Second Opinions: A Health Care Ethics Blog

Musings about Mortality 1.6

secondopinions — Sun, 04 May 2008 13:30:06 +0000

I’ve made great technological progress, I think. Finally made the jump from Manual Tooth Brush to Electric. I was quite proud of myself…it only took a year or so for me to get up my courage to make the adaptation. However, my electric tooth brush coach tells me…I haven’t really made the mark yet. You see, the electric tool stays on for 2 minutes as an internal timing mechanism. Actually it is a fail-safe measure to catch back-sliders who want to hurry up and be done with it. I’m wrestling with the ethical dimensions of man vs. machine. Also, on second thought, should I be concerned about the carbon footprint implications of electric tooth brushes? What if all 6 billion of us had this device humming daily? Go to http://www.carbonfootprint.com/.

The electric brush is not the only health care innovation I’ve added recently to my armamentarium for wellness. After nagging from my primary care physician, I purchased a home-style automatic blood pressure monitor. It did sit in the box for some weeks, much to the chagrin of my BP monitor coach (ally to my PCP). When asked by a health care authority-figure, let’s say a nurse, if I have high pressure, my instinct is to say no…it is under control. Then she asks if I’m on any medications…and so I have to confess that I’m taking BP meds…which of course means I have high BP. Such is the circuitous reasoning of denial.

It was Friday night and we were just finishing meatballs & pasta when I started to get a terrible pain in my lower back that radiated to the front. I excused myself to sit in a lounge chair for some relief. As the pain intensified, I called for my pain relief coach to bring me some tylenol. By the time she arrived, I was experiencing a loss of vision in both eyes and starting to feel a little panic. After a couple of minutes, my vision returned and my pain disappeared. I didn’t seem to have any residual symptoms and so, was ready for a little diversion on TV. My coach gave me the phone to call the doctor and seek advice…and off she went to do the dishes.

I called the PCP office whose automated answering voice advised me if I was having a medical emergency, I should hang up and call 911. Well, no…I may have had an emergency but that was past. Then a real voice came on the line (answering service operator) who asked me why I was calling. I described the experience I had had and she told me if I was having an emergency, she would have the on-call doc call me back. Well, no…I may have had an emergency…but this can probably wait until Monday. With the dishes done, my coach returned but wasn’t too impressed with my performance. It is a gender thing. Aiming at a compromise, I suggested trying out my new BP Monitor. Without the help of the instruction manual, we managed to plug all the wires in the right places and put the cuff on. Result, BP in normal range. Relief. I knew that thing would come in handy one of these days. She accepted my “denial” but kept a close eye on me.

In the back of mind, I was thinking about nosocomial infections. Nosocomial, now there is a word to look up. It had come up earlier when I was reading about hospital care in “Betrayal of Trust: The Collapse of Global Public Health” by Laurie Garrett…a truly scary book about the enormous deficiencies of health care systems in America and the world. Maybe I should go to the ER and get things checked out? Nah…once they get their hands on you…it is one test after another (I had also been reading “How Doctors Think” by Jerome Groopman…another scary book)…and what about those nosocomial things? Putting such thoughts aside, I coasted through the rest of the weekend…knowing that Monday I would have to check in with my PCP.

Monday morning came without much anxiety, I thought. But then as I was contemplating contact with my doctor, I got light headed. I had to sit down. How to deal with the situation? Reach for the Automated BP thing. Friday night’s relief was replaced by much higher than normal number. What to do? Check in with the PCP. No one available to see me. Go to the ER. So I called my Coach and off we went. The triage nurse scolded me gently for not having come in on Friday evening. I had not followed the protocol when such symptoms appear.

Mostly you wait when you’re in the ER…and observe the trials and tribulations of others. How do your troubles compare to theirs? There was a sequence of two young white guys both of whom were in distress…and wishing for some pot to relieve their problems. There was a demented African-American women of undefined diagnosis with her adult children. And there was an older white man who had been on the gurney next to me for many hours…waiting for something. Was he what they call a “frequent flier”? In any case, I was picked up by the neurology team. I should say, the neurology physician group. I am used to teams being interdisciplinary. I could call the chaplain if I needed him or her but my soul wasn’t at risk, at least not imminently. My coach, being a social worker, offered the necessary “counseling.” She was also my health care proxy, just in case I lost “capacity” (she does have her doubts) but I felt ready for…tests…and more tests.

