A call came about noon a few years ago that a patient I’ll call Stella was being admitted once again. She had come into the ER from her nursing home to receive transfusions. These were now needed every two weeks to keep her alive. The problem was that every time Stella was moved she decompensated. Her Alzheimer’s was severe. She no longer recognized her family. She was now 83 and slowly …
When “do no harm” is no longer textbook
Ezekiel Emanuel wrote an article for the Atlantic on “Why I Hope to Die at 75: An argument that society and families — and you — will be better off if nature takes its course swiftly and promptly.” As an oncologist and ethicist, he says he speaks for himself but implies not so subtlety that avoiding our declining years may be in our best interest — and that it …
Ezekiel Emanuel’s wrong ethical view of aging
Brittany Maynard has passed from this life. This brave but unfortunate 29-year-old woman with incurable progressive brain cancer drew public attention by choosing to go public with her choice about end of life care.
“Brittany suffered increasingly frequent and longer seizures, severe head and neck pain, and stroke-like symptoms,” according to a statement Sunday night from Sean Crowley, spokesman for Compassion & Choices, a national nonprofit working to …
Brittany Maynard: It’s more than death with dignity
Much is being made of the AMA’s recommendation to reimburse doctors for the time they take in having end-of-life discussions with their patients. The recommendations appear to have a good chance of being covered by Medicare and certainly are a step in the right direction. But will one conversation and the completed documents really work? Well, like so many other situations — it depends.
How skilled is the medical provider …
End-of-life discussions: Is extra reimbursement enough?
I was taught in medical school (some 50 years ago) that doctors had a special duty to protect the patient. That seemed self evident and logical. “Do no harm” was a first principle dating back to Hippocrates. However the teaching I received extended the concept to also protect the patient from bad news, and to make “the right” decision for them — not necessarily including them in the conversation or …
The evolving physician role in end of life decision making
Agnes was out shopping at her local corner store. At age 82 her body was beginning to show typical signs of aging. She had survived breast cancer surgery, a hip replacement, and cataract surgery. Her doctors told her she had osteoporosis and low vitamin D. She took medications for her hypertension, cholesterol, and osteoporosis. Her spine had begun to curve and her gait was a few steps slower.
Yet, with her …
CPR without informed consent in the elderly
Susan was 76 and dying at home in the days before hospice and before the use of the POLST form. A neighbor came in the relieve Susan’s daughter who went to the store. Suddenly Susan stopped breathing and the neighbor called 911. The medics came and, not having instructions to the contrary, did CPR and brought her to our ER unconscious and intubated. The ER physician called me in the ICU saying, …
When the POLST form is controversial
When I was in medical school, our nutrition researchers taught us that vitamins didn’t do much good and only made expensive urine (where the water soluble ones end up). We did learn about the classic vitamin deficiencies like scurvy, beriberi, rickets, etc. But the evidence that healthy people should take vitamins was marginal at best.
Is our search for immortality the reason that we turn to the pill or potion? Do …
Vitamin and mineral supplements for healthy individuals don’t work
“Hey doc, I saw on an ad on the TV last night about this new asthma inhaler. Shouldn’t I give it a try?”
This type of question would occur several times a week. When I started practicing medicine it was considered unethical to advertise medical treatments. Now, we’re bombarded with enticements for tests and treatments. The inhaler the patient requested cost $264 a month — more than double what he was …
The medical industrial complex and the surge of health costs
Ben’s first symptom was coughing up blood. The cancer had been silently growing for months, if not a few years. He had no pain or shortness of breath. The chest x-ray showed a “5cm L hilar mass” and the subsequent CT scan showed enlarged lymph nodes and likely spread to the liver.
“So Doc, what is it? A cancer? How much time do you give me?” All these questions on a …
After a cancer diagnosis: Giving a patient time
Elton John had it right: “It’s sad, so sad. Why can’t we talk it over. Oh, it seems to me that sorry seems to be the hardest word.” Mistakes are all to common in medicine, but can we say the “hardest word” when we’re involved?
Example 1: There’s a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double …
After a medical mistake: Honesty is the best policy
Les called me about his PSA.
“Jim, it’s rising and now up to eleven and they’re recommending treatment. What would you do?”
Even as a long retired MD, I still get medical calls from friends and relatives. Actually, I feel honored and try to do my best, researching the latest journal articles and editorial opinions. Of course, the prostate cancer literature is cloudy at best with scant evidence that the huge number …
Hospice stays remain far too short
John and Eva had ongoing conversations about their home which was now far too big for their needs and lots of trouble and expense to repair and keep up. John said, “It’s the yard, the leaves, the painting, and general repair and replacement problems. What’s next to go? The refrigerator or me?” Eva was tired of shopping and cooking. Her arthritis was slowing her down. She told John, “Ok, you …
Are we prepared as the Boomer generation downsizes?
Elton John had it right: “It’s sad, so sad. Why can’t we talk it over. Oh, it seems to me that sorry seems to be the hardest word.”
Mistakes are all to common in medicine, but can we say the “hardest word” when we’re involved?
Example 1: There’s a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, …
After a medical mistake, an apology is both simple and difficult
Vermont became the first state to enact a law authorizing physician-assisted suicide through the legislative process. As the governor signed the bill, Jean Mallary watched carefully over his shoulder. She’s the widow of the late Dick Mallary, a former speaker of the House and U.S. Congressman. Mallary was in pain and suffered from terminal cancer when he chose to end his life over a year ago. Jean Mallary’s story …
Death with dignity: Issues states need to consider
Bobby was admitted to the hospital once again with overwhelming fatigue and shortness of breath. Yet this 37 year old farmer looked the picture of health. He grew up on a farm rising before dawn, milking cows and working long days in the fields with hay or corn. He was never seriously ill as a child and was a good football halfback in high school.
But this was his third admission …
Medical problems can be uncovered by a history and physical exam
Pierre arrives at the construction site, has his morning coffee and croissant, then ascends the scaffold to begin his work. He felt a little woozy this morning but ignored it. Becoming more dizzy, he loses his balance and falls two stories fracturing his femur and pelvis. On arrival the paramedics find his health smart card in his wallet, scan it, and instantly have his medical records including medications, allergies and …
We need to use smart cards for our health
If you haven’t seen the movie, “Amour”, but are planning to, you might want to skip this commentary – but by all means do go!
It starts and ends with love, but not in Hollywood’s usual youthful romantic fashion. It also starts and ends with death after much caring, love and suffering. The agonizing toll on the patient and caregiver are equally …
Death by voluntary cessation of fluids and nutrition needs discussion
William would come to see me every three months for his COPD (chronic obstructive pulmonary disease). We would chat about his disease, his meds, and his grief. He had lost his wife a few years back, but after 52 years he found it very hard to be without her.
On one visit he said, “Doctor deMaine, can I tell you something – and promise you won’t think I’m crazy?”
“Sure.”
“Well, my wife …
Should spiritual beliefs play a role in end of life care?
There is a serious cost problem in USA health care which no one denies.
Yet when it comes to suggested solutions, there is a wide divergence of opinion. Attempts to use experts and evidence based guidelines for care are somehow viewed as government interfering with decisions which should be between the doctor and her patient.
States and insurance schemes have made varying attempts to deal with this. The Oregon Health …
Does Oregon have the answer to rational rationing?
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