Tag Archives: death and dying

What Would YOU Do With An Extra Second….Better Decide Soon, Its the Day of the Leap Second!

In medicine, I have learned that time is a precious commodity. Too often, when life slips away and patients and families wish they had just a little more time. For physicians, a little more time may make the difference in a patient’s ultimate outcome and sometimes makes the difference between making it home in time for a family dinner. Today, we add ONE second to the international world clock at midnight. Over fifty years ago, world clocks began keeping time with atomic clocks that are governed by oscillations of an atom–which are determined in part by the rotation of the earth. The earth’s rotation is slowing over time, and in order to keep these clocks coordinated with the earth’s rotation, we must add an extra second from time to time.

What Can You Do With An Extra Second?

While a second may seem like an insignificant amount of time, when you are a careful steward of time much can be accomplished quickly. An extra second can have a substantial impact—Here is my list of possible plans for my extra second:

1.  One more chance to say “I love you”

Too often, the pace of the world gets in the way. We forget those most dear to us and allow our daily challenges—both at work and at home- to take center stage. I may use this extra moment in time to make sure that my wife and daughter know exactly how I feel. Time is unwavering and unyielding. Time rarely stops—actually almost never stops—but today we have a brief pause. We must use it wisely and take advantage of the extra “time” with loved ones and remind ourselves that time spent with those we love is precious

2. An opportunity to pause before pressing send on an angry email

In the heat of the moment, many of us have sent a note that we wish we could have back. Email and electronic communication can be unforgiving. Just think if we were able to use the extra second we are given to pause before sending an angry reply. That one second to ponder the implications of an email response may actually save even more time by preventing hurt feelings, damaged relationships and tarnished reputations.

3. A chance to pause and take a breath

Lets’ face it, today’s world moves at a very quick pace. Electronic communication, social media and instant messaging leave each of us with very little down time. Just recently I flew to Italy from New York and was amazed to have active internet service for the entire flight. Rather than unplug and enjoy the beginning of my vacation, I remained connected and engaged through the flight. Much can be gained from taking a few minutes to meditate, unplug and recharge. All of us can benefit from stepping away from the business of a hectic day—just one second may help relieve stress and recharge the mind–Maybe I should use the extra second to take a deep breath, reflect and relax. If a 5minute meditation works, why wouldn’t a 1 second mini meditation work as well?

4. Send a tweet

Social Media is an excellent example of how we can reach out to others—all over the world—in a matter of seconds. We are now more connected than ever. Twitter brings doctors and patients together and makes the world a smaller place. Twitter provides for the brief communication of ideas, exchange of information and socialization all in a moment. One second is all that is needed to send a tweet. At midnight tonight, I may decide to use my extra second to push send and publish a tweet.  Maybe I will connect with a new friend or colleague.  Maybe my tweet will reach a patient suffering with chronic disease and provide them with new hope.  Maybe my tweet will make someone laugh, or (if I am really lucky) make a lonely person smile.

Tonight, we have a rare opportunity to stop time. At midnight we are able to take back time—if only for a second. I have shared a few of my ideas. What will YOU choose to do with it? Time is ticking away–we have to decide soon how to use that extra time.  Midnight will be upon us soon.  How we use it could change a life….or result in time for one more Zzzz…

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Sharing Bad News or Keeping Secrets—How Physician Communication Impacts Patients and Families

Doctors and Patients bond over time. Information exchange, education and sharing of expertise are critical activities that add to the effective practice of medicine. Delivering bad news is unfortunately an unpleasant part of a physician’s job. Honesty, empathy and clear communication are essential to delivering news to patients and their families—even when the news is unpleasant or unexpected. While communication is an integral part of the practice of medicine, not all healthcare providers are able to relay information or test results in a way that is easily digested and processed by patients. Some physicians may avoid delivering bad news altogether—often keeping patients in the dark. While a paternalistic approach to medicine was accepted as the status quo for physician behavior in the 1950s, patients now expect to play a more active role in their own care. Patients have a right to demand data and understand why their healthcare providers make particular diagnostic and treatment decisions.

Recently, a disturbing report indicated that in a database of Medicare patients who were newly diagnosed with Alzheimer’s disease, only 45% were informed of their diagnosis by their physician. While shocking, these statistics mirror the way in which cancer diagnoses were handled in the 1950s with many doctors choosing not to tell patients about a devastating health problem. With the advent of better cancer therapies and improved outcomes, now we see than nearly 95% of all patients are informed of their cancer diagnosis by their physician.

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How can this be? Why would a physician NOT tell a patient about a potentially life changing diagnosis?

