November 30th, 2008 by Dr. Val Jones in True Stories
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The successful “Engage with Grace” campaign resulted in ~95 bloggers promoting end-of-life care discussions with family members over Thanksgiving. Paul Levy called it the first “medical blog rally on the Internet.” I wonder how many readers took the challenge?
I spent Thanksgiving with my sister (mom of 3) and brother-in-law in Michigan. After our dinner (with the kids tucked in for the night) we enjoyed a glass of wine and a game of Cranium (if you haven’t tried this game yet, you might want to pick one up in time for the next group of holidays – it’s like Pictionary, Charades, Trivial Pursuit, and American Idol wrapped into one). I looked for an opportunity to “pop the question” on end-of-life issues.
During a brief lull between rock song humming I casually inquired about whether or not my sister and brother-in-law had a living will. They said they hadn’t thought of it but agreed that it would be important to have one. We discussed various scenarios related to organ donation, end-of-life care, and cremation vs. burial preferences. Things degenerated a bit as I asked what their individual preferences might be for resuscitation under special circumstances (it was almost like a scene from Monty Python – “So, if you had no arms and no legs and you had a 10% chance of normal brain function recovery, would you like to be tube fed? How about if you had one leg and half an arm and a 5% chance of mental recovery? What about if you had 1/2 a liver, no spleen, and only one eye worked, but you COULD do math questions?”) We all had a good laugh at the black humor, but recognized that something important underlay the jesting. There is no doubt that we each had a 100% chance of dying at some point during our lives.
And then something unexpected happened – my brother-in-law looked me in the eye and said, “If anything happened to us, we’d really love it if you took our children and raised them as your own.”
I was very touched and happily agreed to do so. I replied with a wagging finger, “Now this doesn’t mean that you should take up helmet-free motorcycling…”
We all had a good chuckle and returned to Cranium, each feeling a little richer for the experience – we knew how we’d like to be cared for in case of critical illness, and I’d become the proud new godmother of 3.
November 26th, 2008 by Dr. Val Jones in Announcements
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Matthew Holt and Paul Levy have encouraged medical bloggers to join together around a common goal for Thanksgiving: to talk to our loved ones about end-of-life preferences. Now I know this may seem a bit morbid at first blush – but it is really important that each of us create a living will and durable power of attorney document. There’s no better time to discuss this than a holiday where we all get together with our families to enjoy one anothers’ company and our gratitude for what we have.
I used the Suze Orman site templates to create mine (I received a free CD Rom). It was really easy to do. Living Wills provide guidelines about your wishes for care in the event that you are unable to express your opinions. The Durable Power of Attorney document makes it clear whom you’d like to “call the shots” on your care if you’re unable to do so for yourself.
If you haven’t done so already, why not consider the following three steps over Thanksgiving?
1. Discuss the “Engage with Grace” slide with your loved ones.
2. Fill out living will and power of attorney documents at Suze’s site (or find another site online that has a good template that you can use to express your wishes).
3. Get those documents affirmed by a notary public and send a copy to your doctor to add them to your medical record.
Every person at every age needs to have an end-of-life care plan. Why not join with thousands of blog readers in settling this matter for yourself and your loved ones this Thanksgiving?
November 22nd, 2008 by Dr. Val Jones in True Stories
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I was traveling on an Amtrak train to a dinner meeting in Philadelphia. Two portly business men wedged in next to me and had an animated conversation about which companies do well despite a down economy. Here’s how the conversation went:
Businessman #1: You know, I’ve taken such a beating on the stock market, I just don’t know where to put my money to protect it and grow it. But I was thinking – one thing’s for sure – lots of people are going to continue dying despite the recession.
Businessman #2: So what kind of business insight is that?
Businessman #1: Funeral Homes, dummy. That’s where the action is. People still have to cremate or bury their loved ones, even in tough economic times.
Businessman #2: Nah, that’s not really scalable. I mean, you can’t save on costs with more volume. It’s fixed – a coffin costs what it costs. What you should really get into is Assisted Living facilities. Now THAT’s a growth market.
Businessman #1: No way, people can’t afford to pay for assisted living after the market crash. Their savings won’t last long enough to make it worth my while to take them in. Then when it runs out, what can I do? You can’t put them out on the street so you’re stuck with them till they die.
Businessman #2: You don’t have to be stuck with them, when their cash runs out you can transfer them to a lower quality facility. Then Medicare will pay for it.
August 15th, 2008 by Dr. Val Jones in News
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Thanks to KevinMD for highlighting this fascinating blog post by Pallimed. A recent study in the journal Chest showcases the inaccuracies inherent in translating medical conversations. According to the small study, as many as 50% of the statements made by physicians were altered in some way by the designated interpreters. Generally the certified medical interpreters attempted to editorialize or soften the physician’s language. Here is one specific example:
Doctor: I don’t know. Um, this is a very rapidly progressing cancer.
Interpreter (translating): He doesn’t know because it starts gradually.
Although this study had a very small sample size, in my experience it rings true. I speak three languages (English, French and Spanish) however my proficiency in the last two doesn’t quite reach fluency. Although I can comprehend what people are saying, I make some grammatical errors and demonstrate somewhat limited vocabulary in my responses. For this reason, I welcome interpreter services when they’re available, and when they’re not – I proceed with self-translation for convenience and speed.
This puts me in an interesting position – I can understand the difference between what I say in English and how the interpreter translates it. In most interactions I’ve asked the interpreter to rephrase at least one concept to the patient as I note some inaccuracies in editorialization or softening of concepts. The kinds of translational “errors” include things like:
Dr. Val: We need to use IV antibiotics to treat your skin infection because we don’t want it to spread. If we don’t treat it, the infection could enter your bloodstream and cause serious problems, including organ damage, and even death.
Interpreter: The doctor is going to give you some strong medicine through your IV to treat your skin inflammation.
I agree with the conclusions drawn by the study authors – it’s helpful to speak with the interpreters prior to the patient interaction, and stress the importance of translating the exact meaning of your words. Also, physicians should speak in slow, short sentences to increase the chances of accurate translations.
And patients? Don’t hesitate to ask clarifying questions if anything about your condition or treatment plan is unclear to you. Invite a bilingual friend or family member to the meeting if possible, and realize that the quality of interpretation varies. Make sure you understand the risks and benefits of any procedure or medication before you accept or decline it. When you’re in the hospital you certainly don’t want any aspect of your care to be lost in translation.
*See my interview with Access Hollywood reporter, Maria Menounos, about how her dad’s diabetes care was influenced by a language barrier.*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 15th, 2007 by Dr. Val Jones in Health Policy, Opinion
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More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).
In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):
Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.
Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).
“We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.
While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.
What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?
I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”
My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.
My mother said tersely, “I hope I die in Europe.”
My father replied, “Whether you’re old or young, it’s nice to be alive.”
But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?
This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
