End of Life

End of Life

The above picture is from medlineplus.com

 

Helping patients that are elderly or have terminal illness that are near the end of their life is a sacred duty and calling.

Everything should be done to help to maximize comfort and well being of a patient in their final days here on earth. What is best for the patient at the end of their life? It should be what the patient really wants the most right? Atul Gawande, the author of the book “Being Mortal” addresses this issue beautifully. He focuses on what the patient really wants at the end of their life by asking them what they really want.…. who would have thought? This topic is tip toed around way too much and often not addressed at all.

A do-not-resuscitate (DNR) order is arguably one of the most important decisions in patient care, yet it is an area in which the necessary physician-patient communication is often neglected.15Can Fam Physician. 2012 Apr; 58(4): e229–e233.

According to a study in Maryland which has a similar population to that of America in diversity only 1/3 of the population in the state have an advanced directive.  Pollack KM, Morhaim D, Williams M. The public’s perspectives on advance directives in Maryland: .

One way to respect the rights of patients in their end of life is to have the discussion about their wishes about what they want most at the end of their life. Have the discussion today with your elderly patients, family members, spouses, and loved ones. Does an elderly patient with terminal cancer that has a prognosis of 6 months to live want to try aggressive chemotherapy, radiation with profound side effects of fatigue, sleepiness, and constant nausea to get 1 more month of life? Or do they want 6 months of life to interact with their family members with a clear mind, not nearly as much nausea/fatigue and a much higher quality of life. Obviously each case is different but this happens sometimes with patients that have a terminal condition. They could even have exponentially less pain with morphine from hospice care if the Dr approves it. Ask the physician realistically how much time you have left or your family member has left. Ask the physician to be realistic and clear.

Sometimes it is best for the physician not to aggressively treat to cure. Sometimes it is better for the physician to treat for comfort. This path can help the finances of the patient/family/Medicare system as well.

In 2008 Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients’ lives.  It is estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. cbsnews.com 2009

In 2011 Medicare spent 28 percent of their total expenditure, or about $170 billion, on patients’ last six months of life (Pasternak, 6/3).kaiserhealthnews.org

 

Make sure you have filled out the forms below…

  1. Advanced Directive / Living Will
  2. Do Not Resuscitate Form if desired

 

An advanced directive/Living Will will address things like….I want or I do not want…a ventilator for breathing, a feeding tube, blood transfusions, dialysis, antibiotics, Surgery, life support treatments, pain management strategies.

Decide if you want a Do Not Resuscitate (DNR) order or not.  If your heart or breathing should stop a DNR order will express the desire to not be revived.Below is a critical point!!!! (You would be surprised how many DNR patients get resuscitated.)

In a study about properly executed DNR orders, the medical records of 180 admissions over 3 years, 1991 through 1993, were reviewed for documentation of patients’ advance directive status. The findings showed that only 26% of patients who had previously executed advance directives had their directives recognized during their hospitalization. JAMA 1995 Morrison et al.  Sometimes a DNR order is not followed because it is hard to know if a patient has a DNR  order in a life threatening moment. So one solution is to plan ahead.

  • If you are a DNR patient  make sure you have the pre hospital DNR laminated and signed by your Doctor and displayed prominently on your fridge. Then have a prominent bracelet that displays you are a DNR patient and states the signed forms are on the fridge. Otherwise the default is for Medics/First Responders to resuscitate you by law in most states.
  • If your family member is a DNR patient and in a nursing home or assisted living facility make sure the forms are signed and on the fridge or tacked on a wall above the bed. Also make sure the family member has a DNR bracelet and it states the signed forms on on the fridge or tacked to a wall above the bed.

A DNR order is separate from an Advance Directive/Living Will, even if your Living Will states that you do not want life-support treatments at the end of your life. If you’d like to have a DNR order, you’ll need to meet with your doctor to complete the forms.

 

These forms differ from state to state.

State-by-State Advance Directive For  DNR forms are online as well but need to be signed by the patient, the surrogate, and the Doctor.

Having these desires known and signed by the proper people save so much pain and heartache to the patient, family, and health care staff. Hospice can be a godsend for patients in helping them have comfort with pain medications and not extensive side effects of myriad medicines that may prolong somebody’s life only a few weeks or months and make them profoundly sick.

Ask to have a physician and nurse assigned to you that specialize in end of life and palliative care. They are extremely knowledgeable how to help you improve your end of life quality of life profoundly!

