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Research Shows Some Misunderstanding Among Physicians Regarding End-Of-Life Directives

Struggling with the meaning of life is one thing. Struggling with the meaning of end-of-life directives shouldn’t be.

Physicians misidentify living wills as do-not-resuscitate (DNR) designations and DNR orders as end-of-life care directives, concluded a study. Adding code status designations to a standard advanced directive can ensure that patients receive or do not receive the care they want.

The study, “TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders,” appeared in the Dec. 5 issue of The Journal of Emergency Medicine.

Researchers Read more »

*This blog post was originally published at ACP Hospitalist*

Considering Tuesdays With Morrie When Facing A Life-Threatening Diagnosis

Film adaptation of "Tuesdays with Morrie"

Many of you know about, or have read, the highly recommended book, Tuesdays With Morrie. I am reading it now with my 14-year-old son, Eitan, as part of an assignment for his ninth grade English class. Morrie, a college professor in Boston, was dying, withering away with ALS. Each Tuesday he would have a visit from one of his favorite former students, Mitch, a journalist from Detroit. Morrie, a man in his 70’s, mused about many things including the meaning of life and the inevitability of death. He was prepared for his end.

The other day I spoke about that book with a former high school English teacher – not Eitan’s. The circumstance was not good. The woman, 37, had been diagnosed with stomach cancer just six weeks ago. She’d been having heartburn and it wouldn’t go away. Endoscopy showed the cancer and other tests revealed its spread to her liver and lung – stage 4. The woman and her husband, her high school sweetheart, sat across from me at lunch. They have three young children, age Read more »

*This blog post was originally published at Andrew's Blog*

Are Doctors More Likely To Refuse Certain Medical Care?

No CPRA must-read piece from Ken Murray:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

Worth the full read.

And so true. I’ve joked about getting the above tattoo when my times comes. (I would quibble that the modern CPR success rate is better than infinitesimal, especially with hypothermia, but it still ain’t great.)

It may have to do with Read more »

*This blog post was originally published at Movin' Meat*

Elderly Heart Failure Patients Choose Longevity Over Quality Of Life

Don’t assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.

Researchers looked at patients’ willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure.

End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade.

End-of-life preferences were assessed at baseline, and at 12 and 18 months. Read more »

*This blog post was originally published at ACP Hospitalist*

Broaching The End Of Life Topic With Loved Ones: Join The Campaign

This is my 3rd year participating in The Engage with Grace Blog Rally.  Engage With Grace is a movement designed to help advance the conversation about the end-of-life experience.  It began with a simple idea:  Create a tool to get people talking.  Their tool is a slide with five questions designed to initiate dialog about our end-of-life preferences.  I originally heard about Engage with Grace from Paul Levy and he’s at it again this year.

This campaign has forced me to Read more »

*This blog post was originally published at 33 Charts*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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