End of Life Issues and Family Disagreement

End of LifeI treat a fair number of elderly patients over many years who are now cognitively impaired and in the last stages of their life. Most of the times they live independently in their homes or apartments with the assistance of an aide while their children and closest relatives live elsewhere. End of life issues and discussions are an integral part of my practice in this group of patients. Having a living will and or a medical directive, appointing a health care surrogate for the future and discussing resuscitation status are complex but necessary discussions to have. I try to have these discussions with the patient and their life partner while they are still competent and cognitively intact. I try and review it with the designated health care surrogate if and when their mental status deteriorates. In most cases, when the clinical situation is appropriate for instituting palliative care or hospice care , and the patient when cognitively intact had indicated that this is the direction they wanted to go under these circumstances, these same families have tremendous difficulty in moving forward and following their loved ones plans. It is almost always the absentee children care takers of the Baby Boomer generation , who are now the health care surrogates, who will not institute their loved ones wishes and insist on continuing aggressive and acute care when expected changes in their loved ones health occur. There is always great discord within their families resulting in difficulty knowing who actually is calling the shots especially when all the children have a power of attorney document.

This situation is not unique to my practice. I am interviewed by potential new patients to join my practice all the time. Not a week goes by without a parade marching in of an elderly cognitively impaired patient, their aide, their child or children and sometimes a minimally impaired elderly life partner. The story is usually the same. Mom or Dad has been seeing “Dr. X” for so many years but he has them on too many medicines. They are lethargic. They do not want to socialize. In many cases the children have actually stopped medications based on their internet research, without discussing it with the doctor first. They are looking to change doctors. In most of these cases when I research the patient’s care and records, they have seen a board certified neurologist and geriatric psychiatrist and the diagnosis of cognitive impairment is accurate and appropriate. In most cases the trial of medications is appropriate as well and the care has been superb. In many cases the patient has an end of life terminal disease with a life expectancy less than a year whether it be a malignancy or not. The absentee children just are not able to accept that mom and dad are at the end of the life cycle and have asked for palliative and end of life care. I am sure that the children of some of my patients are seeking care elsewhere as well because they are not ready to accept an end of life diagnosis. This rarely if ever occurs with patients who live with their loved ones who provide hands on care on a daily basis. These hands on caregivers see the deterioration of their loved ones quality of life, understand what is occurring and how their loved one wished to be cared for in this situation.

We talk about death with dignity and living with a high quality of life. No physician or loved one wishes to accelerate the demise of a patient or family member. It is however; very difficult to honor the patient’s wishes when their absentee baby boomer children are not on the same page with their wishes and have not addressed the issues with mom and dad while they are competent and able to do so.

Why I Have “NO” Intention of Retiring in the Near Future

Not ReadyI was a bit surprised when an 85 year old potential patient asked me if I was planning on retiring soon. It is a fair question for someone considering joining a medical practice. They do not want to begin a relationship only to find out that the doctor is retiring in a short time.

I have no intention of retiring for at least the next 10 years. If I am fortunate enough to stay healthy, competent and caring, why would I give up something that I love doing? Practicing general internal medicine and having long standing relationships with my patients is a love and a passion – not a job. I am doing a fairly good job of it, feel confident that I can improve with time and more experience and, at this point, I am healthy enough to continue practicing as well as teaching future physicians.

Over the last 20 years, as medicine has changed dramatically, many of my colleagues who I started practicing with as new physicians in the late 1970’s have walked away from medicine with great disappointment and disgust. I am still having fun! When I converted my practice in 2003 from a traditional practice to a smaller concierge version, which allowed me to practice the way I was trained to practice, it reinvigorated my love for the profession.

I relish being in a position to show doctors in training the way it can be done and should be done to care for complex patients by giving them access to the doctor and time to express themselves while I listen. If you access the website of the American College of Medicine and the American Board of Internal Medicine and check out my data it says I am eligible for recertification in Internal Medicine through 2023. My goal is to continue to practice and remain eligible while practicing at a high level, being available and accessible and helping you to coordinate your care in a forever changing and more complex health care environment.

Patient Hand-Offs and Communication

document businesspeople 1I was finishing tying my shoes as I got dressed to take my lovely wife out to dinner for our 41st wedding anniversary. It was 7:30 p.m. after a hectic day at work and we had a wonderful dinner planned at a local restaurant.