I think that there are many reasons for this finding in Alzheimer’s disease and that we must address these issues in order to provide ethical and timely care to our patients.

  1. Time constraints: Electronic documentation requirements and non-clinical duties allow for less time spent with each patient. In order to deliver bad news such as a terminal diagnosis, a responsible physician must not only spend time carefully delivering a clear message but must also be available to handle the reaction and questions that will inevitably follow. Many physicians may avoid discussing difficult issues due to the lack of time available to help the patient and family process a diagnosis. We must create ways to diminish the administrative burden on physicians and free them up to do more of what they do best—care for patients. More reasonable and meaningful documentation requirements must be brought forward. Currently, many physicians spend far more time typing on a computer rather than interacting in a meaningful way with patients during their office visits. Eye contact, human interaction and empathy are becoming more of a rarity in the exam room. This certainly limits the effective delivery of bad (or good) news to patients. Priority MUST be placed on actual care rather than the computer mandated documentation of said “care”.
  2. Dwindling Long-Term Doctor Patient Relationships: Networks of hospitals, providers and healthcare systems have significantly disrupted traditional referral patterns and long-term care plans. Many patients who have been enrolled in the ACA exchanges are now being told that they cannot see their previous providers. Many physicians (even in states such as California) are opting out of the Obamacare insurances due to extremely low reimbursement rates. Patients may be diagnosed with a significant life changing illness such as Alzheimer’s disease early in their relationship with a brand new healthcare provider. When a new physician provides a patient with bad news—of a life-changing diagnosis that will severely limit their life expectancy as well as quality of life—patients often have difficulty interpreting these results. Healthcare providers that have no relationship with a patient or family are at an extreme disadvantage when delivering negative healthcare news. Long-term doctor patient relationships allow physicians to have a better understanding of the patient, their values and their family dynamics. This “insider knowledge” can help facilitate difficult discussions in the exam room.
  3. Lack of effective therapies to treat the disease: No physician likes to deliver bad news. No doctor wants to admit “defeat” at the hands of disease. It is often the case where some healthcare providers will not disclose some aspects of a diagnosis if there are no effective treatments. I firmly disagree with this practice of withholding relevant information as I believe that every patient has the right to know what they may be facing—many will make significant life choices if they know they have a progressively debilitating disease such as Alzheimer’s disease. In the 1950s, many patients were not told about terminal cancer diagnoses due to the lack of effective treatments. However, medicine is no longer paternalistic—we must engage and involve our patients in every decision.
  4. Lack of Physician communication education: As Medical Students we are often overwhelmed with facts to memorize and little attention is given to teaching students how to effectively interact with patients as well as colleagues. Mock interviews with post interview feedback should be a part of pre clinical training for physicians. We must incorporate lectures on grief and the grieving process into the first year of medical school. Making connections with patients must be a priority for physicians in the future—we must equip trainees with the tools they need for success.  Leaders distinguish themselves by the way in which they share bad news.  According to Forbes magazine the critical components of sharing bad news include–accuracy of communication, taking responsibility for the situation, listening, and telling people what you will do next.

What’s next?

As with most things in medicine, change often occurs “around” healthcare providers without direct physician input. Physicians are appropriately focused on providing excellent care and connecting with patients while politicians and economists craft the future of medicine. The issues with lack of communication of negative findings with patients MUST be addressed. Patients have a right to their own data and have a right to know both significant and insignificant findings. In order to avoid situations where patients are not fully informed about their medical condition, we must continue to remain focused on the patient—even if it means that other clerical obligations are left unattended.

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Attending a Funeral: Mourning the Loss of a Friend AND Learning More About the Art of Medicine

(Please note that this blog is based on real people and actual events.  I am grateful to Ed’s family for granting me permission to use his real first name in this blog)

One of the best things about the practice of medicine is the ability to develop long-term relationships with patients and their families.  As physicians, we have the unique privilege of meeting and interacting with thousands of people throughout our careers.  Every once in a while, there are certain people who really make a lasting impact and forever change us as caregivers and as human beings.  Ed was one of those patients.

This week, I said goodbye to one of my long time patients and dearest friends.  Ed, a Korean War veteran, was an amazing man.  He was a dedicated father, a devoted spouse and lived a life that was an example of faith and service to others.  I met Ed through his daughter years ago.  He had moved locally to live near his children and needed a new cardiologist. Fortunately for me, his daughter asked me to take him on as a patient.

