Articles Posted in End of Life

end-of-life-800-300x198Many hospitals and doctors rightly have campaigned to get more patients to provide information in advance about their end-of-life care choices, but doesn’t that mean that the choices when made should be respected? And if they’re not, what role do the courts have?

Paula Span, a New York Times columnist who writes on aging issues, reports that a growing number of patients and families have sued hospitals, doctors, and nurses for disregarding or overriding advance directives. There are various kinds of these legal documents. But they often become part of patients’ medical records, directing caregivers, for example, that an individual does not want extreme measures taken to resuscitate them or to sustain their lives.

This can go against deep traditions in medicine, especially for caregivers accustomed to crisis responses in difficult, exigent circumstances. They think of themselves as life changers and life savers. At the same time, patients have insisted that their rights and choices demand respect. Many physicians and hospitals have recognized and encouraged this, as has the U.S. health care system more generally, for example, via Medicare.

NL_DifferenceThere’s  more encouraging news about dementia rates, which a new study has found fell 24 percent between 2000 and 2012, decreasing among Americans 65 and older from 11.6 percent to 8.8 percent. The experts aren’t sure why the rates declined. But it means that 1.5 million or so seniors will be spared the severe cognitive declines that would have been expected from earlier rates of the tragic disease.

Researchers, who published their latest findings in the peer reviewed and respected Journal of the American Medical Association, said that greater educational attainment and improved heart health may have led to the decreases in the prevalence of the condition associated with loss of memory or other mental abilities so severe it interferes with daily life. Alzheimer’s disease is most commonly linked to dementia. Vascular dementia is the second most common type of dementia and occurs after a stroke.

The new study, funded by the National Institutes of Health and on Aging (NIH and NIA), produced continuing surprises as experts have projected an explosion in cases among Americans, who are increasingly gray, obese, and diabetic—factors that significantly increase dementia risks.

death-certificate-state-by-state-default-750_50California regulators have reversed themselves and decided to require hospitals to report outbreaks of “superbug” cases, rare infections that also can prove deadly. At the same time, officials in the Golden State haven’t moved to increase the information disclosed on death certificates−data that advocates suggest would give the public clearer outlines of just how severe a problem hospital-acquired infections have become.

Kudos to the Los Angeles Times, which delved in a recent front-page investigation into the dearth of information disclosed on death certificates, especially about hospital-acquired infections. The paper detailed how a Los Angeles area patient had contracted, while hospitalized, a rare carbapenem-resistant enterobacteriaceae or CRE infection. This superbug resists treatment with an array of antibiotics, eventually killing half those it afflicts. Its outbreaks are a huge concern for public health authorities.

But, The Los Angeles Times said, hospitals had cried “poor me” to the state, saying it required extensive resources to monitor and report CRE outbreaks. The death certificate for the patient with the CRE infection, the newspaper said, listed a perforated ulcer as her cause of death. Her family was outraged because they had urged Torrance Memorial Medical Center to report a CRE outbreak to the state.

Layton Reid is a 40-something-year-old husband and dad who lives in Halifax, Nova Scotia. A few years ago he had a growth taken off his back that turned out to be melanoma. It’s now in his brain.

Mr. Reid has a Facebook page that celebrates living life in the moment. He wrote a post on September 11 addressed to “Dear Mel.” An excerpt:

i know we’ve had our differences in the past and i know we’ve not always seen eye to eye, but i’ve learned so many lessons i never would have, had we not been introduced a handful of years ago in the back of a sketchy walk-in clinic in downtown ottawa. back where this whole silly adventure began. back when you taught me all the ultra important rules to remember about this unmistakably messy yet miraculous life of mine.

