Dr. Cranquis' Mumbled Gripes
(Disclaimer: Questions related to medical topics will be answered to the best of Dr. Cranquis' (and Google's) knowledge, but the internet-delivered wisdom on this blog CAN NOT AND SHOULD NOT SUBSTITUTE for your Real-Life Doctor's personal attention + examination, and your own common sense too! If you think you're having a medical emergency, hang up and go email 911. The author of this blog takes no responsibility for any medical, relationship, scholastic, financial, or other decisions you may make based on information found in this blog.)
Some of the saddest cases I’ve seen in my career are patients with sudden catastrophic illness or trauma for whom their families are expected to make health-care decisions — and the families don’t know what the unconscious/critically-ill patient would want. Families are torn apart, arguing over whether to continue all life-prolonging interventions, vs focusing on keeping the patient comfortable.
You may think you’re too young and healthy to need an Advance Directive, but massive trauma or overwhelming infection can happen to anyone. Do your family a favor and check out this website, which provides the simplest End of Life Wishes discussion guide I’ve ever seen, and includes links for creating an Advance Directive. Use it, and pass it on!
New York Times op-ed article.
“…As the aging baby boom generation places unprecedented demands on the health care system, there is little ordinary citizens can do — witness the tortuous arguments in the Supreme Court this week over the constitutionality of the Affordable Care Act — to influence either the cost or the quality of the treatment they receive. However, end-of-life planning is one of the few actions within the power of individuals who wish to help themselves and their society. Too few Americans are shouldering this responsibility.
Of course many people want more aggressive treatment than my mother. And advance directives aren’t “death panels”; they can also be used to ensure the deployment of every tool of modern medicine. They can be changed or withdrawn at any time by a mentally competent person.
But public opinion polls consistently show that most Americans, like my mother, worry about too much rather than too little medical intervention. In a Pew Research Center poll released in 2006, only 22 percent said a doctor should always try to save a patient’s life, while 70 percent believed that patients should sometimes be allowed to die. More than half said they would tell their doctor to end treatment if they were in great pain with no hope of improvement.
Yet only 69 percent had discussed end-of-life care with a spouse; just 17 percent, or 40 percent of those over 65, had done so with their children. One-third of Americans had a living will and even fewer have taken the more legally enforceable measure of appointing a health care proxy to act on their behalf if they cannot act for themselves.
The latter omission is especially disturbing because by 2030, more than 8.5 million Americans will be over 85 — an age at which roughly half will suffer from Alzheimer’s disease or some other form of irreversible dementia. For many members of the baby boom generation — more likely to be divorced and childless than their parents — there may be no legal next of kin.
Without advance directives, even a loving child may be ignorant of her parent’s wishes. My mother remained conscious and in charge of her care until just a few days before she died, but like most women over 85, she was a widow. My younger brother died of pancreatic cancer two weeks before she did. It was an immense comfort to me, at a terrible time, to have no doubts about what she wanted.
My mother drew up her directives in the 1980s, when she was a volunteer in the critical care lounge of her local hospital. She once watched, appalled, as an adult daughter threw a coffeepot at her brother for suggesting that their comatose mother’s respirator be turned off. Because the siblings could not agree and the patient had no living will, she was kept hooked up to machines for another two weeks at a cost (then) of nearly $80,000 to Medicare and $20,000 to her family — even though her doctors agreed there was no hope…”
All credit for this motto goes to drshutterbug.
I just may need to get this image tattooed on my xiphoid process. XD
Powerful article, with insight on how many doctors refuse to receive the very life-prolonging (but NOT life-improving) interventions which they feel “pushed” to provide for many terminal/critically-ill patients.
Personally, I’m “No Code”, and ever since med-school ICU rotations, I’ve often spoken with my medical colleagues about my mental list of conditions for which “If I had X diagnosis or X medical situation, just let me die.” Who has two thumbs and isn’t going to die riding a ventilator? THIS DOC.
Furthermore, I strongly believe that we (Americans and the US healthcare system) do not utilize Hospice Care soon enough/often enough for terminally ill people. The average American terminally-ill patient is enrolled in hospice less than 48 hours before he/she dies… yet doctors can certify a patient to receive hospice services if the doctor just thinks that it would be “reasonable to expect that this patient could pass away from a medical condition within the next 6 months.” And as this article states, many hospice patients have longer QUANTITY of Life, along with infinitely-greater Quality of Life, while on hospice.