The telephone rang with the caller ID identifying a call on my office work line. “Hello this is the Emergency Department, please hold on for Dr S.” Before I could get in a word edgewise I was put on hold. Five minutes later Dr S. got on the line. “Steve this is Pete. “Dr. Rheumatology” saw your mutual patient Mrs. T this afternoon and she was complaining of shortness of breath beginning three weeks ago. She complains of overwhelming fatigue. He sent her here for evaluation. Her exam is negative. At rest she doesn’t look short of breath. Her EKG doesn’t show any acute changes but I do not have an old one to compare it to. Her chest x ray is negative and her oxygen saturation on room air is 97 % (normal is greater than 90%). She has lupus and multiple autoimmune problems and is on many immune modulators. Maybe she has a constrictive cardiomyopathy or restrictive lung disease. I called Dr. Rheumatology and he said this isn’t his department to call the PCP (primary care physician) to admit the patient and you are the PCP. “I told the ER physician I had not seen the patient in over six months or heard from her but I would be right in to see her”.

I explained to my wife that duty calls and there was a sick patient in the ER. She was extremely understanding. On the drive to the ER I called the Rheumatologist to ask him his clinical impression because he had been seeing her every two weeks and had examined her just that afternoon. He returned my call and we discussed the clinical aspects of the situation and his thoughts. Then I told him that I thought he should have called me when he sent the patient to the ER if he expected me to assume care. If he did not call then he most certainly should have called me when the ED doctor called him to report on the findings and he said call the PCP. Hand-offs should be direct especially in an acute situation and especially if you sent the patient to the ER and do not intend to take ownership of the situation you sent the patient to the ER for.

He told me that in 30 years of practice no one had ever criticized him for this and he does it all the time. He told me he had been working long hours and did not have time to call referring physicians. I told him that was no excuse and if he was working that late maybe he needed to restrict his patient volume so he could communicate in a professional manner.

I arrived at the ER 20 minutes later and learned that the patient had been there for three and half hours already. She had been in the ER while I had been at the hospital earlier that afternoon checking on another patient. Had I known she was there I could have easily seen her, cared for her and still made my anniversary dinner.

A review of her old EKG and comparing it to the new one, plus taking a thorough history and exam, revealed the problem. She was having a heart attack. Her bouts of shortness of breath with activity with overwhelming fatigue were her equivalent of crushing chest pain.

Getting called to the hospital during “off” hours is part of a physician’s way of life. Having a colleague take your role and time for granted at the expense of the patient is disturbing and unprofessional.

All too often today physicians, both specialists and primary care, don’t take the time to communicate directly and clearly with their colleagues about patient care.  When this happens, clearly the patient is negatively impacted.

ACO’s and the Patient Centered Medical Home will not cure this. Only courtesy, respect and putting the patient first will change things.

New Test for Colon Cancer Screening Approved

Colon Cancer RibbonThe Cologuard test is the first DNA based screening test for colorectal cancer that has received approval for use from the FDA and preliminary approval by Medicare to cover the cost of the test. The test detects hemoglobin ( a component of red blood cells) and abnormal DNA in cells picked up by stool . A positive test indicates a need for colonoscopy to identify or eliminate colon cancer as a possibility. We currently screen patients with the fecal occult blood slide test and the more sophisticated fecal immunochemical test or FIT. The new Cologuard detected 92% of colon cancers and 42% of advanced adenomatous colon polyps as compared with 74% and 24 % for FIT. While the Cologuard test was accurate in picking up more colon cancers than the FIT it had slightly more false positive tests than the traditional Fecal Occult Blood Slide.

The Center for Medicare Services ( CMS) is proposing allowing coverage of the DNA test once every three years for beneficiaries who are 50 – 85 years old, asymptomatic and have average risk of colorectal cancer. The new test adds another non-invasive means of screening for colon cancer. We will need to see the cost of the test to the individual patient and accumulate more data on its accuracy in the near future before it becomes a mainstay of colon cancer screening.

At the same time that Cologuard was approved, researchers at the University of Michigan in Ann Arbor published in the online journal Cancer Prevention Research, information showing that evaluation of the pattern of bacteria in the colon of patients improved performance and detection of colon cancer by more than 50% as compared to the Fecal Occult Blood Test alone. Researchers using DNA sequencing and polymerase chain reaction methods were able to identify distinctly different patterns of bacteria in colon cancer and pre-cancerous polyps than in patients with no colon lesions.

