This Saturday every American has the opportunity, like we do every day, to take steps to ensure that our wishes regarding future health care wishes are honored.  National Healthcare Decisions Day is now in its 4th year!  This is a chance to think through your values regarding your health care, and to choose the person you would trust to make decisions on your behalf if you were ever incapacitated to the point that you could not express yourself.  As a physician, I deeply appreciate when my patients have taken this important step.  Once you have chosen your trusted person, have a conversation with them about what is important to you when it comes to your health, particularly if you were to face a serious accident or health crisis.  Then, complete Power of Attorney for Health Care paperwork to officially authorize this person to make decisions on your behalf.  (Link is specific to my home state of NC).  Finally, thank your Power of Attorney for their willingness to play this important role!

For more information (and for links to other states’ forms) visit NHDD.org.

What is Supportive Living?  Find out more here.

Or download this informative summary from the Afforadable Assisted Living Coalition.

I will be joined by Wayne Smallwood, Executive Director of the AALC, and Rick Banas of BMA Management tonight on House Calls.  If you want to learn more about Assisted Living and Supportive Living, this is the show for you!  Tune in and call in live with your questions.

April 16th is National Health Care Decisions Day.  When a health crisis occurs, many individuals and families are unwillingly thrust into a situation where a difficult decision must be made, and the values or preferences that would guide that decision were never discussed.  Don’t let this happen to you.  Take time to choose your power of attorney for health care, the one person you would trust to make decisions about your health care on your behalf if you were ever unable to express those wishes.  Let that person know that you would be honored if they would play that role for you.  Talk with them about what is important to you if you ever encounter a scenario in your own health where you cannot verbalize your wishes.  You don’t even have to discuss specifics, but it may help that person if they know what type of approach you would want if you were in that situation and you had very little hope for recovery.  Then, complete the Durable Power of Attorney for Health Care form.  It can be downloaded here.  Make copies for your power of attorney, yourself, and give one to your doctor and anyone else you think should have a copy.  If you need help, make an appointment with your doctor to specifically discuss this issue.

Today I attended the Million Med March held in cities across the US and here in Chicago.  It was sponsored by Docs 4 Patient Care, a grassroots organization of physicians, healthcare professionals, and concerned citizens who want to reform health care while preserving the integrity of the patient-physician relationships we enjoy in this country.  I didn’t know much about the group before today.  There weren’t exactly 1 million doctors at Chicago’s rally today- maybe 200-300.  Even so, there were some important messages.  Here is a summary of what was said, and my reflections on the event.

2. Doctors are bad protestors/activists.
Today’s rally lacked the energy that I have experienced at other public events.  It was not because the doctors present do not believe strongly in sensible health care reform.  I think most physicians, in an effort to provide their patients with the best, evidence-based medical care, get used to just falling in line with the latest recommendations and “standard of care.”  Protests do not come naturally.  That, combined with the even-tempered personalities often found in physicians, makes us bad activists.  We are not a “rah-rah” crowd.

Most of the doctors I talk to are not in favor of the current health care bill.  Most of them also feel there is not much they can do to impact the health care reform efforts in Congress.  Part of that is due to the fact that very few doctors were actually invited to participate in the process.  The American Medical Association (AMA) supports the bill, but it represents less than 30% of doctors.  (Many AMA members are newly graduated physicians who have not taken time to cancel the free membership they received as a medical student.)  Another reason doctors don’t feel we can have an impact is that, for whatever reason, we tend not to rally together.  Perhaps it is the self-sufficiency we learned in medical school and residency training.  It may be that we are too busy to ask each other to participate in an event seen as an “extra” thing.  The laws prohibiting physicians from forming a union also prevent us from uniting around a cause.  I am proud of those physicians who attended today.  As one physician and speaker put it, “I wasn’t going to come today because I have a busy practice, a family, and few minutes to spare, but then I realized, that is why I needed to come today, because health care reform is going to affect all of those things.”

3. The introduction of a public option will lead to government-run health care.
Even if this is not the stated intention, offering a government-subsidized health insurance plan to all will eventually destroy private health insurance as we know it.  The argument for the “public option” says that health insurance companies need a competitor to “keep them honest” and the government needs to provide this competition to prevent abuse.  Sounds great, but since when did the US government compete with its own people?  One enters a competition for one reason: to win.  That means that the clandestine goal of the government-run plan is to make private insurance companies into losers.  Since a government plan does not have to remain profitable to stay in existence, it will play by different rules.  Since its inception in the 1960′s, Medicare has operated at a $37 trillion loss, yet it is bigger than ever.  No private company can “compete” against a beauracracy that bulletproof.