/rant
Thanks for the heads-up on this article, doctom666!
MOST MEMORABLE (Part 2)
Also, what was one of your most discerning and humbling moments? Perhaps one when you knew that going into the profession was right where you belong.
Thank you again for all that you do, and I hope you have a great day!
Best,-Meghan
Ok, as promised in my reply to your original question, here’s the second story.
I was an intern in Family Medicine, struggling through a medical ICU rotation. Lots of data to keep track of, lengthy patient presentations, and lots of procedures (which were fun, but were often performed by the senior residents instead of little old me— boooo). I was feeling simultaneously overwhelmed and underappreciated; I had to come in 2 or 3 hours before morning rounds in order to collect scads of lab results and vital signs for my patient presentations, only to have most of that info get brushed aside by residents and attendings who “already saw that information before rounds” (HUH?! Grrr.)
One of my patients was an elderly Mexican male (let’s call him “Mr. Mendoza”) with heart failure, bilateral pneumonia, and worsening kidney function. He’d already been in the ICU, unconscious and “riding the ventilator” for 7 weeks before I joined the team, with no improvement. 1 week into my rotation, I was feeling as frustrated as his (exceptionally-large) family clan, who stood guard in shifts at the ICU doors, ambushing me with questions every time I walked by. The patient’s prognosis was atrocious, and the team had held weekly family conferences in an attempt to convey this reality to the family, but the family’s reply was unchanging: “He’s going to wake up, don’t stop anything.” The patient did not have any Advance Directives, and his wife refused to discuss anything which even smelled like “Withdrawal of Interventions”. VERY. FRUSTRATING. for everyone involved.
Then came that week’s family conference, and my moment of self-awareness.
As I’ve mentioned before, I speak Spanish fluently and have a Hispanic background from my mother’s family. Nobody else on the team spoke Spanish, and none of the Mendoza’s spoke English, so prior family conferences with the Mendoza clan had been interpreted by a telephone-service through a speakerphone. But at that week’s conference, the attending poked me in the shoulder as we walked into the room and said, “You speak Spanish, it’s your patient, YOU do the conference.” His tone implied that he didn’t really think anything was going to get accomplished today anyways, given the family’s “stubborn” refusal to accept their patriarch’s grim outlook.
Yeah, I was just a bit nervous. (!!!!)
But as it turned out, my combined skills of (1) speaking Spanish fluently, (2) being able to break down complicated medical situations into simpler concepts, and (3) having a bit more patience than the other team members were what this family had been waiting for. The conference, scheduled for 15 minutes, turned into a 90-minute saga of sudden comprehension of Mr. Mendoza’s grim outlook and lack of curative options, weeping and hugs among the family members as they all finally understood that they were just delaying the inevitable by keeping their unconscious Papa on the ventilator, and an unexpected outpouring of gratitude (and more hugs) for my explanations.
Mr. Mendoza was disconnected from the ventilator 2 days later, and died painlessly and calmly an hour later, surrounded by his tearful-but-relieved family — and me, a suddenly honorary member of the Mendoza clan who now knew that being a doctor was something I could do, in ways that would benefit my patients, my healthcare team-members, and even my soul.
***Pending Cranquis-Mails: 7; InBox: Closed***
Hola Dr. Cranquis! I am a neophyte nurse and I just started to work in a geriatric facility. And with that I would like to ask if what are the usual signs that a patient is about to die? Like an hour or two before a peaceful death? I’ve never experienced handling one before, so I’d like to know what signs (vital signs, o2 sat and all) to look for in case I have one so that I can call the family who would want to be there when the time comes. Thank you so much and wishing you all the best!
Ooh, excellent and thoughtful question, Neophyte Nurse! I applaud you for being so “whole-person” oriented, and considering the needs of terminal patients’ families to “be there” when the end comes.
There are many signs that a patient is approaching death or actively dying, but NOT every patient will show all the same signs or follow the same “dying timeline”. This is probably the most crucial thing to emphasize to family members, so that they don’t (1) become too worked up everytime that one possible sign develops, or (2) get taken by surprise when their family member passes away after actively showing signs of dying in the preceding days/hours. Not enough healthcare providers actively communicate about the dying process with family members ahead of time.