The events of recent days ─in Texas, Louisiana, and Minnesota─ have been so tragic that it’s easy to despair. Here are four health-related people stories worth reading to remind us of humanity’s enduring better side:

  • In the horrors of Syrian combat, medical Samaritans strive to maintain some kind of care

syriaFirst, let’s stipulate that there’s almost as much barbarous conduct as can be imagined in this recent New Yorker report about the struggle to maintain medical care in combat-ravaged Syria. President Assad’s predation on his own people has become an international abomination, including his forces unleashing snipers to maim emergency medical personnel, and their dropping barrel bombs, laden with lacerating shrapnel, on hospitals or known care-giving sites (February, 2016, photo of a bombed hospital from Doctors Without Borders/Medicins san Frontieres).

In medical science as well as advocacy, the anecdotal has its limits as evidence. But nothing illustrates the complexity, headaches, and heartaches of modern health care like real people’s stories, such as these recommended reads:

patientThe answer is “yes,” according to a new study which  finds that medical students hold “fantastical” views about biological differences between blacks and whites, and this may result in blacks receiving less help in managing pain.

Another new piece of research finds that doctors communicate with black patients worse than whites about important end-of-life decisions.

Although minority patients long have suspected uneven quality of care, the issue has grown as demographic trends change America’s population, and the nation seeks to improve its health system to make it more effective, efficient, and less costly.

rxopioids40dailyUncle Sam has sent one of the sternest messages possible to doctors nationwide that they must slash their dispensing of powerful prescription pain-killers. These drugs, for which doctors wrote 249 million prescriptions in 2013, have been blamed in 165,000 fatal overdoses between 1999 and 2014, more than 420,000 emergency room visits in 2013, and the addiction or abuse by almost 2 million Americans in 2012.

Federal authorities now recommend that physicians tell patients first to take ibuprofen or aspirin for pain, and only then with great caution, to look at  prescribing opioid medications with ingredients like hydrocodone (Vicodin) or oxycodone (Percocet and OxyContin). When opioid drugs are prescribed, they should not be given for short-term pain for more than three days, and only rarely longer than seven days.

Doctors were urged to prescribe the lowest doses possible of the powerful painkillers. They were advised to cross-check in databases that exist in 39 states to see if patients had sought and were receiving multiple prescriptions for potent pain-killing drugs. MDs were urged to closely monitor patients prescribed the drugs.

Americans are legend for their discomfort in discussing death. That makes conversations about end-of-life care a big challenge, even though the medical attention paid to the dying can drive up health care costs.  A quarter of traditional Medicare spending for health care is for services provided to program beneficiaries in their last year of life—a proportion that has remained steady for decades. But new studies shed interesting light on the end-of-life experiences of patients with cancer, as well as how physicians themselves spend their last days. And it is worth watching how California grapples with the tough issues tied to doctors’ roles in assisting the dying in ending their lives.

Let’s look first at the provocative, published findings of an oncologist and a radiation oncologist about aggressive care for those with late-stage cancer. The researchers compared U.S. patients with patients in other countries. They focused on cancer because, “in developed countries, it is the second leading cause of death and the most expensive per patient.” The researchers found that just under a quarter of Americans with cancer die in hospitals — a lower rate than occurs in Canada, England, Norway, the Netherlands, Belgium, Germany, and six other industrialized nations they studied. Further, as they wrote in a New York Times Op-Ed:

America was not the most expensive country in which to die. On average, $21,840 was spent on the last six months of hospital-related care for dying cancer patients in Canada and $19,783 in Norway. In the United States, the bill was $18,500 per patient. (That figure does not include physician costs, which are part of hospital spending in other nations. Including them brings America’s costs up by about 10 percent, leaving us still below Canada and about equal with Norway.)

It’s the most final diagnosis a caregiver can make. So why, as a newly published study discloses, are there variances and lapses in how hospitals determine whether a patient is brain dead?

The American Academy of Neurology recognized five years ago the complexity of the decision-making in determining brain death, issuing a national practice policy to assist practitioners and institutions. But the Yale neurologist who helped write those recommendations has found significant variances in how almost 500 hospitals and health care systems have put brain-death policies in place and how they use them.

Researchers, fortunately, found no legitimate reports of any patient ever being declared brain dead when they weren’t. But the authors, in the careful language of scientific publishing, reported that  “Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters.”

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