4. The “opt-out” provision in the Senate bill is a sham.
To create the impression that the public option is not being forced upon us, the Senate included language that will allow individual states to opt out of offering the public option.  What is not publicized is the fact that states who opt out will still pay the same taxes as states who opt in.  They will incur the same costs but no benefits.  It’s doubtful that any states will opt out of the plan, since they cannot opt out of the cost.

5. Estimates of the bill’s costs are grossly underestimated.
You have probably seen the CBO estimates of a $849 billion price tag for the current health reform bill.  The CBO numbers are based on a ten-year projection.  Since the changes to the health care system are slated to take place in 2013, the estimates only include 6-7 years of costs, but they include 10 years of increased taxes that will start immediately.  In other words, three of those ten years are income-only years for the program, with no costs.  Let’s say you move into a house in June and paying six months of mortgage payments of $1000 each.  Would you then assume that, since you paid $6000 for your mortgage this year, that you would pay $6000 again next year, and your payments would only be $500/month?  Of course not, because you failed to take the entire year into account, but that is essentially the way the CBO is projecting the costs of this health care plan.

Plenty more was talked about today, and I encourage you to read as much as you can and get as involved as you can.  To learn more about today’s event, visit Docs 4 Patient Care.

Tuesday morning on WMBI a caller asked if there was something safe that her daughter could take in her 7th month of pregnancy to help her sleep.  In the midst of a busy morning of calls, I gave her a kneejerk response by recommending the antihistamine diphenhydramine, the active ingredient in Benadryl.  This approach is safe, as diphenhydramine is a pregnancy category B medication (meaning that studies in humans have proven it to be generally safe for the unborn child).  However, I did not take the opportunity to discuss other natural remedies, as well as behavioral strategies for sleep in the later stages of pregnancy.  My response brought to light one of the problems in our health care system, namely, that the increasing demands of insurance companies and health care systems force doctors to rush through an office visit, and we often fall back to the old playbook of the most commonly recommended pharmaceutical solution, rather than exploring other ‘natural’ and behavioral remedies. I felt like I did the radio equivalent of a rushed office visit on Tuesday. Thankfully, I have the opportunity to follow up and explore those alternatives here.

Sleep patterns are clearly altered for pregnant women as they approach the birth of their baby.  The expanding uterus presses on the surrounding organs, making it difficult to last the night without having to get up to empty the crowded and shrunken bladder.  The sheer discomfort of the expanding abdomen, and the often corresponding back pain, make it difficult to sleep comortably, especially if the woman is used to sleeping on her stomach.  I believe that the disturbed sleep can help prepare an expecting mom for motherhood.  Once the baby is born, new moms are called upon to spend odd hours nursing and caring for their baby.  Every new parent knows that while their newborn may sleep 18 out of 24 hours, the sleep usually comes in 90-120 minute spurts followed by 1-2 hours of wakefulness.  Furthermore, newborns tend to have an opposite sleep cycle after birth, spending more time sleeping during daytime hours and more time awake at night.  In a way, the woman who has to adapt to irregular sleep patterns is being trained for the physical demands of early motherhood.

That being said, there are some simple ways to improve sleep during pregnancy.  The basic behavioral recommendations to improve sleep still apply.  Try to wake up and go to bed around the same time every day.  Avoid caffeine in general, but especially in the afternoon and evening.  It is important to continue to drink plenty of water during pregnancy, but try to limit your intake for 2-3 hours prior to sleep, and be sure to empty your bladder fully before bed.  Many women state that sleeping on the side and placing a pillow between the legs provides additional comfort.  Continuing to exercise during pregnancy is safe, and regular exercise has a positive impact on sleep.

Regarding “natural” sleep aids, some are safe in pregnancy and some are not.  It is important to remember that herbal and ‘natural’ remedies are not regulated by the FDA, so they can claim anything they want on their packaging without having to prove their claims with scientific studies.  Also, the FDA does not test the products to ensure that the ingredients listed on the label are actually contained in the supplement.  Some of the more popular sleep aids are below.

Melatonin is a chemical that resets the body’s 24-hour clock, called the Circadian rhythm.  Pregnant women have naturally lower melatonin levels, and these lower levels may be important to the baby’s development.  Therefore, I would not recommend melatonin durnig pregnancy.

Chamomile is commonly used to make tea that is used by many as a sleep aid.  Most would consider chamomile tea to be safe, but probably not the more concentrated chamomile oil.  I can safely recommend chamomile tea during pregnancy.

