Tag: Medicine

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Medical marijuana: a boon & a challenge

by Fran Johns

When my sister Mimi found that marijuana could relieve her severe gastrointestinal distress, years ago, one joint after dinner was all it took. Unfortunately we couldn’t keep up the supply. After one foray into the rather scary realm of pot-dealing in a state (Georgia) where we could have wound up in jail very quickly, we decided that not even such clear relief was worth the risk.

Today, at least in California and 14 other states — with the District of Columbia possibly to be added soon — the risk is minimal but the dosage is fuzzy. The conundrum was outlined by writer Lena K. Sun in the San Francisco Chronicle:

On Tuesday, District of Columbia officials gave final approval to a bill establishing a legal medical marijuana program. If Congress signs off, D.C. doctors – like their counterparts in 14 states – will be allowed to add pot to therapies they can recommend to certain patients, who will then eat it, smoke it or vaporize it until they decide they are, well, high enough.

The exact dosage and means of delivery – as well as the sometimes perplexing process of obtaining a drug that remains illegal under federal law – will be left largely up to the patient. Doctors say that upends the way they are used to dispensing medication, giving the straitlaced medical establishment a whiff of the freewheeling world of weed.

Even in states where marijuana is allowed for medical use, doctors cannot write prescriptions because of the drug’s status as an illegal substance. Physicians can only recommend it, and have no control over the quality of the drug their patients acquire.

Because there are no uniform standards for medical marijuana, doctors have to rely on the experience of other doctors and their own judgment. That, they say, can lead to abuse.

California’s “quick-in, quick-out mills” that readily hand out recommendations have proliferated, worrying advocates. The state, the first to legalize medical marijuana 14 years ago, allows for a wider range of conditions, including anxiety.

To guard against abuse, some doctors say they recommend marijuana only after patients exhaust other remedies. Some doctors perform drug tests as part of pre-screenings.

Mimi died over a year ago. Her last decades, like almost all of her adult life, were spent in the State of Georgia, where medical marijuana is still against the law. I know what her required dosage was; legalization and proper oversight would allow doctors to learn dosages that work for their patients. It seems worse than cruel that thousands of other sick and dying citizens continue to be denied the potential relief that legalized medical marijuana could bring.

Dispensing medical pot a challenge for doctors.

California/Health/Medicine/New York/seniors
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Dementia: stories and sources

by Fran Johns

The post about dementia sufferers and their tendency to wander (May 6) evoked a host of stories about temporarily lost parents, grandparents, friends and relations. Almost everyone, it seems, has such a story — and unfortunately, those who haven’t may collect one or two in the future.  Reader Cathy Jensen sent a poignant tale of a friend who went wandering in his pajamas during the pre-dawn hours, but was found by the garbage collectors and brought home on the back of their truck. And reader Tom McAfee, en route to see his own mom and hopefully jog memories of children and grandchildren with photos, sent a link to a podcast aired on WNYC in March.

An offbeat idea, the WNYC piece explains, turned out to be a good solution for a nursing home in Germany from which residents were wandering off. Administrators created a bus stop in front of the home, complete with bench and a painted sign for a bus that never came. It provided a place where many wanderers could sit and wait until the urge to go back home, or elsewhere, melted away. Might not work everywhere, but it worked in Dusseldorf.

And reader JTMcKay4 sent, in case you missed them in the comments section, links to the Alzheimer’s Association’s “Safe Return” program and to a source for a long list of related documents. State-specific advance directive forms can also be downloaded, free, from the “Caring Connections” site maintained by the National Hospice and Palliative Care Association site, and this space remains committed to the support of the nonprofit Compassion and Choices, from which forms can also be downloaded.

There is no guarantee against winding up in a memory unit. But a little preparation can go a long way toward helping if the time comes.