Ed had an ischemic cardiomyopathy and suffered from complications of congestive heart failure (CHF).  He was fairly well compensated on medical therapy but continued to have worsening CHF.  During the course of his illness, we eventually  implanted a Biventricular ICD and his symptoms improved significantly.  As with most patients with CHF, over the years, he began to have more frequent hospitalizations for CHF exacerbations.

Through it all, Ed was always cheerful and never complained–in fact it was sometimes difficult to monitor his symptoms due to his demeanor.  Ed always put others before himself.  His wife, suffering from her own chronic illness, was the focus of his final days.  He loved her deeply and wanted to be sure that she was comfortable and well cared for.  Because of my relationship with Ed and his family, I have been made a better cardiologist, and most importantly, a better man.

Men like Ed are few and far between–I was honored to care for him.  My professional role as his cardiologist is what provided me with the fortunate opportunity to be a part of his life and develop a relationship with he and his wonderful family.  As I have said many times before, Medicine is best practiced when relationships and tight bonds are formed between Doctor and patient.  As I left the chapel where the Catholic Mass celebrating Ed’s life was held, I could only wonder if I would ever have the chance to meet another “Ed”.  Healthcare in the US has become more fragmented than ever and care is no longer contiguous in many cases.  Many patients are experiencing access issues and are being told that they can no longer see their long time physicians because of “network” issues or insurance coverage rules.  Doctors are forced to spend more time typing and glaring at  computer screens and less time actually getting to know the “people” behind the diseases they treat.  Connections like I had with Ed are harder to form and personal bonds are less likely to occur in the current environment.  I fear that medicine is becoming more about the “system” and managing regulation than it is about listening and caring for those who suffer from disease.

Ed taught me many things during the time that I cared for him.  He taught me humility, kindness and selflessness–I have never met anyone quite like him. Most importantly, he taught me the value of relationships and TIME.  Even in death, he inspires me to be more to each of my patients–in spite of increasing government demands on both my time and talents.  Ed never stopped caring for others–he never wavered in his commitments to his God, his wife and his children.  It is my hope that I can stand firm and continue to fight for my patients and their right to receive exceptional care.  While I continue to actively speak out against the Affordable Care Act and the regulation of medicine that separates doctor from patient, I must do so in a way that is constructive and advocates for the patient rather than for the doctor.  That is how Ed would see it–of that I am sure.

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Should We All Die at 75?: Addressing the “Emanuel Principe” in Obamacare

Ezekiel Emanuel, one of the authors of the Affordable Care Act spoke publicly this week about his own desire to “die at 75” in a article published in the Atlantic.  In his piece, he argues that as he ages, he wishes to stop all preventative medical measures and “let nature take its course” as he approaches the age of 75.  This includes screenings such as colonoscopy as well as taking flu shots for the prevention of communicable illness.  While currently in excellent health, Mr Emanuel believes that while death is a loss–”living too long is also a loss.” He argues that the American obsession with living longer results in a larger number of elderly, disabled citizens.  I take significant issue with this position and fear that this is simply the beginning of a new phase in the ACA debate–the rationing of care. From the outset, many of us in healthcare and scholars of healthcare policy have seen Obamacare as a way to promote the rationing healthcare (particularly for the elderly).  While the administration has vehemently denied these claims throughout the legislative and implementation phases of the new healthcare law, it is particularly revealing that one of the principal architects of the law firmly believes that we should not pay attention to life expectancy statistics beyond the age of 75.  Medical advances have made it increasingly possible for seniors to lead healthy, productive exciting lives well into their 80s.  Now, I certainly am not arguing for providing futile care in the setting of terminal illness but–Why then should government (instead of doctors) now have the right to determine how healthcare resources are utilized and who gets what?  Is it all about age?  Do we value the young more than the more “seasoned” citizens? The US healthcare system, while certainly imperfect, offers some of the greatest technological advances in the world and the most significant thing that has always set US healthcare apart form others has been CHOICE.  With Obamacare in place, we now have less choice in our healthcare and very little improvement in access.  This latest article by Mr Emmanuel is no surprise–he has been clear about his belief in allocating health care dollars away from activities which may extend lifespans for Americans.  While, Mr Emmanuel certainly has the RIGHT to refuse care for himself at a certain age neither he (NOR OBAMA or any GOVERNMENT agent) should be able to determine an “acceptable” life span for each of us. Quality of life and health status can be very subjective and care must remain individualized rather than mandated (or withheld) based on actuarial tables or government rationing of resources. Medicine is all about innovation and the development of new technologies.  Through technology we are able to provide longer, more productive lives for our patients.  Our patients are able to retire from a life of work and enjoy spouses, family and friends–well into their 80s and 90s WITH a quality of life.  In fact one of my favorite “golf buddies” is 80 years old and going strong–He can still shoot in the 80s from time to time and never misses a game. In MEDICINE one size does not fit all.  OBAMACARE wants to force a ONE SIZE FITS ALL healthcare system on all of us and as a physician I find this to be unacceptable.  Just as we must cater therapy to individual patients—when (and how) you die must also be catered to each individual patients needs, desires and beliefs. Chronological age such as 75 may be different for different people AND we must respect individual needs.  Medicine is a clearly a science but in many cases the practice of medicine –particularly when making decisions about end of life issues–makes it more of an ART.  The government has no place in dictating ART.  Government should help to preserve and curate art–not regulate and mandate the way in which medical care is delivered to individual patients based on age. Ultimately, left to its own devices, I believe that the ACA will create rationing of care for Americans and we will have two classes of people–those that are wealthy and can afford private care and can pay cash for it–these can make their own healthcare decisions and decide when enough is enough.  The others–most of us–will be lumped into the disaster that IS obamacare and will have little or no choice in how our healthcare is delivered.  Waiting lists for advanced procedures and denials of advanced care for the elderly will be the standard–Just as Mr Emanuel envisioned it when he crafted the law just a few short years ago.