Valerian is an herb that has a mild effect on the body and is one of the safer herbal sleep aids, however, there is conflicing evidence about whether it is safe during pregnancy.  Therefore, I would play it safe and not use valerian during pregnancy.

5-HTP is a supplement used for depression that can also aid in sleep.  It affects serotonin levels, and while many doctors consider serotonin-altering medications to be generally safe in pregnancy, we do not have convincing evidence that it is completely safe.  Therefore, I would not recommend 5-HTP.

Kava was once a popular herbal supplement used for anxiety symptoms and insomnia.  Many problems with kava have been uncovered, including its harmful effects on the liver.  I do not recommend taking kava for any reason.

Tryptophan is not available as a supplement but is present in turkey, cheese, nuts, beans, eggs, and milk.  High levels have induced fetal tumors in laboratory animals, so seeking out tryptophan in high doses is not advised.  The amount of tryptophan in a glass of warm milk would be safe, and it may be enough to assist with falling asleep.

In summary, about the only “natural” sleep aids that I recommend are warm milk or chamomile tea.  Making some behavioral changes may also help with sleep during pregnancy, but in the later stages, it is probably unrealistic to maintain normal sleep patterns.  If you find yourself wide awake and frustrated as your due date nears, take a moment and pray for your baby.  It’s a great way to prepare yourself spiritually and emotionally for the arrival of your child, while your body trains itself physically for more sleepless nights ahead.

The fine people at the Albert Schweitzer Fellowship recently invited me to participate in their “Five Questions for a Fellow” feature on their blog Beyond Boulders.

Read the article here.
Read more about Albert Schweitzer here.

Here it is: the breakdown you’ve been looking for on the flu vaccines.
Who should receive them?

First- the regular seasonal flu vaccine, available now.
You should get the flu vaccine this year.
The only people who should not are infants less than 6 months, people with an egg allergy, and people with a previous reaction to the flu vaccine.

Next- the H1N1 vaccine, available in the next few weeks.
The following groups of people should get this vaccine:
Pregnant women
Children age 6 months to 18 years
Caregivers for children this age
Young adults 18-24
Health care workers
People age 25-64 with a chronic medical condition
(Examples include diabetes, asthma, COPD, and autoimmune conditions)

People age 65 and older are at lower risk for H1N1, so they are not recommended for the vaccine until the higher priority groups are inoculated.  Sometime in December or January, people age 65 and older may be recommended to receive the H1N1 vaccine.

The H1N1 vaccine will be available as a nasal spray and as a shot.  Pregnant women cannot receive the nasal spray because it contains a live virus.  It is safe for everyone else except those with a compromised immune system (as in HIV).  Children under 10 will require 2 doses about 4 weeks apart.  Everyone else will need only one dose.

Today’s article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

The article also explains more about Someone to Trust and what we are trying to accomplish in Chicago.

Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn’t it? What they don’t mention is that these documents are already available for free, and you don’t even need a lawyer in order to complete them.

The most important advance care planning document, and the one everyone should have regardless of age, is the Durable Power of Attorney for Health Care (DPAHC). This is the document that names someone to make decisions on your behalf if you ever are in a situation where you cannot express your own wishes. Most people, when asked, know immediately which person they would trust in that situation. It is important to name this person in writing, because state laws vary, and without the proper paperwork, it is possible that someone other than the person you want would have authority over your health care if you could not express yourself. For example, I recently admitted a patient to the nursing home whose granddaughter cared for her at home for many years. The patient had become very ill and could no longer express her own wishes, but she had expressed her wishes to her granddaughter during previous conversations. Unfortunately, they never completed a Power of Attorney for Health Care. The patient’s estranged son arrived on the scene and began to demand a course of management that went against the patient’s wishes. In spite of the granddaughter’s protests, the nursing home was obligated by law to follow the wishes of the son, because Illinois law gives adult children priority over grandchildren for decision making authority when there are no papers. Such a scenario could have been avoided had my patient completed her DPAHC and named her granddaughter.

If you live in my home state of Illinois, the official DPAHC form can be downloaded for free here. Most other states make their forms available as well, and you can find them by doing a web search for “(your_state) power of attorney for health care”. Once you have the form, you simply need to identify your person of choice, fill in their name and contact information, and sign the form. In Illinois, you will need one witness to also sign the form. You don’t need an attorney, and you don’t need a notary public. You don’t even have to have your decision-maker sign the form. I still recommend this, because the person you choose needs to know of the important responsibility you have given them.