California/General interest/Health/Politics & Causes/seniors/USA
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Quality health care at lower cost? It could happen

by Fran Johns

It seems a no-brainer: reward the doctors and hospitals that give the best care, latch on to programs and ideas that offer quality over quantity. But innovation in health care, even when it proves out, has always taken a very long time to work into the system.

In a ‘Talk of the Town’ piece appearing in the latest New Yorker magazine, writer Atul Gawande offers a thoughtful look at some of the hurdles ahead for the newly-passed health bill. They are primarily political: conservatives — even if they’re talking less and less about repeal — will run on pieces they plan to strip out, states will fight the insurance exchanges (such as those that make health coverage near universal in Senator Scott Brown‘s Massachusetts.) And other battle lines will be drawn.

But one primary problem with the dysfunction we are hoping to fix, Gawande points out, is that the current system “pays for quantity of care rather than the value of it.” He illustrates this with a case that makes you cheer, and then feel a little hopeless:

Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged. But an empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions. Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.

There is in the new bill, though, a ray of hope:

The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.

Imagine innovation being rewarded, communities being encouraged to find ways to improve quality of care at lower cost. That’s real reform, and it could just happen.

The next attacks on health-care reform : The New Yorker.

California/General interest/Health/Lifestyle/Medicine/Politics & Causes/Religion/seniors/Women
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Patients fight hospitals (& not just Catholic hospitals) for proper care

by Fran Johns

“Suppose I wind up being taken to a hospital,” said the lady with the penetrating blue eyes and a lovely, long braid over her shoulder. “How can I keep them from doing all those things I don’t want — ventilators, feeding tubes…?”

The lady with the lush braid was among a small group of retirement community residents with whom I spoke yesterday about end of life choices. None of them fear death. All of them fear aggressive, unwanted treatment. A colleague and I had been invited to talk with them about documents (advance directives, POLST forms, etc) and legal measures that can help insure a compassionate end. But the distressing reality is that there are no guarantees.

This is where we are with health care: patients having to fight against doctors, hospitals, systems — and directives from Bishops — for the right to die in peace.

A recent Kaiser Health News article (KHN is a publication of the Henry J. Kaiser Family Foundation and unrelated to Kaiser Permanente) cited problems arising from directives to Catholic hospitals about a variety of issues. The directives, issued in November by the U.S. Conference of Catholic Bishops, changed the policy on feeding tubes, for example, from “presumption in favor of”  to an “obligation.”

“This obligation,” the bishops said, “extends to patients in chronic and presumably irreversible conditions,” such as persistent vegetative state, who might live for many years if given such care. A feeding tube is not required, however, if it wouldn’t prolong life, would be “excessively burdensome for the patient,” or would “cause significant physical discomfort.”The directive raises fresh questions about the ability of patients to have their end-of-life treatment wishes honored — and whether and how a health care provider should comply with lawful requests not consistent with the provider’s religious views. Hospitals and nursing homes do not have to comply with requests that are “contrary to Catholic moral teaching,” according to longstanding policy that, as in the case of the revised directive, applies to non-Catholic patients as well.

As the women in our group yesterday understand, you can wind up with unwanted treatment in all sorts of circumstances, not just when you’re dying.

Dr. Lachlan Forrow, a Harvard University medical ethicist and palliative care specialist, expressed strong concern about the new policy, stressing its potentially broad scope. “That gets to be a very, very large number of people,” said Forrow, who heads a panel developing recommendations for the state of Massachusetts on end-of-life care.

(A)ccording to Catholic officials and outside experts, the directive may well apply to a wider range of patients, those that it describes as having “chronic and presumably irreversible conditions,” though the organization representing Catholic health facilities downplays the impact. Experts say this affected group could include those with massive strokes, advanced Alzheimer’s disease, traumatic brain injury and Lou Gehrig’s Disease.