Of course these are deeply personal decisions but the discussions must be had. If a patient wants to treat their terminal condition aggressively to prolong their life prolonged that is wonderful. If a patient chooses to have less side effects from myriad medications and a shortened life that is wonderful too. Let’s just have the discussion. Let’s find out what a patient really wants at the end of their journey here on this earth.

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Kyphosis/Slouched posture

Kyphosis is excess curvature of the thoracic spine region. It is also associated with a forward neck posture. A picture is shown above of this condition. It commonly affects women because of the anatomy of a woman. The breasts will often pull the shoulders forward and the head will also be more forward.

A Caucasian and Asian female over the age of 65 will be more likely to have complications with this condition because it may cause an anterior wedge fracture of the vertebrae.  This is because they are more likely to have osteopenia or osteoporosis.

The thoracic facet joints will often be stiff. The pectoralis major /chest muscles, upper traps , levator scapulae will be tight. The middle trapezius muscles /lower trapezius, rhomboids, serratus anterior muscles will often be very weak. Consult a local physical therapist for help with this condition. Below is a picture of some of the areas that I am talking about. Other issues related to this condition are pinched nerves in the neck and problems of circulation down the arms called thoracic outlet syndrome.

thoracic spine

Some treatments for this are:

Continue reading “Kyphosis/Slouched posture”

Osteoporosis

Osteoporosis is a condition which results in the bone density becoming decreased. It is from too much bone absorption versus not enough bone being produced. Some common causes are :

  1. Insufficient Calcium
  2. Insufficient Vitamin D which helps absorb calcium in the bones
  3. Insufficient estrogen for women and androgen for men
  4. Insufficient weight bearing/ resistance training exercises for muscles and bones
  5. Smoking
  6. Anorexia

Calcium   recommended daily intake  1000mg Under age 51,   1200 mg Over age 51

TUMS has 1000mg per tablet as a side note

Calcium-Foods

 

 

Vitamin D:

Vitamin-D-foods

(Dr Axe Pictures as source)

400 to 800 Under age 51

800 to 1000 Over age 51

Best weight bearing exercises for osteoporosis

High-impact weight-bearing exercises help build bones and keep them strong. If you have broken a bone due to osteoporosis or are at risk of breaking a bone, you may need to avoid high-impact exercises. If you’re not sure, you should check with your healthcare provider.

Examples of high-impact weight-bearing exercises are:

  • Dancing
  • Doing high-impact aerobics
  • Hiking
  • Jogging/running
  • Jumping Rope
  • Stair climbing
  • Tennis

Low-impact weight-bearing exercises can also help keep bones strong and are a safe alternative if you cannot do high-impact exercises. Examples of low-impact weight-bearing exercises are:

  • Using elliptical training machines
  • Doing low-impact aerobics
  • Using stair-step machines
  • Fast walking on a treadmill or outside

Muscle-Strengthening Exercises

These exercises include activities where you move your body, a weight or some other resistance against gravity. They are also known as resistance exercises and include:

  • Lifting weights
  • Using elastic exercise bands
  • Using weight machines
  • Lifting your own body weight
  • Functional movements, such as standing and rising up on your toes

https://www.nof.org/patients/fracturesfall-prevention/exercisesafe-movement/osteoporosis-exercise-for-strong-bones/

 

A Bone density scan involves a T score. Here are the basics to look out for in the test.

 

The T-Score
Level Definition
Osteoporosis Bone density is 2.5 SD or more below the young adult mean (−2.5 SD or lower).
Severe (established) osteoporosis Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.

http://www.niams.nih.gov/health_info/bone/bone_health/bone_mass_measure.asp

 

 

Between -1 and -2.5 Your score is a sign of osteopenia, a condition in which bone density is below normal and may lead to osteoporosis.

mayoclinic.com

 

The most common sites of osteoporosis fractures are the wrist, spine, hip, and shoulder.

 

Pneumonia

  1. Pneumonia can be seen on the left lower lobe of the xray as infiltrates in the above X -ray picture. It is the white area in the right hand corner.
  2. “Pneumonia is a leading cause of hospitalization and death among adults in the United States and in 2011 the medical costs exceeded $10 billion,” said CDC Director Tom Frieden, M.D., M.P.H.).
  3. According to the Journal of Aging and Disease (.pdf), Volume 6, Number 3; 174-179, June 2015 . Physical therapy reduces 30-day hospital readmission rate with older adults with pneumonia.