There are other sections of the form that allow you to express specific wishes, such as a procedure you definitely would or would not want, or specific organs you would want donated. It is not necessary to fill out these portions, though it may be helpful for your decision making agent to know this information. However, he or she is not obligated to follow what is written there. That is why the best approach is to have a conversation about your wishes with the person you trust. This will give them the opportunity to ask you questions and to see and hear directly from you what is most important about your individual wishes.

Another advance directive is the living will, which gives you the opportunity to state that you would not want to be kept alive artificially if you contracted a terminal illness and doctors believed you had no hope of recovery. This document also gives you the opportunity to define specific courses of action. I have run into problems with this document and I do not find it as useful as the Power of Attorney. One problem with the document is that you can fill it out and never tell anyone. If you were to become very ill, unless someone has a copy of your living will, it may never be followed. It is much more powerful to have a living, breathing advocate (your Power of Attorney for Health Care) who understands your wishes and can help guide your doctor through the myriad of possible scenarios that can occur if and when you become ill. I do not have a living will, but I do have a Power of Attorney for Health Care. I know the President told us recently that he and his wife have a living will, and that it is important to have one, but I think it is far more important to have your Power of Attorney for Health Care.

Once you have filled out your advance directive, keep a copy for yourself, give a copy to your decision maker, and give a copy to your doctor. There is a movement to standardize these documents and make them more accessible across health care systems. In Chicago, a large coalition called Someone to Trust is working to accomplish this goal for the first time in a large, multiethnic city. Google Health recently added a section where you can scan and store these documents so you can authorize your agent or doctor to access them in time of need. If you feel comfortable using this service it is a good resource.

For more information on Advance Care Planning, visit the website for National Health Care Decisions Day.

Today while driving between nursing homes, I heard Rush Limbaugh talking about the health care reform bill’s Advance Care Planning Consultation section. He, like some other conservative talkers, was complaining that the government was mandating these consultations as a way to usher patients towards an early death in order to save money. In my previous post I explained why this was an unfair characterization of Section 1233, and that it makes sense to reimburse doctors for the time they spend talking with patients and families about their health care wishes. I decided to call in, and I actually got through. “Dave in Chicago, you’re next..” Rush said.

I explained that I was a physician, and that there are many aspects of the current health care reform bill that I disagree with, but that this provision was actually a good idea. I said that I often take extra time to ask my patients about choosing their power of attorney and about their end-of-life care wishes, and that it was smart of Medicare to encourage these conversations by providing a small reimbursement to doctors who initiate such discussions, since the current structure requires doctors to essentially offer this service for free. I started to explain that the bill actually does not mandate these conversations between doctors and patients, nor does it mandate their content. Then I realized that Rush was talking and my voice was turned off. He once again incorrectly insisted that the bill will mandate a consultation promoting “death care,” a term he claimed I had used. He said that I was welcome to have those conversations with my patients, but that anyone who had a doctor like Dave in Chicago who insisted on talking about “death care” should find a new doctor. I tried to protest but quickly realized that my voice was turned off and that our “conversation” was over.

Rush Limbaugh’s reaction to my call was a stark reminder that many people completely misunderstand palliative medicine and end-of-life care. While he railed on about doctors being mandated to discuss death with their patients, I could sense an underlying fear, perhaps about his own mortality. Death is inevitable, and one of the greatest gifts I can give my patients is to help them look ahead to possible scenarios and to express their thoughts and wishes about their medical care while they are still able. Those of us who practice this skill do not attempt to usher our patients toward an early death for the sake of utilizing fewer health care dollars. All too often I have watched patients and families undergo painful and invasive treatments which are unlikely to extend life or provide any healing, simply because they felt they were obligated to submit to such treatments. No doctor had ever laid out the real picture, that their prognosis was poor and their choices were limited by their disease. They needed to hear that their realistic options had shifted away from the best course for avoiding death to the best way to maximize the quality of life remaining. They needed to know that there was another path, and they probably needed to hear that from a doctor. Many doctors avoid these conversations because they are uncomfortable or awkward. Doctors who talk about death with their patients are brave.

I do understand the fear that more government-sponsored health care will lead to rationing and could result in seniors being denied services simply because of their age. That is a real concern. It is a reason I am not in favor of more government involvement in health care. However, please do not make the same mistake Rush Limbaugh made today and equate coversations about end-of-life care with promoting “death care.” Expressing your wishes to your doctor, and asking about options if and when you become ill, serves to promote patient choice and control, not take away from it. I still think government-run health care is a bad idea, but as long as Medicare pays for most seniors’ health care, I think it is admirable that they are looking at ways to make it easier for doctors to assist their patients with advance care planning.