If a patient or family didn’t want a feeding tube “and the reason they don’t want it is they basically want to die, then the Catholic institution would explain to them they can’t cooperate with that and they would have to go to another institution,” said the Rev. Thomas G. Weinandy, executive director for doctrine at the bishops’ conference, who helped draft the policy.

Weinandy said “obviously the public should know what the directives say,” and patients and relatives “can easily download the directives or get a copy.”

Oh, sure. The EMT people are loading mom into the ambulance, and you ask them to wait until you download a few pages of papal edicts.

In the days before she died two weeks ago (in a non-Catholic hospital) my sister Jane occasionally showed signs that, though sleeping, she might be experiencing pain. My niece, who was keeping round-the-clock watch over her mother, more than once asked the attending physician for additional pain medication and was told, in a “There, there now, dear” voice that “We can’t hasten!!” My niece is a tenured law school professor.

Doctors make a lot of fuss about that “First, do no harm” business in the Hippocratic oath. Is withholding pain medication because it might cause death a few hours sooner than later doing no harm? Is inflicting painful, unwanted and unwarranted interventions for some obscure religious reason doing no harm?

Catholic Directive May Thwart End-Of-Life Wishes – Kaiser Health News.

California/General interest/Health/Medicine/Politics & Causes
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Life, love and palliative care

by Fran Johns

My greatly beloved sister Jane died this morning, a peaceful end to 84 years of a life extraordinarily well lived. For a few days she had been on palliative care.

Palliative care. File that term away for yourself, your parents, your friends and family. It’s the new best thing, even though for centuries it was the old best thing: keep me comfortable and let life come full circle. For centuries we believed that life was a cycle: birth, Stuff, death. Some people’s stuff was better than others, but there was a general agreement that death happened, so it made sense to ease it along when the time came. Usually it didn’t take long. Often, if ease was not to be had, the family doctor invited everyone in briefly to say goodbye, closed the door and administered a shot of morphine.

Then we invented chemotherapy and ventilators and feeding tubes and miracle drugs and adopted the national attitude that one is supposed to live forever. Plus, we invented lawsuits. So dying turned into something horrid and often painful, something one is really not supposed to do. Physician aid-in-dying for the terminally ill became illegal; even talking about it gave Sarah Palin the death panel willies.

My sister Jane was a gifted artist who told me, a few days before she died, that she’d reached the apex of her career because one of her recent paintings was stolen from a show currently on view. (She was also delighted that others were selling well.) She was a remarkable mother, hostess, book-lover, friend, and about the world’s best big sister. The day after our last conversation she had respiratory failure (quit smoking, please, if you haven’t already) and began to die.

Jane was briefly on a ventilator, which I hated as much as she, but one does what needs to be done. Very quickly she moved from that to palliative care. Her husband, four daughters and assorted grandchildren gathered around to sing songs, hold hands, administer foot rubs, report to her remaining two sisters and innumerable friends that all was well.

This is not an argument against miracle drugs or aggressive interventions when appropriate, or even against feeding tubes and ventilators — although if you catch my children approving such things after I conk my head on the curb please remind them of my explicit instructions to the contrary. But it is an argument to confront mortality, complete your advance directives, talk to family and friends about your own wishes no matter how young and immortal you feel yourself to be, support compassionate and humane dying. Advocating for decent health care for the living wouldn’t be a bad way to start.

Palliative care is a valuable new/old thing. So are big sisters like Jane, although they are hard to come by.

California/General interest/Health/Lifestyle/Medicine/seniors/Sports
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Breaking news on broken-down joints

by Fran Johns

There’s old news — joint replacements for athletes are downright commonplace, seniors in their 80s and 90s are getting new hips — and now there’s good news. Researchers at the University of California San Francisco, led by sports medicine chief C. Benjamin Ma MD, are finding that damage to the cartilage connecting the foot bone to the ankle bone to the leg bone etc might not have to be permanent.