This thorough list from the Hospice Patients Alliance reviews the signs and symptoms of patients in “pre-active” and “active” dying phases. You’ll notice that very few of those signs involve the classic “vital signs” of blood pressure etc. As you (and any healthcare worker who experiences death regularly) will discover, you develop a “Spider-Sense” about impending death which looks at the Big Picture and the Overall Trend. That Sense isn’t infallible, but it’s valuable.
Of all those signs, the main ones that I would point out to family members (ahead of time, preferably) would be:
- progressive lack of responding to external stimulus
- movements and facial expressions which serve no purpose (and which are usually not attempts to communicate or express pain in the active stage of dying, assuming that the patient’s pain is being well-controlled.)
- Noisy, slack-jawed breathing and rattling in the chest
- the LACK of a Hollywood-style sudden period of acute awareness and lucidity just before dying (“The treasure is buried in the old…UHHhhhhhhh……”) — This is vital information, so that family members don’t feel (so) bad about not “being there at the moment of death.”
If you haven’t encountered the world of Palliative Care/Medicine yet, you should check it out. There is a tremendous need for actively-interested and knowledgeable healthcare providers in this field that specializes in relieving symptoms of terminal illness and providing support to the patients’ families as well. I wish you all the best in your new job, and I know that your patients and their families will benefit tremendously from your thoughtfulness and compassion. :)
***Pending Cranquis-Mails: 4; InBox: Closed***
Hey, thank you, and good luck with your Medical Journey! :)
Your description of grandma’s mental-status changes (self-discontinuing medications, paranoia, anxiety, along with worsening memory) could be manifestations of either delirium or dementia (or both! Tough to say in conditions like your grandmother’s). Parkinson’s Disease can cause dementia, and pretty much anything that happens in the life of a sick elderly person can cause delirium. So it COULD be one of her Parkinson’s manifestations, but I surely hope that her doctor has experience with ruling-out delirium (checking for infections, electrolyte imbalances, hearing disorders, etc) before just chalking all those things up to Le Parkinson’s.
So yeah, aging relatives — even if they don’t have a number of debilitating and tough-to-control conditions (as your poor grandmother does), your elderly family members will always have certain crucial healthcare-related issues that need to be addressed at some point — and way too many elderly people do not plan these things ahead of time (yet another example of how lousy the American health-care system is at preventive healthcare — Heck, when we doctors finally get a semblance of “popular” support for designing a proper system of preparing our aging patients for their eventual Death and Dying, then it gets all politicized and suddenly the IDIOTIC AND IGNORANT “death panels” term gets invented…. but I digress.)
Where was I? Oh yes, Things to Prepare for when you have an Aging Relative with (or without) chronic debilitating diseases — here’s some questions that will prompt the necessary preparations:
- Where does she want to die? Intubated in an ICU, being kept alive by machines for weeks past her due date, unconscious or delirious, sustained by IV drips or feeding tubes, marinated in antibiotics for pneumonia or urinary-tract infection? Or: at home, receiving (always excellent) care from a hospice nurse/team, surrounded by family and friends in a familiar surrounding which will help to minimize delirium, quietly sliding closer to her eventual Sleep?
- Who is her legal decision-maker, and does that person (and the rest of her family) know how/where she wants to die? Too many people (young and old) assume that “My family will just know what I would have wanted/chosen in the myriad of decisions which surround a hospitalization, intubation, resuscitation, surgical intervention, nursing-home placement, etc etc”. Then when the patient is unable to communicate their desires, their Legal Power of Attorney for Health Care (POAHC) suddenly realizes that maybe, just maybe, there should’ve been some discussion about all this beforehand. And even if the POAHC knows what the patient would’ve wanted, the other family members disagree, and the POAHC caves in to the family “in order to keep the peace.” Having a written-and-discussed “Advance Directive” can make a huge difference with this situation.
- What are her goals for living? What does she consider “being alive”? Knowing these definitions will make a LOT of the future decisions easier for everyone involved.
