End of Life Issues

Sun and Wispy Clouds Over MountainsIt is the right of every individual to choose and define how they wish to be treated if they are faced with a terminal or life threatening illness and are incapacitated and unable to make the decisions needed to provide care and relief of discomfort. It is best to make these decisions while alive, healthy and mentally competent. The State of Florida has created the Florida Living Will which directs how you wish to be cared for if you develop a terminal illness and end stage condition or enter into a vegetative state and are unable to convey the answers about your care yourself. It is a nonspecific document requiring your signature and the signature of two witnesses. I address these issues with my patients frequently. The living will should be reviewed and signed and given to your physicians, lawyers and a copy kept at home. I usually advise patients to be more specific than the document requires. Do you wish to have a feeding tube placed and be fed artificially if you stop orally taking food and liquids due to a life ending illness? Do you wish to be resuscitated if your heart stops or you spontaneously stop breathing. There is a particular form called a Do Not Resuscitate or DNR form that should be signed and prominently displayed on your refrigerator if you do not want caregivers or first responders to perform CPR on you. A copy can be kept in your wallet and your physician and attorney should have a copy.

You should appoint a health care surrogate to make decisions about your care if you are unable to. This should be someone who knows you and has discussed with you how you wish to be treated in these situations. There is a form to designate a surrogate and it too must be signed and witnessed by two people. It is best to have one surrogate and one alternate. Appointing all your children surrogates just leads to confusion and conflict by committee when a decision that you have already made needs to be instituted.

As a patient you have the right to change your mind at any time either verbally or in writing. It is not unusual for patients to change their mind when they develop an acute medical illness which complicates their chronic life threatening issues which led to executing these documents. Make your choices for yourself. Your doctor and attorney should be able to direct you to the appropriate documents and discuss these issues in greater detail with you.

Geriatric Fellowship Program with Model Senior Citizen Home for the Aged Needed

Nursing homeI have practiced general internal medicine and geriatric medicine in the South Palm Beach County, Florida area since 1979. I have seen the growth of the medical community from a sleepy seasonal coastal distribution of hospitals east of I-95 to a sprawling plethora of corporate and not for profit facilities sprouting in areas of population growth. While cardiac, stroke and trauma centers have evolved to meet the needs of the community; there has been no development of state of the art care for our aging and infirm seniors.

Yes there are many skilled nursing facilities in the area receiving patients from local hospitals following an acute illness or injury and attempting to rehabilitate the patients so they can eventually resume their lives. These facilities are paid primarily with Medicare funds if the patient has spent three nights in the hospital. The staffs of these facilities are numbered based on federal and state requirements. It is not unusual to see one registered or licensed practical nurse with a patient load of 20 or more patients. The nurses are assisted by aides, many of whom are paid minimal wages and who lack the language and training skills to recognize changes in their patients’ health conditions until those conditions have advanced to a critical level. They are not able to care for many of the simple day to day medical emergencies that we deal with at home on a daily basis such as cuts and abrasions, simple upper respiratory tract or gastrointestinal infections. Their mantra is “call 911 and send them to the ER while we copy the chart for transfer “(not always in that order). They are doing what they are told to do by administration and legal counsel and, frankly; their training and staffing does not allow them to do much else even if their hearts and souls feel differently.

We need the FAU Charles Schmidt College of Medicine or the University of Miami Miller School of Medicine or Nova Southeastern School of Medicine to partner with the Lynn School of Nursing at FAU and organize a geriatric fellowship program in medicine, nursing and care giving. The program would be taught at a model senior geriatric care center staffed by medical students, interns, residents, fellows in geriatrics, nursing students and graduate nursing students plus appropriate representatives of the other allied health supportive fields such as physical, occupational and speech therapy, nutrition and dietary and social services. Funding would come from philanthropic donors, federal and state grants, Medicare and Medicaid funds. The goal would be to train care givers to go out into the community and raise the bar and standard of care available to our senior citizens requiring acute rehabilitation or chronic custodial care while providing a local example of how excellent care can really be delivered. By raising the bar locally at a model facility we will be raising the bar throughout the region.

The Beat Goes On

Graduates Lifting MortarboardsLast month, I attended the University of Miami Miller School of Medicine graduation for the class of 2013. It had special meaning for me since this was the last group of students, at the University of Miami Miller School of Medicine/ Charles M Schmidt Florida Atlantic University (FAU) joint venture, to pass through my tutelage prior to the Boca Raton program becoming solely an FAU program.

One of the graduates visited my office weekly for two years and then once per quarter the following year.   He came to me as a first year student to learn how to take a history and do a physical exam after being out in the world working for a few years, post-college, as a psychiatric nurse.  He was extremely nervous about being able to remember how to study and succeed at test taking with the younger more academic students.  He brought a mature determined attitude to his mission and was now finishing at the top of the class. 

Also among the graduates was my niece who liked the small class size of the program, the early introduction of patient contact and the ability to develop strong relationships with the faculty. Despite being a mature 23 year-old future pediatric emergency room physician , at 56 inches and 85 lbs. she still got “carded” when she ordered white wine at a post ceremony celebration. 

