When is DNR not DNR?

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Patients are often encouraged to make wishes known with a living will or other instrument. If someone says they would not want resuscitation if their heart stopped, they are said to be DNR, as in Do Not Resuscitate, or more accurately DNAR, Do Not Attempt Resuscitation. Success rates one month after out of hospital cardiac arrests when CPR is performed are only about 4.9% to 9.2%.

In Washington State per a directive it often say,

“(a) If at any time I should be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness, that would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.”

For many patients this is reasonable, but not for all. No one lives forever, but even a generally healthy 98-year-old does not have a terminal condition. Many of my older patients tell me they are DNR, but most are surprised when I tell them their health care directive says they would want to have CPR and get shocked with a defibrillator if their heart stopped, as they do not have a terminal condition.

I think this is probably a failure of lawyers drawing up the health care directive to modify the language to what makes sense for their clients. I’m not a lawyer, but they might add something like:

(b) If I attain the age of 80-years-old, then I do not want to have my life artificially prolonged, other than using medications, including intravenous medications, and oxygen. An exception is that if I’m undergoing a procedure and develop a cardiac rhythm not compatible with life, then I would approve of an immediate attempt at shocking my heart back into rhythm if the physician deems there is a reasonable chance of success.

Just because a lawyer inserts boilerplate language, does not mean it cannot be changed.

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FMLA Paperwork

I’m often asked to fill out FMLA paperwork, formally known as Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act). This is either because my patient is ill and they or a family member need to take time off work, or because my patient needs to take time off to care for a family member. Employers want the form as proof that the time taken off is legitimate, even though it is not paid time off.

The four page form is onerous to fill out. If you read the fine print you can see that the Department of Labor estimated it would take 20 minutes to fill out. That’s more time than I get to see a complex medical patient, and at most we charge $25, and often don’t get paid at all. It may be a service to patients, but most of the information requested is not needed, and is not the employer’s business. This task usually falls to primary care physicians. If it’s something we need to do, it should be as simple as possible and not waste our time filling out irrelevant information.

Below is a letter I sent as a suggestion to simplify the form to a single page (formatting of the form altered a little for web display). It has been over two years without a response. Continue reading

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Epic SmartPhrases

If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.

I previously wrote that I have done a lot of customizations to Epic. In this post I’ll explain how I use SmartPhrases. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period.

My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. I also don’t like to pull in information into my note, such as past history, labs, etc. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is .soap which looks like this: Continue reading

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How to Get Rich – A Guide for Pharmaceutical Companies

The Changling Ming Dynasty Tomb of the Yongle Emperor

The Changling Ming Dynasty Tomb of the Yongle Emperor – copyright 2012 Daniel Ginsberg Photography

Thanks to Congress, Medicare is not allowed to negotiate for the cost of medications. The bill was shepherded through by congressman Tauzin, the chairman of the House Energy and Commerce Committee that regulates the industry, who subsequently stepped down then took a job as the President and CEO of the Pharmaceutical Research and Manufacturers of America. This is a lobbyist group for pharmaceutical companies.

Here’s a suggestion to pharmaceutical companies; the next time you come out with a new first in class medication, for which there are no other medications that can be substituted, price it at 10 billion dollars a month. After the first prescription gets filled, it may move Congress to act, but by then you will be set and it won’t matter if you don’t sell another pill.

Posted in Business of Medicine, Medical Politics, Pharmaceuticals | Tagged , , , | 2 Comments

Quitting Smoking and Happiness

The FDA is proposing a new rule in regards to tobacco regulation. As detailed recently in the New York Times, the benefits of stopping smoking, such as less heart and lung disease, would need to be discounted 70%, making it that much harder to justify spending money on smoking cessation. It sounds like something inserted at the bequest of tobacco lobbyists. Tomorrow is the deadline to make a public comment. Here is what I submitted:

I think it’s a dire mistake to discount the economic and health benefits of stopping smoking because of the loss of enjoyment. Although smokers may get temporary enjoyment from smoking, they also get enjoyment from being healthy. Surely one gets more pleasure taking a walk in a park and living at home, than pushing an oxygen tank down a hall in a nursing home because of severe emphysema. Smokers die at a younger age than they otherwise would. What about the enjoyment their partners, children, and grandchildren lose when the smoker dies prematurely? Loss of enjoyment should not be part of the equation, unless it’s a negative number which would serve to magnify the cost smoking places on individuals and society.

Posted in Government, Legal, Medical Politics | Tagged , , , | 1 Comment

If Doctors Ran Their Practice Like The Airlines

Copyright: <a href='http://www.123rf.com/profile_itrace'>itrace / 123RF Stock Photo</a>Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for two hours of wi-fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

Posted in Business of Medicine, Medical Humor | Tagged , | 1 Comment

Up in Arms, Up in Smoke

20090715_japan_0671If you apply for health insurance, you may find you have to pay higher rates if you’re a smoker. Now federal regulators are trying to decide if insurers who participate in the Affordable Care Act (aka ObamaCare) exchanges can add a surcharge for those using e-cigarettes or vaporizers.  They already can for cigarettes in most states.

Some argue against this, in the name of harm reduction, the idea that if people are going to smoke, it’s better to smoke something safer. For example, Reynolds American Inc spokesman David Howard, said, “We don’t believe policies should be implemented that might deter current smokers from considering switching to smoke-free alternative products like e-cigarettes.”

Numerous studies have, shown, however,that the best way to get people to cut back on smoking, is to make it more expensive. E-cigarettes and vaporizers are cheaper than cigarettes, so paying more for insurance for all forms will encourage more people to stop smoking. No one is suggesting that those smoking alternative forms of tobacco be charged more than those who smoke cigarettes, so even if insurers charge extra for those who use e-cigarettes or vaporizers, they will not pay more than if they stuck with cigarettes, so really it won’t deter smokers from switching. People switch because it costs less, it’s more socially acceptable, or they perceive it to be safer.

In that last regard, vapor may be safer than cigarettes, but we really don’t know. Recent studies show they can definitely have known carcinogens, such as formaldehyde. Would you really want to inhale a chemical used to embalm corpses? I tell my patients that if they use e-cigarettes to help them quit smoking, which may or may not help, then I’m alright with that, but the goal should be to stop using tobacco products, and not just switch from one habit to another.

 

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Humor Down Under

Bathroom door at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.

Bathroom door at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.
Bathroom doors at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.

Continue reading

Posted in Medical Humor | Tagged , , | 2 Comments

Who Are You Calling Old?

Moth on bricksA local family medicine residency program sends second year residents to rotate through my internal medicine clinic. Reviewing the note that one of them wrote, I saw that he described my 66-year-old patient as, “Elderly, ” though did note that she appeared younger than her age. I let that young whippersnapper know that age is relative, and that I doubted he would consider 66 as elderly once he reached his 50′s!

Posted in Medical Humor | Tagged , , | 2 Comments

Pierce County Medical Society Website Launch

Pierce County Medical Society LogoI’m proud to announce that today the Pierce County Medical Society (PCMS) went live with a newly redone website. I’ve been working on it for over a year.

There is a lot to see on the site. I’ve created a video that gives a tour of the site. It’s aimed at members, who see a link after logging on, but most of the content is useful for the general public, including how to use the Physician Search section to find a doctor in Pierce County.

Posted in Community, Informatics | Tagged , , , , , , , , , , , , , , , | 2 Comments