During my 30 hour stay at the hospital, they did the MRI thing to scan my brain. And the EEG to see if all those electrical impulses are firing as they should. Good news is that there is something in my cranium and apparently it functions pretty well. Then there was the echo-gram (& continuous monitoring) for my heart and ultrasound for my kidneys. I am probably missing a few things but I am sure the hospital bill won’t. I was getting antsy to break out but my coach cautioned me if went “AMA”, the bill might fall into my lap (rather than to Excellus BC/BS). That was enough to calm me down…and I would never want to do anything “against medical advice” anyway. Right. Thank god for the cardiologist consultant. He took pity on me…unhooked my IV and called the neurologist in charge to get me moving before a second night arrived.

At the time of my discharge, a diagnosis was lingering…most probably, passage of a kidney stone (worse than childbirth one mother told me). Now, I am a new person with another label attached to my health status. Now I remember my father had a series of kidney stones and my older brother too. What else runs in the family? Do I really want to know. Denial is such a blissful place of ignorance. My PCP gave me a prescription for strong pain meds, just in case denial is overruled by another stone.

Musings about Mortality 1.5

secondopinions — Fri, 04 Apr 2008 00:31:02 +0000

We were in New York City recently, visiting my 30 year old son. He sells used books on the Internet, lives in groovy Brooklyn and otherwise enjoys being part of the 21st century culture….something his father at 62 is still adjusting to. He took us to the Apple Store (no, not the local grocery) in SoHo at 103 Prince Street. Yahoo describes it in this way: “Upon entering…you are immersed in a sea of technology including iPods, laptops, speakers, and digital cameras to mention a few. The new age architecture consists of a stunning glass staircase with a huge skylight that naturally illuminates the entire store. … Come check it out and be amazed by the breath-taking structure in addition to the wide variety of computer hardware and software.” This short spacial encounter produced overwhelming waves of culture shock…at a warp somewhere in time and place that I hadn’t quite mastered yet. I’m clearly not a Dr. Who type.

What can I say? Confession time. I’m a late-adapter. It is not that I can’t imagine the possibilities. It is just that my mental system isn’t quite nimble enough to handle to the tech-no how. It doesn’t help that Thomas Friedman (The World is Flat) reminds me that the future belongs to “The Great Adapters.” The work place now rewards those who are “more adaptable and versatile.” “Versatilists…apply depth of skill to a progressively widening scope of situations and experiences, gaining new competencies, building relationships, and assuming new roles.” I like the “building relationships” side of things. But really…is there any hope for a guy who hasn’t yet gotten his own cell-phone. I know, shocking…how can I survive…what if I get lost in the mountains without a honing device. I guess I’ll be eaten by a bear.

According to the Washington Post, ”we’ve passed a watershed of more than 3.3 billion active cell phones on a planet of some 6.6 billion humans in about 26 years.” “There are at least 30 nations with more cellphones than population.” Maybe I need to go back to Tanzania soon. I observed a flurry of text messaging there when visiting in January. How did Tanzania, one of the world’s poorest countries, get ahead of me. Actually I did my first text message ever there [thanks to Kristopher Hartwig]. Maybe I need to return to East Africa for more retooling since the overall pace there is a little frenetic than SoHo. For starters, I promised my dental hygienist this week that I would move up to an electric tooth brush. Of course, I have been promising her that now for a few years. I’ll get around to it. There is hope; I now use dental floss. How many years did that take?

Why is it so hard to change our behaviors…even in the face of good scientific advice…to improve our health and wellness? I’ve been reading a book on Social Marketing. It suggests that many health promotion organizations see “the customer as an adversary, as someone who has the wrong habits or wrong ideas or is just plain ignorant or unmotivated.” Among a number of points, the book by Alan R. Andreasen, offers that the social marketer needs to see the customer as “someone with unique perceptions, needs and wants to which the marketer must adapt.”