It is clear that as researchers apply DNA technology to cancer screening their ability to detect abnormalities and avoid invasive colorectal screening will improve. At the moment recommendations for screening colonoscopy at age 50 remain but as science moves forward that too may soon change.

Flu Shots for the 2014- 2015 Season

Flu vaccineOur offices supply of influenza vaccine has been delivered to the office this week and we will begin immunizing patients on October 1, 2014. The Center for Disease Control in its Morbidity and Mortality Report of August 15, 2014 recommended that all adults be immunized against influenza this year beginning at a time that is appropriate to the appearance of influenza in your community. We generally do not see any significant influenza in South Florida before Thanksgiving with the season usually lasting through March. It takes ten days for the vaccine to take effect and your body to develop the immunity to resist the flu invasion. Immunity after vaccination begins to fade at 3 months and is markedly reduced or absent in most individuals 65 years or older at 6 months. Most pharmacies locally will begin their vaccine campaign in September. If you receive the vaccine then there is the chance that your immunity will be decreasing by December. For this reason we prefer to vaccinate you on October 15 or later. Please call the office for an appointment.

We will be administering the senior high potency vaccine which is the usual trivalent inactivated influenza vaccine at four times the dosage given to younger patients. Research has shown that the higher dose is needed to get senior citizens immune response to work well. Despite the higher dose, there are no more side effects reported than in the usual dosage administered to younger individuals.

For individuals younger than 65 years we will be administering the recommended quadravalent vaccine which is also an inactivated viral product. We will be charging $35 for the shot. Patients with egg allergies are encouraged to obtain the trivalent recombinant influenza vaccine (RIV3, known as FluBlok). It is available in limited supplies at the Health Department and at Passport Health.

Feel free to call the office if you have any questions at 561.368.0191

Haste Makes Waste in Meeting Core Measures

Obamacare v1Once again Government regulators have put in place well-meaning rules without anticipating the consequences. We all hate sitting around in the Emergency Department waiting to be seen and to be treated. On October 15, 2014 as part of the new Affordable Health Care Act and the patient satisfaction portion, hospital ER’s will have about 180 minutes from the time you arrive and sign in to evaluate you , treat you and make a disposition or decision. The game starts on Oct. 15 but already hospital administrators have their systems operating to prepare to comply. If you fail to comply the hospital will be punished financially with fines and reductions in payments. Take the case of LH who is 88 years old, demented and lives with her loving and nurturing son in South Florida. She went to the beach with her son on a hot humid day in August with temperatures in the 90 degree range and humidity of almost 80 percent for a feels like temperature of 110. While she sat under an umbrella for several hours, the beers she drank to celebrate her birthday did not react well with her medications for dementia. She stood up and swooned to the ground and ended up in the ER. Labs, EKGs and Chest X Rays were done and it was decided that she was dehydrated. She was given some fluids and sent home. Two days later a urine culture obtained at that visit became positive indicating an excessive number of bacteria and she was placed on an oral antibiotic for ten days.

Six days later she was still feeling weak and shaking when she stood up and moved about. Her son took her back to the ER concerned that she was having seizures. She was evaluated by the ER staff and noted to be running a fever. A Chest X Ray was taken and was read as left lower lobe pneumonia by the radiologist without comparing it to her film six days prior. As I was finishing up with my last morning patient I received a phone call from the ER physician advising me that my patient was there with pneumonia and fever and required admission. He told me he had obtained blood and urine cultures and started her on Rocephin. I reminded him she was already on an antibiotic trimethoprim/sulfamethoxazole for a urinary tract infection. I told him I could be there in about 30 minutes and asked him to keep her in the ER until I got there. He said that was fine. To meet the Core Measures need for a quick disposition I suggested that the patient be admitted to a medical floor on my service, be given a clear liquid diet and I would take care of the rest. He said that was fine.

