On Loss, Death and Dying

As an internist with “added qualifications in geriatric medicine” I care for a great many elder individuals. In most cases these are individuals I met 20 or more years ago and have been privileged to share their lives with them as they aged.

The circle of life is relentless and unforgiving so there comes a time when these relationships end. In some cases it comes when they can no longer care for themselves and I suggest they move out of the area to be closer to a loved one who will provide support and care. In some cases the patient moves from their home into a senior assisted or skilled nursing facility out of the area.

There have been a few situations where an adult child from out of the area shows up on the scene and transfers their loved one’s care elsewhere. These are the most difficult situations because the children are stressed and put out by the responsibility and inconvenience of suddenly having to care for their loved one. They do not have the longstanding professional relationship with me that I have with the patient. They expect quick and simple answers and treatment plans in most cases when for the most part we are dealing with complex issues involving many professionals and treating one condition fully often exacerbates another.

Then of course there are the patients who pass away. As detached as you try to be, those of us who care invest a bit of our heart and soul in each patient who comes to us for care. I see that investment made in the vast majority of my colleagues across all the disciplines and specialties. When you lose someone, even an ancient senior citizen, it takes a piece of your being with it.

I too am no spring chicken. I talk about Medicare from experience now. Morning stiffness is a shared experience, not a term in a medical textbook. Male urinary problems, once something you treated in older guys is now a way of life. My older colleagues are retiring. When making hospital rounds I notice the prevalence of younger physicians.

My beloved pets age too. For the last 16 years my Pug (Pugsly) and my mixed-breed sweetie (Chloe) greeted me at the door, took long walks with me and provided fur therapy after a stressful day. Pugsly expired a year ago. His mate Chloe left this world in November. For a clinician well versed in Elizabeth Kubler Ross’s book “On Death and Dying” and dealing with life and death daily, the loss of a beloved pet should be easier. The pain is palpable. The sadness recurs and the heaviness on the shoulders, eyelids and heart wears you down.

I have several younger patients valiantly battling against horrible malignant diseases. Their drive and courage to overcome illness and enjoy the time they have with family and friends is inspirational. They do not know it but they are my role models for how to deal with the adversity of losing loved ones, human and pet, and sharing the diminishing independence and health that my long time patients now experience.

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A Clinician’s View of the Opioid Crisis

“Do Not Get Caught.” seems to be the real rule of the law in S. Florida, where I live.

I was trained to limit the use of controlled substances, narcotics, hypnotics and sedatives. Their use can affect consciousness, ability to drive a car and work.  More severe consequences include respiratory depression and overdose from too high of a dosage or mixing too many medications and over the counter items.

The Joint Commission on Accreditation, medicine’s good housekeeping seal of approval authority, along with major medical organizations have accused clinicians of under treating pain. “Pain” is the fifth vital sign, they said.

This was accompanied by professional society leadership and academic researchers receiving grants from pharmaceutical companies touting the newer longer acting pain medications which “have very little addictive potential”. We were then informed we would be receiving evaluations and scores of our treatments of pain which would influence our reimbursement if we under treated pain.

In my current concierge medical practice I see 10 or fewer patients per day. In my previous general practice I saw 2- – 30 patients per day. I could go days without prescribing a narcotic pain medication. In most cases when I wrote out a script for a narcotic pain medication it was for a patient with a severe chronic pain problem, seeing a specialist for that problem, and requiring a pain pill because there were few effective alternatives. The patient visits to doctors and physical therapists and massage specialists and other alternative pain therapies were well documented in the medical record and mostly unsuccessful in attempts to relieve the pain.

This contrasts markedly with the opening of pain clinics in nearby counties with their own in-house prescribing pharmacies. One or two physicians wrote thousands of pain pill prescriptions per day. Patients lined up around the block to see these employed physicians of the pain clinic with many arriving in cars from other states. The cash flow generated was so vast that the clinics needed private security to protect the profits. Many of the security hired were off duty city and county police officers trying to supplement their income.

It’s hard to imagine that law enforcement and the DEA, were unable to recognize the difference between pill distributing centers and legitimate practices prescribing medications on a limited basis to individuals with documented needs. City, County and State governments gladly accepted the tax benefits, occupational license fees and pharmaceutical license fees from these sham clinics while drug dealers drove in and out of our state to obtain prescription pain medications for sale in their home towns. Of course the blame for this was placed on the doctors and dentists.