Recently, I lectured to the physician assistant graduate students about Advance Care Planning….that is, conversations about your future needs for health care, particularly when faced with a life threatening condition. It is all about your ability to make decisions through a proxy who will respect your values when it comes to tough choices. This is a hard sell. Few people want to think about their mortality; let alone commit to paper an authority to have a trusted family member or friend serve as your advocate when you may no longer be able to speak for yourself.

There is still got a lot of work to do to help folks with their “unique perceptions, needs and wants” about end of life care. Hospice is being more and more marginalized by a perception of it as a service agency for ”brink of death” care. Perhaps ”holistic palliative care” will mean more for baby boomers who are looking for creative choices when it comes to their life style needs. A little less intimidating. Whether it is hospice or palliative care on the horizon, all of us could benefit from reading Irvin D. Yalom’s new book “Staring at the Sun: Overcoming the Terror of Death.” We can decide for courageous living… including designating a health care proxy.

Since my wife is my proxy and my son is my alternate proxy, I’ve got time and energy to focus on more immediate needs. When visiting Soho, we also came upon a place called “Rice to Riches.” A trip to their web site, http://www.ricetoriches.com/index.2.php, is the next best thing for those who want to visit this rice pudding nirvana. My son had “cinnamon sling” with caramel topping and I indulged “the edge of rum raisin” with whipped cream. With 21 such flavors, how can you go wrong making a decision. While I may not be quite ready to join the iPod generation, we can share comfort food for the journey.

Origins of Second Opinions

secondopinions — Sat, 24 Mar 2007 13:15:43 +0000

My blog, Second Opinions, was conceived in Syracuse and born in Brooklyn. Although I enjoyed writing e-ssays at an earlier stage in my professional life, I’ve only been on the margins of blogging since this phenomenon emerged with such enormous social force. The need to express ourselves is lodged in each of us but most are reluctant to risk exposure, at least my generation, roughly speaking older baby boomers. My transition from hospice work to teaching ethics has taken a bit of exploration until I reached a point where I felt I had something reasonable to say. We all have opinions but are they are informed with anything more than tradition or bias? I’ve come to see blogging as a means of thinking out loud. Of course, the danger here is that our thoughts are not quite formed sufficiently in a way that they may be presentable “to the public.” So be it.

So, Second Opinions, was born in Brooklyn, not in old staid Syracuse. Reading from Tom Friedman’s “The World is Flat” this morning, I was reminded that the baby boomers have had to struggle in mid-life to adapt to all these new modes of communicating. Ergo, I turned to Generation X for technical assistance to re-wire my brain. My son, Jeremy, a denizon of Brooklyn, was very patient with his old man as he led me through the loops of blogging. He and some of his buddies had spawned a blog on Syracuse University basketball and hence he had gone to cyberspace where many in his generation feel quite at home and light years ahead of me.

I took the title for this blog from the notion that after receiving a medical recommendation from a physician, a patient might pursue a second opinion or even more of them. There is a given tension with second opinions because if you are accustomed to being the authority figure, you may think that the discussion should stop there. Why shop around for other perspectives and just get confused when you’ve already been given the best advice? Well, while I value my views on topics or issues, my ego is stable enough to actually encourage others to provide me with feedback and to offer alternative ideas.

When hunting for a blog title, my mind flashed to the title of a book using the same words, authored by Jerome Groopman MD. And sure enough, Dr. Groopman, has his own web site and blog (of sorts). I add “of sorts” because it appears that Groopman’s blog is oriented toward selling more of his books. Not my idea of blogging. I’d like to get some fresh insights from him rather than be solicited for a book purchase. By the way, let me add that Groopman is an excellent writer. I recently finished his “The Anatomy of Hope – How People Prevail in the Face of Illness” (library copy) and found it very helpful. Perhaps I should consider buying his new book, “How Doctors Think.”

“How I think” is another story all together. But that is the subject or subjects of this blog. Help me by adding a comment at the end of this minor dissertation. I have noticed signs of a small backlash about such free thinking. The other night there was a piece on one of evening network news shows blasting Wikipedia, the open encyclopedia on the internet. They were warning parents that not all the facts found in the pages of Wikipedia might be accurate and hence their kids term papers be subject to greater scrutiny. With many cyber sexual predators on the move, I hardly think Wikipedia represents a significant challenge to the intelligence or morals of our communities. Even our local newspaper’s humorist, Jeff Kramer, has taken a stab at bloggers with his recent column, “Stop presses for a day; let bloggers covers news.” Are we feeling a little job insecurity Jeff? I must stop now and walk down to the corner to get my copy of The Post Standard. I still believe in the free press…and free blogging.

