone explained there was nothing more that could be done for this patient, who had advanced heart failure, chronic lung disease and diabetes.

After a brief conversation, Dr. Nazir agreed to admit her to a nursing home and try to keep her out of the hospital, respecting her recently signed “do not resuscitate” order, or D.N.R.

It was a promise that was broken within several hours, much to Dr. Nazir’s dismay. The reasons highlight troublesome problems with long-term care that frequently frustrate caregivers and that are receiving fresh attention from medical providers and Medicare. More

Oct 11, 2012Three Generations Gather for End-of-Life Conversation

by Maggy Patrick
ABC News
October 9, 2012

Norb Ranz and his daughter Maureen Jennings have always talked about everything — except one thing. So the two decided to gather three generations at Jennings’ childhood home on his 85th birthday to talk about what Ranz may want at the end of his days.

“My dad is 85 today… he’s still very, very active,” she said. “He’s a great storyteller and a wonderful friend.

The family talked about everything from what the service would be like to what they would do if Ranz’ health declined.

“Now we’re just asking that you share some of your thoughts about what you would like at the end of your life, so that we can honor your wishes,” Jennings said.

“How strongly do you feel about staying in your house? If you have the resources to stay here … is that something that’s really important to you?” she asked him.

“I would miss it, but anybody would,” Ranz responded. “If the time comes and I can’t take care of it, or know enough people who will help me take care of it … but it’s still kind of fun to be here.”

Jennings and her sister Molly Calhoun used their mother — who passed away earlier this year — as a touchstone to talk about how important knowing their father’s wishes were to them. More

Oct 9, 2012Teens Want Voice in End-of-Life Decisions

By Serena Gordon
U.S. News & World Report
October 9, 2012

Teens and young adults who are seriously ill should have a chance to be involved in end-of-life decisions, and a new planning guide — developed especially for this age group — can help, researchers say.

“It’s OK to raise these issues and open up communication,” said Lori Wiener, director of the pediatric psychosocial support and research program at the U.S. National Cancer Institute and lead author of a study that helped develop the new guide.

“Adolescents and young adults often stay silent and secret because they don’t want to share their fears — because they don’t want to upset their parents. And parents don’t bring up end-of-life issues for the same reasons,” she explained. More

Sep 27, 2012End-of-Life Options Worthy of Attention

By Joe Timmerman
The Badger Herald
September 25, 2012

Death is a very difficult topic to discuss. It’s not a subject that most people enjoy pondering. It is especially difficult to discuss with someone whose death may be imminent. Like many issues, it might be easier to just avoid the topic altogether. However, as is often the case, pretending the issue doesn’t exist won’t make it go away, and can often make the end result more difficult to deal with. Thus, the news the Madison medical community will start providing end-of-life planning as a standard patient service is welcome, indeed.

End-of-life planning involves sitting down and coming up with an “advanced directive.” An advanced directive is essentially a set of written instructions regarding a patient’s preferred medical care that are carried out in the event the patient is no longer able to make those decisions. For example, a patient might specify that, if they should enter into a vegetative state, they should be taken off the ventilator and allowed to die.

Preparations for death, such as end-of-life planning, are becoming increasingly accepted in the medical community. According to guidelines published by the American Society of Clinical Oncology, all terminally ill patients should sit down and discuss their end-of-life wishes with their family and health care team.

Advanced directives are beneficial for a variety of reasons. To begin with, people should have their health care administered according to their own preferences. If someone wishes to be kept alive on a ventilator, then he or she should be able to. If someone wishes instead not to be put on a ventilator, then they shouldn’t have to be put on one against their will. Just because someone can’t communicate his or her preference doesn’t mean it shouldn’t be honored. Either way, this is utility enhancing for the patient. More

Sep 25, 2012Doctors Are Practicing Irrational Medicine at the End of Life

By Monica Williams-Murphy, MD
KevinMD.com
September 22, 2012

I just took care of a precious little lady, Ms. King (not her real name), who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practice at life’s end.

Ms. King was a case in point: She was a 92-year-old nursing home patient on hospice for metastatic breast cancer. Ms King had been transferred to the ER for a sudden drop in blood sugar, presumably due to her oral diabetes medication. Her appetite had apparently been trailing off, as is common at the end of life, and her medication appeared to have become “too strong.” Her glucose level had been corrected by EMS during her trip from the nursing home to the Hospital, so when I came into see Ms King she was at her ‘baseline.’

I opened the door to bed 24 and a grinning little white-haired lady peered at me from over her sheet. “Hi,” she said greeting me first.

“Hi, Ms King,” I smiled back at her and picked up her hand.

She reached over with her free hand to pat me on my forearm, “You sure are a cute little doctor,” she said smiling.

I couldn’t hold back a little laughter. “Well, you sure are a cute patient too,” I smiled and winked at her.

She winked back at me.

“Wow, this is the most pleasant 90-year-old I have cared for in a while,” I thought to myself.

As we chatted it became clear to me that she had some mild dementia but had no pain or complaints at the time. She just said, “I think I had a ‘spell’” ( a “southernism” for some type of unusual and undefined episode of feeling ill or fainting); and “I’m not hungry” when I offered her food.

Leaving her room still smiling after our pleasant exchange, I went back to look at her medical record from the nursing home and two things immediately struck me:

1. She was on 20 medications, only about half of which seemed needed or appropriate to me. For instance, if someone is expected to die from cancer in the next 6 months (which is why she was on hospice care), why should that person take a cholesterol pill every day?

Is it going to change her outcome? No.
Will it add to her comfort? No.
Could it possibly cause unnecessary harm? Yes.
So, why is she on this medication? No rational reason that I can think of, other than mere habit on the part of the doctor.
- Doctor habit: See an abnormal lab value ( i.e. elevated cholesterol) = give a pill to correct it. While this is a fine default among the rest of the population, this type of unconscious medical practice at the end of life is contributing to wasteful drain of precious and scarce Medicare and Medicaid dollars. We cows (doctors), need to depart from these types of paths. If the usual pill, practice or procedure does not have any benefit for the dying person, if the typical treatment doesn’t create comfort, or may actually harm this person, then DON’T DO IT! Get off this path!

2. She was on hospice care but her order sheet read, “Full Code.” I can never figure this one out. If you or your family member enters hospice care this means that you generally accept that your time on this earth is limited, specifically to less than 6 months or so. Thus, it is irrational to ask for chest compressions or shocks or artificial life support measures when your expected end comes. Right? Didn’t you sign up for hospice because you were wishing for a peaceful, natural death? Well, not everyone agrees with me, so I called Ms. King’s power of attorney to clarify this point, it was her son, Mr. King.

Mr King was a pleasant man who said that he was unable to come to the hospital because he himself had suffered a stroke. After I explained the full code vs Do Not Resuscitate/Allow Natural Death pathway, he said, “Oh No! she never wanted all of that life support stuff. Both of us want what you said, ‘ a natural death.’” More

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