The State of Florida tightened up its laws and somehow law enforcement was given the tools to see and eradicate what was occurring right under their very noses. As prescription drugs dried up, the Mexican drug cartels got smart and flooded the market with cheap strong heroin. It was obviously the fault of the physicians and legitimate pharmacies that white working class people were buying plastic bags full of dope and inserting needles into their veins to avoid the pain of life.

As drug addiction soared, City and County Governments found it in their hearts to sit as zoning boards allowed drug rehabilitation centers to open up in the heart of their communities. There was little or no effective investigation of who was running these clinics and or their previous experience, methods and or success rates. If you want to read about where the soaring number of narcotic overdoses occur in our community – follow the zoning board’s placement of rehab centers and sobriety houses. What better way to increase your drug overdoses than to encourage unsuccessful addicts to come to your community and leave their money and their family’s money to improve the tax base and create new headaches for EMS and police officers?

Somewhere there should have been a higher level of thought by our elected and appointed officials about the consequences of bringing hundreds of drug dependent individuals into our area before they permitted these facilities to open.

Last week my advanced pancreatic cancer patient with severe back pain tried to purchase a controlled substance prescribed by his oncologist to relieve his suffering. Six pharmacies no longer stocked the product due to their fear of liability. It took hours to find a pharmacy that would order the medication for the patient. Physicians, pharmacists and law enforcement accessing our state narcotic registration website clearly can see that this patient only uses his medications as prescribed by one physician. This patient, and others like him, are victims of the government legitimizing of pain pill mills and drug rehabilitation centers in their communities.

As a physician we all have our failures in this area as well. I painfully recall the doctor’s wife I sent to a disciplined pain doctor to wean her off narcotics prescribed by a rheumatologist, urologist and gastroenterologist for legitimate reasons documented by tests and biopsies. I refilled the prescriptions for her convenience and ease never dreaming I was contributing to her problems.

I feel for my colleagues in the Emergency Department and in orthopedic offices having to daily differentiate acute pain requiring intervention with controlled substances as opposed to individuals with drug seeking personalities. This being said, the opioid crisis was caused by the most trusted members of the academic medical community in cooperation with the medical inspection and certifying agencies in concert with public officials and law enforcement looking the other way. They all made a great deal of money at the expense of the public. Now as they struggle to clean it up they give us medical and recreational marijuana.

Extreme Exercise Tied to Gut Damage

I was out doing my morning two mile trot on an unseasonably cool late spring morning in South Florida. The crispness of the day, coupled with unexplained lack of my normal warm up aches and pains made me particularly frisky. I had walked the dog for a few miles slowly, then engaged in my normal pre-run stretching routine and felt unusually energetic and fluid. I was enjoying the outdoors and weather, while listening to music on my play list and struggling to stay within the parameters of speed, pace, and target heart rate appropriate for a 67 year old man. The inner competitor within me was screaming, “You feel great, go for it.” Moderation and common sense are always the great traits to keep exercising and not injured. The inner stupid competitor in me said pick up the pace. I did pick up the pace. I completed my course far quicker than usual. I performed my cool down and stretching routine and was feeling pretty cocky about doing more than I should when I heard that rumble in my gut and saw the distention begin. The distention was followed by cramps, gas and profuse uncomfortable loose stools for several hours. My gut was sore and my appetite was gone.

I mention this after reading an article review in MedPage Today about a publication in the journal Alimentary Pharmacology and Therapeutics published by Ricardo J.S. Costa, M.D., of Monash University in Victoria, Australia. He and his colleagues showed that exercise intensity was a main regulator of gastric emptying rate. Higher intensity meant causing more disturbances in gastric motility. High intensity exercise at a rate you are not used to for a period of time longer than you usually exercise leads to gut problems including all the issues I experienced. Low to moderate physical activity was found to be beneficial especially to patients, like myself, suffering over the years from irritable bowel syndrome.

The researchers found that ultra- endurance athletes competing in hot ambient temperatures running in multi stage continuous 24 hour marathons were far more likely to develop exercise associated GI symptoms than individuals running a less intense half marathon. The results are fairly clear for us non ultra-endurance athletes. There is great wisdom in regular moderate exercise to keep your effort within the parameters your physician and trainer recommend based on your age and physical training. Even if it’s a cool crisp day and you feel that extra surge of adrenaline and competitiveness, moderation is best for your health and your gut. I hope the competitor in me remembers that the next time the urge to push the limit pops up.