Medical Marijuana: It’s the Right Thing to Do!

secondopinions — Wed, 21 Mar 2007 02:36:54 +0000

I find myself cutting through the ambiguity of ethical decisions on another issue, medical marijuana. My positive judgment is “It’s the Right Thing to Do.” The other way of putting it is that denying very sick people medical marijuana is wrong. I borrowed the affirmative expression from Gov. Bill Richardson who is poised to sign a bill making New Mexico the 12th state to legalize medical marijuana. We ‘re not quite at the tipping point for a national change on this issue but we’re getting closer.

The “War on Drugs” was coined by President Richard Nixon in 1971 when he initiated renewed efforts at drug prohibition. And since then, we have been stuck in this rut of blind obedience to our fears of mild altering drugs…at enormous costs to the budgets of our local, state and national governments…as well as to the countless lives of persons caught in the web of the illicit drug business. My point here is not to argue for regulating the marketplace of currently illegal drugs by government…except for those drugs that have been shown to have legitimate medical use. It is indeed ironic that we add sick patients to our list of the criminals who now manage the supply & demand of such drugs.

Marijuana is the perfect example of a drug whose stigma of reckless youthfulness needs to be tabled for the purpose of reducing the suffering of ill persons. We need marijuana in our bathroom medicine cabinets just like hundreds of other drugs that can be abused if not properly used. I am not trying to make the libertarian case that adults should be able to make the choice for recreational marijuana use. Someone else can do that.

But as a health care professional working in the field of hospice & palliative care for almost 30 years, I continue to be appalled that so-called morals trump the suffering of patients. Our medical community needs to help expand the advocacy for adding another tool in pain and symptom management. It has taken years for us to give up the ridiculous notion that terminally ill persons could become addicted to narcotics. How much longer must we wait for persons like Angel McClary Raich to get the medical marijuana she needs to deal with her inoperable brain tumor and other serious ailments. A panel of federal appellate judges recently ruled that although they had been shown “uncontroverted evidence” that Ms. Raich needed marijuana to survive, she lacked legal standing to challenge the federal law.

Meanwhile, the research on positive benefits continues to come in. Compassion requires that we put ethics above the law. What we’re lacking is the political will to loosen the strangle hold of the police mentality when it comes to drugs we have demonized as bad. Thanks goodness that Governor Richardson has the courage to ignore the advice of the White House not to sign the bill.

Giving Birth at 62?

secondopinions — Mon, 26 Feb 2007 20:27:20 +0000

When teaching ethics, I have tried to steer my students away from the polarities of right vs. wrong. I’ve suggested that more often than not, we have issues of right vs. right. This R-R perspective is larger than a question of relativistic ethics where everyone can have equally valid opinions based on differing values. I do believe we live in an era where pluralist views are necessary to get the whole picture. Imagine my surprise when I read about the British woman who has given birth at 62 and my reaction was that this is WRONG.

Perhaps it is because I turned 61 this past December and can’t imagine starting over with changing diapers and then chasing a toddler. I can wait for grandchildren, thank you. Could it be that the new mother missed out somehow on giving birth at an earlier age and now wants to reclaim her maternal prerogative? No. She has three grown children from a previous marriage. So, maybe this act is about contraceptive failure? Wait a minute. 62. Menopause. Nope. This product was the result of intentional fertility engineering. But just because we can implant a woman in her 60s with an embryo, should we?

On second thought, have I become one of those right vs. wrong persons? Don’t I respect the autonomy of the individual? Whatever happened to choice? Maybe I need to understand the need for a love-child by her 60 yo husband? Give me a break. Old men have been irresponsibly sowing their seed for a long time. That doesn’t compute either. The simple math is that this couple will be hitting their 70s when their child hasn’t even entered puberty. He will not have graduated from college by the time they are in their 80s….or are dead. Responsible? No way. Selfish? Give them the Oscar.