Then there was “Mike” a young enthusiastic African American student who I met for the first time last year while “chaperoning” a community service health screening in an impoverished section of Fort Lauderdale. My first year student is his best friend and he sent Mike over to me because his mentor was not present.  “I have this middle aged woman with a butterfly rash and all the signs and symptoms of lupus. I have never seen lupus before so how do I help her.”  Mike was correct in his diagnosis and then became her supporter and advocate in helping her gain access to medical care and follow up. 

At the post ceremony reception we met Adam, the son of a colleague, who gave my wife a big hug because she was his teacher in 3 year-old preschool and he remembered her because she taught him to love education and learning.

The President of the University of Miami, and former Secretary of Health and Human Services, Donna Shalala, presided over the ceremonies and reminded the new physicians of what an exciting time this was to be entering the field of medicine.  These young physicians will be at the forefront of the changes in health care delivery in medicine.  They have been given the best of training over four years in evidence based medicine and all the latest technology without forgetting the importance of the personal touch and humanism.  The caring and compassion for others putting the patients’ needs first was the theme hammered home all night by the talented and accomplished faculty and guest speakers. 

I left the ceremonies with a new sense of optimism looking at a diverse but already accomplished group of young physicians.  I feel comfortable they will steer patient care in the correct direction and I feel fortunate that I was able to play a very small role in their nurturing and education.

No CPR Policy at California Independent Living Facility

Young Man Doing Chest Compressions on Elderly ManLast month, an 87 year old resident of a California senior living facility dropped to the floor suddenly with no spontaneous respirations or heart beats. A nurse on duty immediately called 911 to summon medical assistance. The 911 operator instructed the nurse to begin cardiopulmonary resuscitation. The nurse refused stating that the facility had a policy of calling for help but not providing any medical help. The 911 operator begged the nurse to begin CPR or at least call another resident or worker to begin the CPR policy. She refused per institutional policy. When the paramedics arrived a few minutes later, the 87 year old was clinically dead.

The facility took the position that its residents or their health care surrogates knew of the “NO CPR” policy in advance and were comfortable with it. The family of the woman said they were aware of the no CPR policy in advance and were comfortable with the care and compassion the patient had received while a resident. The incident caused a national furor and outcry over the “NO CPR” policy.

In the State of Florida, those residents requesting a NO CPR or Do Not Resuscitate status need to fill out and display the yellow Do Not Resuscitate form # 1896. It is a two-part form. The larger part should be displayed prominently in one’s home, usually on the refrigerator. The smaller copy should be placed in one’s wallet and be available at all times. Your doctor will be required to sign both forms. Your physician should be given a copy for their records as well.

When you enter a hospital electively or emergently you will need to inform the staff that you have a State of Florida DNR form #1896 and they will make a copy and place it on your medical record chart. You may rescind this order and request full resuscitation status if you so desire at any time!

 

It is important before you enter or contract with a senior facility to live there that you learn what their policy is for providing all types of care. You will need to agree with the policy or you should choose to live elsewhere.

Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

Computerized Prescribing and Pain Medications

As part of the government initiative to modernize health information recording and exchange , doctors and health care providers are encouraged (with financial incentives) to prescribe medications using the computer.  This “e-RX” system allows you to send prescriptions to the patients’ designated pharmacy right from your computer screen with a few clicks and turns of your computer mouse controls. The only medications you are not permitted to prescribe are narcotics, controlled substances and pain medications with narcotic contents.

At the same time this initiative is occurring, there is a massive crackdown in the State of Florida on prescribing medications for pain. Sloppy legislation in Tallahassee by the State Legislature led to the opening and growth of “pill mills.”   Drug addicts and suppliers from all over the country routinely travelled to Florida to obtain massive quantities of prescription medications from these fraudulent facilities staffed by criminal physicians. The medications ended up on the streets causing numerous drug and alcohol related deaths around the country.

The “sloppy” Florida State Legislature then attempted to rectify the problem by passing new rules and regulations that closed the “pill mills” with the help of the police and drug enforcement authorities but has frightened the legitimate physician population into not being willing to prescribe for legitimate chronic pain. Their actions included updating physicians’ online profile with the state licensing agency to declare whether you write narcotic scripts for chronic pain or not.  If you reply “yes” you are apparently placed on a list of “chronic pain” prescribing doctors that the public can access as well as the criminal elements looking for doctors to write scripts for cash.

At the same time legislation now requires doctors to take specific courses to prescribe some of the newer pain delivery products necessitating the physician to leave their practice to train on the use of the new medications. The result is that legitimate neurologists and anesthesiologists are shying away from seeing chronic pain patients less than 65 years of age even if they have been referred and have legitimate needs for pain medications.

This brings me back to computerized prescription ordering. If you are trying to track narcotic prescriptions, why prevent the doctors from using the computer to prescribe controlled substances?   What is easier to track and trace, a computerized order or a hand written prescription?   It would seem that computerized record keeping through electronic order entry would be the preferred method of tracking narcotic prescriptions.