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How To Ensure Productive Interactions Between Clinicians And Patients

I sat in a dingy pharmacy near the Seattle airport over the holidays, waiting for an emergency prescription.  For over two hours I watched a slow-moving line of people sign a book, pay and receive their prescription(s). The cashier told each customer picking up more than one prescription or a child’s prescription to wait on the side.  In minutes, the harried white-haired pharmacist came over to ask the person if they were familiar with these medications, described how to take them, identified the side effects to look out for and demonstrated the size of a teaspoon for pediatric medications.  Then he asked the person to repeat back – often in broken, heavily accented English – what he or she had heard and patiently went over the parts they didn’t understand.

I was impressed. This is what every pharmacy should be like – except, of course, for the dinginess, the creeping line and the fact that it was so crowded I could overhear these conversations.  Maybe if we got federal legislation enacted requiring pharmacists to offer counseling with each prescription filled, this kind of attention would be the norm, adherence to medication regimens would improve and drug-related injuries would be reduced.

Wait a minute.  Someone already had that good idea.  It was Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

End-Of-Life Care: When Medicine Prolongs Dying, Not Living

The recent Washington Post article entitled, “Who decides when medicine prolongs dying, not living?” perfectly captures my earlier blog on why we’re afraid of death. An excerpt from the Post piece:

[There's a] huge gap between Americans’ wishes about end-of-life care, as expressed in numerous public opinion polls, and what actually happens in too many instances–futile, expensive, often painful procedures performed on people too sick to leave the hospital alive–much less survive with a decent quality of life. Ninety percent of Americans say they want to die at home but only 20 percent do so. Half of Americans die in hospitals and another 25 percent in nursing homes, after a long period of suffering from chronic, incurable conditions that finally become untreatable. An astonishing one out of five die in intensive care units, often unconscious, isolated from loved ones and hooked up to machines that do nothing but prolong an inevitable death.

This happens partly because of the natural human tendency to procrastinate about addressing painful subjects with relatives and partly because doctors are often too pressed for time–and too uncomfortable with death and dying themselves–to respond when patients do bring up such issues. Just try to get a straight answer out of an oncologist, as an 89-year-old friend of mine did when her doctor advised another course of chemotherapy even though her cancer had metastasized to her brain. “Doctor,” she asked, “what chance is there that I’ll have a few months more of life that I can enjoy with my family?” He replied, “We can’t know these things.” She replied, “No, but we can use our common sense,” and declined further treatment. She died a month later in hospice, surrounded by her children, grandchildren and great-grandchildren. What if she hadn’t been clear-minded enough to to speak for herself? What if her children, out of love, guilt or a combination of the two, had subjected her to treatment that she wouldn’t have wanted? That is what advance medical directives are intended to prevent. Read more »

*This blog post was originally published at A Medical Writer's Musings on Medicine, Health Care, and the Writing Life*

End-Of-Life Planning Makes It Easier To Say Goodbye

This is a guest post by Dr. Barbara Okun and Dr. Joseph Nowinski.


End-Of-Life Planning Makes It Easier To Say Goodbye

Saying goodbye as the end of life approaches can be difficult, even for those with a gift for words. In a moving account in a recent issue of The New Yorker, writer Joyce Carol Oates describes the last week of her 49-year marriage, as her husband was dying from complications of pneumonia. Like A Year of Magical Thinking, Joan Didion’s poignant memoir of her husband’s sudden death and its aftermath, Oates’ essay highlights the need for each of us to think about death and dying — and discuss them with loved ones — long before they become a likelihood.