- Is she currently safe? This raises the topic of elder abuse (a largely-ignored aspect of “being old” that causes much suffering physically and financially and emotionally, among our elderly population — Oh hey, it’s Elder Abuse Awareness Day next week, June 15 2011!), and also the topic of getting an in-home safety evaluation (since your grandma already has nursing support, they either have done or can do this for her, but you can check a lot of potential-hazards yourself) to help prevent in-home accidents which are a HUGE cause of injury/death among the elderly.
- When can/will hospice care be utilized? In the US, insurance coverage of home hospice care usually kicks in when the patient’s physician states that “It would be reasonable to expect the patient to pass away within 6 months or less” — but sadly, average “days survived after enrolling in hospice” was 18.3 days in 2007. Does this mean that hospice is killing-off patients? NO. Families and doctors all-too-often consider hospice enrollment as a “death sentence” or a “sign that we’re giving up on the patient” or “something that we may need later, but not right now”, and so they delay and delay until the patient is almost dead, and then rush them into hospice for their last few days — yet family members of patients who have died while enrolled in hospice consistently express more satisfaction than families of patients who were not in hospice care. Hospice is so much more than just “a nurse who knows what to do when your grandmother dies in the house.”
That’s what comes to mind, for now. Hope that helps.
***Pending Cranquis-Mails: 1: Ask Box: Closed***
Two excellent and difficult questions, Gallant Gull.
Ok, you’re referring to the BRCA1/BRCA2 genes which, if mutated, greatly increase a person’s (male or female!) chances of certain cancers, including breast cancer. I think the most understandable review of BRCA genes and related issues is at the National Cancer Institute BRCA webpage. Going by the USPSTF recommendations about BRCA testing (better summarized on the NCI website here), your risk of having a familial BRCA-mutation depends on specific combinations of “first-degree vs. second-degree relatives” with cancer, types of cancers, and extent of the cancer (with even greater chance within Ashkenazi Jew populations). I’ll let you figure out your risk-factors for yourself — after you do that, speak with a doctor (yours, or your mother’s) about those risk factors. I am not fluent enough in the field of oncology to help you decide on that question.
As for your second question — that’s such an ethical quagmire! As I’ve hinted at in a post about the oncology specialty, doctors and patients often lose sight of the forest (the patient’s overall quality of life, goals for care, and acceptable outcomes) for the trees (cell counts, medication interactions, chemo and radiation dosages, a “We’ve come this far already, why stop now?” attitude, and more…). Your grandmother needs to decide what is more important to her: a shorter life with the ability to ambulate and be (more) able to care for herself, or a longer life with all the medication side effects and costs (financial and otherwise). I guarantee you that, with the majority of cancer specialists out there, your grandmother’s only hope of ever having a discussion about this will be if she (or a family member) raises it with the doctor. And perhaps, until you bring up the topic of “end-of-life goals” with your grandmother, your grandmother will never think about it either — or perhaps she’s afraid to bring up the topic herself, because it might appear that she is “suicidal” or “doesn’t appreciate what the doctors are doing for her”?
To answer your question directly: I can’t tell your grandma what to do, but if I was the patient in this scenario, I would feel quite satisfied with 80 years of family and living, and I would rather live just a couple more years of being more-or-less independent for ambulation while receiving Palliative/Hospice Care for any cancer-related symptoms, rather than tacking on 3/5/10+ years of “extra life” to be spent in a wheelchair or hospital bed while enduring a Cure that may make me feel worse than the Disease.
I hope my rambling reply helps you in some way. Good luck to you and your family.
***Pending Cranquis-Mails: 23***
Anonymous Asks:
I was just wondering if you have any suggestions to interesting, detailed (not the watered-down summary versions you find on NBC/ABC etc) articles I could read? Or even just interesting topics involving American health care that I could find articles about? What topics would you want to write about?
cranquis Said:
Aloha, Topical Trilobite!
What an interesting class! If you’re looking for a good list of “controversial topics” in medicine, check out bioethics.net — scroll down on their main page to see a list of bioethical hot topics. They link to lots of news articles, but there are also website and scholastic-article links in there.
If I was taking that class, my topic of choice to explore would be end of life issues. I think we (America) are really failing to properly prepare people for all the sociopoliticoreligioeconomic issues which center around a patient’s death and dying. Lots more scientific/scholastic info about that here.