 

 

Many times your physician will recommend your bed to be at an angle of 30 to 45 degrees to help lung drainage and reduce pneumonia risk. Check with your Dr if you are in the hospital or have had pneumonia or are at risk.

ventilator-associated-pneumonia-care-and-prevention-39-638

 

Spirometer device. Amazon.com about 8 dollars.

Try to suck in as deeply as you can 10 x. Make sure it is clean and dry. Perform 4 x a day. This can help get rid of phlegm and mucus in the lungs which can quickly lead to pneuomonia.

images

 

Expand a lung device about 40 dollars amazon.com

Perform 10 deep inspirations. You can also perform expirations as well. You perform on a light resistance setting for the first week. Then you improve it every 2 weeks. Perform 4 x a day 10 breaths. Make sure you check with your Dr or respiratory or speech therapist first.

eal-2t

  • Some patients are at risk of aspiration pneumonia where food or beverage goes down the wrong tube when they swallow.
  • Your healthcare provider may suggest making a change in liquid/food texture, consistency or temperature.
  • It is important to take smaller bites and eat slowly.
  • Your caregiver should also follow prompting strategies for increased safety.
  • It is important to maintain a proper positioning while eating. The best way is to eat while sitting in an upright position with chin tucked slightly at a 90° angle. Now you want to check with your speech therapist first because some research says to use a chin tuck and other research says not to use the chin tuck /neck bend forward.
  • Stay in an upright position even after you have finished you meal. Don’t change your position for at least 45 minutes after your meals.
  • Keep the head of the bed at 45° if the patient has been diagnosed with GERD as well.
  • Never eat or give a patient of aspiration anything to eat a couple of hours before bedtime.
  • Take medications that reduce reflux and promote stomach emptying. Newhealthadvisor.com

 

Abdominal aortic aneurysm

The abdominal aorta is the largest artery in the abdominal cavity.

 

What is an abdominal aorta aneurysm? It is an enlargement and weakening of the walls of  the main blood vessel that delivers blood to the body in the abdominal region.

Symptoms:

Pain in the abdominal region that is constant, back pain , flank pain. There may be a pulsating abdominal feeling in the abdominal region. There may be nausea. The problem with this condition is many times it goes undetected.

The most common cause of an aneurysm is arteriosclerosis- hardening of the arteries, smoking, trauma, high blood pressure, and hereditary causes.

 

The typical threshold to have surgery is a distension of the aorta of 5.5 cm. You can choose to have the operation opening the abdominal area or a less invasive procedure through the groin region.

open-uri20130407-28277-5mjhvd

Patients that are at high risk of a rupture have the following criteria:

  • 6 cm distension
  • .6/cm per year increase in distension
  • COPD/Smoker
  • HTN poorly controlled
  • Women
  • High wall stress
  • Shape very eccentric of walls or artery
  • Family history of this condition Vanderbeltuniversity.com

So the take home message here is this…

It is hard to detect if you have this condition so if you are a smoker, age over 65 and have smoked more than 100 cigarettes in your life  you need to be screened for this condition. If it ruptures death will happen rapidly.

Your Doctor will do an ultrasonography.

 

 

Pressure sores

  1.  Pressure ulcers cost $9.1-$11.6 billion dollars per year in the US.  The cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.)(https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit
  2. The picture above shows common areas of pressure sores with prolonged laying down. An ounce of prevention is a better than a pound for the cure.

Below are some common areas of skin breakdown with sitting for a prolonged time and prevention/treatment options.

Continue reading “Pressure sores”

Falls and physical therapy

  • .Falls are the number one cause of injuries and deaths from injury among older Americans.
  • In 2014 alone, older Americans experienced 29 million falls causing seven million injuries and costing an estimated $31 billion in annual Medicare costs.
  • There are 27,000 fall deaths in older adults each year. Centers for Disease Control reports.
  • Each year over 300,000 older people—those 65 and older—are hospitalized for hip fractures. CDC (many of which are caused from falls some estimates are 95%)
  • For men and women the risk of death is increased 2 to 2.5 x as high after a hip fracture. (Many hip fractures are due to a fall) http://www.medscape.com/viewarticle/729944

Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling Cochrane Database Syst Rev. 2012 Sep 12;(9) Interventions for preventing falls in older people living in the community.Gillespie LD et al.

Some ways to help prevent falls indoors are:

Continue reading “Falls and physical therapy”