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Courage to Care for the Dying: The Importance of The Art of Palliative “Caring”

As healthcare providers we are focused on Life.  We are committed to healing.  We measure success by lives saved.  Unfortunately, many diseases remain incurable.  Some diagnoses do carry with them a death sentence in spite of the best that modern medicine has to offer.  Even in theses extremely devastating cases, WE can still make a huge difference in the lives of our patients in the way in which we help them handle their own death.  Too often, treatments are prescribed which may have the effect of only prolonging suffering.  In some experimental chemotherapies, treatment may raise survival only a few percentage points.  As caregivers, we become so focused on changing the inevitable outcome that we often forget about one of the more important reasons we are treating our patients–to ease pain and suffering.  In the case of terminally ill patients, we can help shepherd them through the process of death.  Too often, however, we as healthcare providers are ill-equipped to tackle this task.

Last week in  New York Times, author Abby Goodnough chronicles the hospice care death of Martha Keochareon who happened to also be a nurse.  As described in the Times piece, Ms Keochareon, during her final days,  heroically wanted to help other nurses understand how to care for the dying.  She reached out to her former nursing school and asked if there were students who needed to do a case study for class.  She volunteered to have them come to the house and learn about hospice care–what she taught them was so much more powerful.  The students began to learn what is most important to the terminally ill patient.  Ms Keochareon taught them the importance of a gentle touch, of listening, and most significantly, taught them how to truly care for a patient facing inevitable death.   Too little time is spent understanding death and dying.  The selfless act of Ms Keochareon opened the eyes of young nursing students–in effect, the time they spent with her made them better caregivers.

As a whole, medical education for both physicians and nurses lacks formal training in dealing with death and dying.  There is little standardized palliative care training in the Residency curriculums of most programs in the US today.  Although some programs do provide a palliative care experience, many do not.  Learning from a palliative care expert and from experiences with terminally ill patients can be a career changing experience.  No matter what specialty a healthcare provider ultimately decides to focus on, all of us must deal with death and dying in one way or another.  HOW we deal with death, may impact our patients in ways that are just as significant as performing a life saving operation or providing other life saving therapies.  When patients enter into the phase of their disease where death is inevitable, quality of life, quality of interpersonal interactions and quality of companionship often become incredibly important.  As a resident at the University of Virginia, I had some exposure to an inpatient hospice unit.  Although it was often sad to see patients slip away, my experience there made a huge impact on my development as a physician.  In my residency experience, I had the benefit of watching the interactions and care provided by experienced hospice nurses and physicians.  The thing that affected me the most was the concern in the eyes of the caregivers–the connection that each of them made with their patients.  Gentle touch–carefully timed smiles–and non verbal communication through caring glances seemed to make enormous impacts.

Ms Keochareon inspirational story can teach all of us something about the process of dying.  To learn, we just have to open ourselves up to our patients and carefully listen and observe.  Even in her death, she intended to give to others.  She opened the eyes of young, impressionable nursing students.  I suspect that those students are better for having known her–even if just for a little while.  Rightly so, we are all trained to focus on the cure and to strive to make our patients well.  However, we must not forget about patients when they approach the other end of the spectrum.  It is our duty to guide our patients as comfortably and gracefully through the process of death and dying as well.  As healthcare providers, we must all work to perfect the “art” of caring–even at the very end of life’s journey.

Holding Hands with Elderly Patient