In our work with individuals and families facing death, we have seen too many people miss the opportunity to say goodbye because they avoid what feels like a scary or taboo topic: What do I want to happen when I die? Beginning this discussion early, preferably while you are in good health, can help pave the way for a “good death.” In our new book, Saying Goodbye: How Families Can Find Renewal Through Loss, we offer a guide to help individuals facing a terminal illness and their families navigate the realities of death and dying. Planning ahead is essential. Here are some suggestions for doing that:

Choose your team. Identify support people and specialists (legal, medical, financial, religious) you can count on to advocate for you and help you make decisions. Designate these people to act for you by signing advance medical directives. Read more »

*This blog post was originally published at Harvard Health Blog*

End-Of-Life Wishes: How To “Engage With Grace”

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again. And again. 

This weekend the “Engage With Grace” message is being broadcast virally, through a “blog rally,” at a time when many people are with family and friends over the long weekend. The point is: We all need to have the potentially uncomfortable conversation with people close to us about what kind of treatment we would want, and they would want, if incapable of making or communicating healthcare decisions. CNN ran a story on “Engage With Grace” yesterday.

End-of-life decision-making has long been an issue of great personal and professional interest to me, and I am proud to have played a role in having out-of-hospital DNR orders recognized in Massachusetts by EMS providers, as an example. Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

Death Planning

There’s a case for killing Granny?  I guess so, or at least according to Evan Thomas’ article in the most recent Newsweek. Thomas, after sharing the story of his mother’s last days, concludes that death is the key to health care reform:

Until Americans learn to contemplate death as more than a scientific challenge to be overcome, our health care system will remain unfixable.

Does everything need to have a political spin on it nowadays?

But let’s take Thomas’ advice and talk about death.  Not “death panels,” not the politics or the cost of end-of-life care.  Just plain old death.

I was reminded recently of how fragile life is.  It made me remember something I read after our oldest child was born.  I realized that one day she would learn the truth about death.  And I thought how bad that was, and how I wanted to protect her from it.  But then, by chance, I happened across this interesting little saying.

When your children are young, all you think about is that you don’t want them to die.  But when they get older, all they think about is that they don’t want you to die.

It touched me, and it made me think about how my responsibility to protect my children extended even unto and beyond my own death.

It’s a nice philosophical point, but there are very practical things each of us can do to fulfill this responsibility.  Here is my list of just a few of the very important things we all should do to plan for our deaths:

Buy life insurance

If you’re young and in reasonably good health you should be able to buy a term life insurance policy for a few hundred dollars a year.  You should do this so your family can have your earning potential replaced in the event of your death.  Find a good insurance broker and make sure you get coverage that suits your needs.  Even if you have a pre-existing condition (like a chronic illness) a good broker should be able to find you some kind of coverage.  You won’t be able to buy any coverage at all if you become acutely ill, so don’t wait until it’s too late.

Make a will

This is so much more than just planning for your family’s financial future.  For example, if you have children, have you figured out who will take care of them if both you and your spouse die?  There are many important and potentially difficult conversations that go along with this kind of planning – but you’re much better off having them now.  After you die, those left behind will end up fighting out these issues not knowing your wishes.  Find a good lawyer to help you.

Make an advance directive

You need to think about what kind of medical care you want if you become incapacitated and unable to decide on your own.  Do you want to live for 30 years on a ventilator, unconscious?  Do you want to undergo extensive and painful treatments if you don’t have much hope of a meaningful recovery?  Don’t leave your family alone trying to make that decision for you, wondering what you would have wanted. Write down what your wishes are.

Appoint a health care proxy

Pick someone who you trust to make your medical decisions for you if you are unable to do so.  Write it down and make clear what you want that person to do, so if the time comes there isn’t any dispute among your family as to who is in charge.

There are many other things you can do, but to me these are four of what I think are the most important things you can do to prepare for your death.  Maybe some commenters can add some more that I missed.

Now, with all that said and done, I will still disappoint Mr. Thomas.

Why?  Because I still prefer to think of death as a scientific challenge to be overcome.  And you know, I’m glad that many other people feel that way, too.

Especially the people who make medical breakthroughs – I’m really glad they feel that way.

*This blog post was originally published at See First Blog*

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