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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.

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*This blog post was originally published at ACP Hospitalist*

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*

Latest Interviews

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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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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.


Click here for a musical take on over-testing.

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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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