In August, Boca Raton, Florida is a sleepy seasonal vacation town enjoying the offseason quiet with its two colleges and seasonal visitors off on holiday. Restaurants are never full. There are no lines at the movies. There are few if any traffic jams and beds are readily available in the hospital. The hospital is usually 1/3 to ½ full at best. Our brand new emergency room is bright, wonderfully equipped with digital and manual blood pressure cuffs, otoscopes and opthalmoscopes at each bedside in marked contrast to the paucity of them on the hospital inpatient floors. It is always easier to be thorough and complete in your exam in the emergency department where you are not wasting time looking for equipment to examine the patient. I arrived at the ER in 40 minutes and was met by the icy stare of the staff nurse who said, “She has a bed upstairs can I send her?” My response was, “Not until I have a chance to take a history from her and her son and examine her.” While I was taking the history and doing the exam my cell phone went off. It was another physician in the ER department calling to talk to me about another patient who was in the department having been sent there by his surgical specialty physician who had just examined him in his office for a problem. I excused myself and walked toward another section of the ER when my patients nurse asked, “are you finished can I send her up?” I again declined and informed her that Dr L in the urgent care session wished to talk to me about a patient now and I would be back. My patient was not critically ill. Antibiotics, food and fluids had been ordered. Taking a short break to speak to the other ER doctor would not jeopardize her care or safety.

I returned 10 minutes later to learn that the nurse had called the Nurse Practitioner working with the hospitalist service and she had written admitting orders in my absence to speed the process along the way. In the hospital’s view the most important issues were to move the patients along, get the medication reconciliation form filled out and get the form on preventing phlebitis and use of anticoagulants filled out so they can meet their Core Measures goals. I went into the patient and son , completed my exam, explained my findings and disappeared into the physician computer room to enter orders, dictate the admission summary after I had reviewed the nurse practitioner’s orders, reviewed the chest x ray and all the lab data. The computerized orders revealed the patient had been admitted to a medical floor, on antibiotics, on heparin for phlebitis and pulmonary embolus protection. They had missed the fact that the patient had executed a “Do Not Resuscitate “form and her son had brought it with him. This was not recorded in the orders. They had also missed the fact that the pneumonia or left lower lobe consolidation they diagnosed was the same on the x ray from 6 days prior and another from one year prior. I walked over to the radiology reading room and pointed this out to the radiologist who said what was being called a pneumonia was actually an innocent long standing hiatal hernia appearing behind the heart on x ray. Despite not having pneumonia, the patient was sick, weak, and febrile and needed admission to sort it out. I sat down at the computer and spent thirty minutes on the orders and admission notes and then spoke to the patient and family. At that point I allowed the ER nurse to call the transporter and bring the patient up to the floor. The nurse literally scowled at me and told me I was violating their Core Measures policy and their director would not be happy and would want to talk to me. I told her I had another patient to see and that if her director wanted to talk to me they knew where to find me since I have been on staff for 35 years. I reminded her Core Measures criteria did not officially start for three more months and that with an empty ER she needed to take a deep breath, count to ten slowly and relax. My comments were not appreciated.

The next morning I arrived at the hospital and looked up the patient’s location. To my surprise despite requesting a medical bed for a “DNR” patient she had been located on the cardiology telemetry floor and was hooked up to a monitor measuring her heart rhythm. Why would I put a patient who asked not to be resuscitated, who was not having irregular beats, who did not have blood chemistries favoring the development of an arrhythmia on a cardiac monitor? The hospital gets paid a flat fee for her admission practically independent of how much service we deliver. I had no idea how this happened but realized that on the computerized order sheet even though it listed the bed as “medical” the nurse practitioner had ordered a cardiac monitoring bed. This flaw in our computer entry ordering system does not allow visitors to see the type of medical bed requested unless you know to click on it. The extra cost of the monitor approaches a $1000 per day. Her antibiotics for the pneumonia she doesn’t have also were quite costly. Yes the hospital expedited her trip to the floor to meet Core Measures but did so at the expense of making the wrong diagnosis, applying the wrong treatment and providing an expensive service the patient did not need. Haste makes waste. This is just the tip of the iceberg. On October 15th the best is yet to come. Pity the poor patients.

Medicare Part D Open Enrollment For 2015

MedicareFrom October 15, 2014 through December 14, 2014 Medicare beneficiaries will have an opportunity to choose their 2015 prescription drug plan. These plans change annually. If you do nothing you will remain in your current plan in 2015 even though the price will change and the drugs covered will change.

On your computer go to http://www.medicare.gov . Choose prescription drug plans. You will be asked to put in your name, your Medicare ID number and your zip code. They will ask you to enter your favorite pharmacy and then all your medications by name, dosage and frequency of administration. You will then run the program and it will suggest the best plan for you. I suggest you choose the least expensive plan. There are elective add on features which pay your drug deductible and even cover the donut hole for a higher fee.

If you have any questions feel free to call us. If you cannot use a computer and need our help please let us know.

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