Ambulatory Blood Pressure Checkups versus Clinic Blood Pressures

General internists and family practitioners have very little equipment to use in diagnosing our patients other than a light, a reflex hammer, a stethoscope, an EKG machine, a spirometer (to test breathing) and a pulse oximeter. Some offices still have an x- ray suite today but that is less common in small independent practices.

The ambulatory blood pressure cuff is a device introduced as a way to test whether patients with office-based hypertension had an isolated anxiety elevation of their blood pressure because of the physician’s “white coat” or an ongoing problem that needed to be addressed. The monitor itself is a routine blood pressure cuff with a computer device and timed inflation and deflation mechanism. It was designed to take six blood pressure readings per hour while you were awake and four readings per hour during the night.

Patients are asked to bathe and groom themselves prior to arriving for an appointment and we then placed the cuff on their arm and activated the device. They returned it the next morning and we connected the recording chip to our computer. We received multiple readings per hour and the machine calculated average blood pressure readings, made graphs and answered the question of what type of blood pressure elevation we had seen in our office.

We have performed hundreds of these procedures on patients and it is extremely rare to see a report of a sustained or average elevation of the systolic or diastolic blood pressure in a range that requires the use of medication. We only use the ambulatory monitor on patients who took their blood pressures at home and said it was normal but always had a dramatic elevation while in the doctor’s office.

I was entirely surprised to read the article in Circulation which looked at employees of the State University of New York at Stony Brook and Columbia who had ambulatory blood pressures compared with “clinic” blood pressures. 893 individuals wore the ambulatory monitor and were compared to 942 who had clinic blood pressures taken. These were all young healthy individuals with none taking blood pressure treatments.

They found that the ambulatory monitor readings were higher (average 123/77) compared to clinic readings which averaged 116/ 75. The average BP was 10 mm higher in young healthy adults with a normal body mass index. This elevated ambulatory blood pressure was found to be most pronounced in young healthy individuals with the difference being less apparent with increasing age.

While the result was surprising it still supports the use of the machine in our older population of individuals who come in with a story of elevated blood pressures in the doctor’s office but normal blood pressures at home. We will continue to use the machine for just that purpose.

Hospitalized Seniors Say No One Coordinates Their Care

Anthem Healthcare had a survey conducted of over 1,000 senior citizens older than 65 years of age in the hospital between September 26 and October 13, 2016. This Harris Poll found that 85% of the participants had a real medical issue. The poll also indicated:

Sixty-four (64%) percent said they had at least three different health care providers (at one time these were called doctors.)

  • Sixty-nine (69%) percent rely on a family member or themselves to organize and coordinate their care.
  • Sixty-four percent (64%) of those recently hospitalized said no one helped coordinate their care after their hospital discharge for months at a time.
  • Less than half of those surveyed (<50%) said that they were asked about medications or treatments provided by other physicians that might impact their current care. With no one checking drugs and drug interactions this raises major safety issues.

The findings are not surprising to me and reinforce why I limited my practice size and leave sufficient time to learn about who else is caring for my patients and what, and why, they are recommending their specific care plan. It requires reviewing medication lists painstakingly including accessing pharmaceutical data bases and asking patients and their caregivers to bring all their medications and supplements to the office in their original pill bottles. For instance, you can’t tell how much potentially dangerous fat soluble vitamins your patients are ingesting without reading the labels. You need to run the drug-drug interaction software to insure that medicine combinations are not making your patient ill

It’s important to know who else is providing care to this patient and why. As their primary care physician, you need to ask patients to request old medical records and request a consult summary from their other doctors.   You then need to invest the time necessary to review these documents.  It’s a two-way street; providing your patients’ other physicians with your office notes as well as lab and test results. Sometimes a phone call to another doctor is necessary to clarify treatment recommendations and to then assist and educate your patient concerning the reasoning and goals of the treatments.

Often, family conferences in person or by phone are needed to inform caring relatives about what support and assistance the patient requires and how they can be of help. It takes time listening to your patients’ concerns, advocating on their behalf and preventing well-meaning treatment from others from causing harm because they are unaware of the patient’s medication or problem list.

In today’s world, concierge and direct pay primary care practices are providing these services while polls sponsored by mega-health entities confirm those organizations are falling far short in doing so!

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?