Good luck with your papers!
***Pending Cranquis-Mails: 30***
shweter Asks:
I'm preparing for med school interviews...and trying to read pretty much everything there is to know about health care issues. It's not working out so well, particularly because there's SO MUCH STUFF OUT THERE.
Do you have any recommendations for me? What should I be reading? Where can I look?
Thanks, and Happy New Year! :)
cranquis Said:
Hey hey hey! Happy New Year to you too!
Oooh, med-school interviews… those were SO nerve-wracking for me. Later on in my medical journey, I got to GIVE some interviews to applicants in my residency program, and I realized that no matter how nice the interviewer (such as myself) tries to be, the interviewees (the applicants) always took a long time to relax and truly use the interview as a way to not only flesh-out the “skeleton” which was represented on their CV’s, but to also milk me for details about the program.
So, recommendation #1: try to go into the interview as if the med school was desperate to admit you into their program, rather than the other way around — and use the interview as a time to let them pry into you while simultaneously prying back at them for details that a current med student would care about (residency match rates vs scramble rates, board exam average scores for their students, satisfaction ratings of lecture and clinical experiences by currrent/former students). Nothing looks worse to an interviewer than an interviewee who is too nervous to enter into a genuine conversation, and who doesn’t have any good questions to ask back at the interviewer.
As for reading about health-care stuff… you don’t need to be able to provide in-depth analysis of the Medicare budget cuts or anything, but you should be familiar with the current medico-legal environment facing doctors nowadays. Some basic concepts (for US medical-school applicants) that you should probably read a bit about would include:
- The need for tort reform and the rising costs of malpractice insurance
- Physician reimbursement for assisting elderly patients with end-of-life planning
- The disparity in health-care services across various parts of the country
- Practicing evidence-based medicine vs. practicing “order every test possible just in case the patient decides to sue me later” medicine (this also relates to Tort Reform)
- The aging medical population and the lay-person’s expectations that “Everything should be done to keep someone alive” when this can actually just prolong suffering, lead to a “bad” death, and increase the family’s medical costs needlessly.
- The controversy between giving parents freedom to not vaccinate their children due to unscientific beliefs in “autism caused by vaccines” vs. the resurgence of previously-well-controlled public health illnesses (pertussis, measles, rubella) in populations that don’t have enough vaccinated people.
That’s just a few topics that come to mind.
I have found the Medscape website to be very useful for providing an up-to-date source of medical news info. You can find plenty of articles on all the above topics, and more, there — for free, as far as I can tell.
I also recommend reading the “Health” section on one of the major news websites (MSNBC, CNN, etc.) on a regular basis — good way to keep your finger on the pulse of “what’s hot” in the popular medical newsfront.
And if you have access to journals (such as through a medical library), the Journal of the American Medical Association (JAMA)has some good editor-opinion articles which can help synthesize some of these “hot topics” for you.
Hope that helps! Good luck! Don’t forget to freshen your breath and empty your bladder before the interviews! :)
Anonymous Asks:
cranquis Said:
If I had to do it (medical training) all over again, I can think of 3 fields I might have chosen instead of Family Medicine/Urgent Care:
- Emergency Medicine: Love the variety and the shift-work, kinda nervous about having to handle major multi-system trauma.
- Geriatrics: Love (most of) the patients, enjoy being able to help families come to grips with the realities of Grandpa’s waning medical condition, don’t enjoy the “puppy-mill” atmosphere in most nursing homes.
- Palliative (“Terminal/End of Life”) medicine: LOVE finding creative medical and non-medical ways to help people manage their pain and suffering, LOVE having discussions with patients and families about realistic goal-setting for their end-of-life medical care, HATE watching terminal/comatose people be forced to receive CPR because some well-meaning idiot of a family member can’t let go.*
Notice, however, that I don’t want to deal with any of those intriguing issues (major trauma, sick nursing home patients, or terminally-ill patients) IN MY URGENT CARE. :p
*Speaking of CPR: Was anybody else PISSED at House MD Season 7 Episode 7, when House started doing chest compressions and defibrillation on a man who had just died from a lingering painful uncurable disease? WHAT WAS THE POSSIBLE BENEFIT, HOLLYWOOD? Grr…. :(