As almost anyone with a series of sports injuries may know, cartilage damage is permanent. In the words of Dr. Benjamin Ma, chief of sports medicine at UCSF, “cartilage is just lazy” — it doesn’t like to regenerate, so when it gets damaged or worn down through use or injury, it won’t come back on its own.

But Ma and his research team have discovered that given very specific circumstances, cartilage will, in fact, regenerate. The team has been taking knee cartilage from subjects and placing it on a matrix and under some very specific conditions, it is forced to regenerate.

“Cartilage cells are very lazy. They don’t like to grow if they don’t have to,” he said. “So we fool them by doing this particular maneuver and they feel they have to grow, and they form new cartilage. Then we glue it back into the knee.”

The new method has proved to be safe and it helps improve function, and now it is undergoing Phase 3 clinical trials to see whether it in fact works better than microfracture surgeries currently used to treat cartilage injuries.

Down the road, Ma and his team hope to see if there is an application of this method that could help people suffering from arthritis, which is also a cartilage disorder.

That cheer being heard across cyberspace is coming from millions of amateur athletes and the entire population over 50, almost every one of whom could use a little newly invigorated cartilage.

Read more at the San Francisco Examiner.

California/General interest/Health/Politics & Causes/seniors/USA/Women
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Doctors making house calls? An old idea whose new time has come

by Fran Johns

Could house calls make a comeback? It’s already happening. The University of California at San Francisco, for one success-story example, started the UCSF-Mt. Zion Housecalls Program in 1999 with a philanthropic gift. Its original goal was to teach medical students about home care, but with the exploding need for primary care for homebound elders it has evolved into filling that need throughout San Francisco — while still teaching the new generation about house calls.

In an article in the San Francisco Chronicle, staff writer Victoria Colliver details some of the many advantages that such programs have.

June Hagosian’s brain tumor has made it difficult for the 77-year-old San Francisco woman to leave her house in recent years, keeping her mostly confined to her bed.

For someone like Hagosian whose medical needs require frequent doctor visits, that would usually pose a problem. But because of a program run by UCSF, the doctor comes to her. She has had to leave her bright yellow home in the Richmond District to go to the hospital just three times in the past seven years.

“This program has been so wonderful,” Hagosian said during a recent home visit with her physician, Rebecca Conant, director of UCSF’s Housecalls Program. “I wish everyone could have it.”

Conant, who had just 15 patients when she took over the program in 2001, is one of five part-time UCSF physicians who spend all their clinical time outside the office, traveling from home to home visiting frail and elderly patients. Housecalls currently serves nearly 100 San Francisco residents and has an eight-month waiting list.The Housecalls physicians visit patients whose conditions make it so hard for them to go to the doctor’s office that they might otherwise put off seeking medical care. By then, they would be so sick they would need an ambulance and end up in a hospital emergency room. The program takes patients regardless of whether they have insurance or an ability to pay, which separates it from private practices that offer home visits as a convenience but at an added cost.

UCSF’s 10-year-old Housecalls Program is an old idea that has gained new traction. Both the House and Senate versions of the health reform bills contain proposals to examine whether home-based care improves the health of chronically ill patients and saves the government money by reducing hospitalizations and ER visits.”There’s no question there is both a medical need and substantial cost savings to the Medicare program,” said Constance Row, executive director of the American Academy of Home Care Physicians.

The Department of Veterans Affairs’ Home-Based Primary Care program, which has been operating for more than two decades, has showed a 24 percent reduction in costs for those patients, and some studies suggest savings as high as 40 percent, Row said.

UCSF’s Housecalls Programs operates on an annual budget of $300,000, almost all of which is devoted to physician salaries. That’s an average cost of $3,000 per patient, which does not include the cost of hospital care when needed. Medicare spends a national average of $46,412 per patient over the last two years of life, when patients typically have several chronic illnesses, according to researchers from the Dartmouth Institute for Health Policy and Clinical Practice.

But new technology – the ability to X-ray patients using portable machines, conduct blood tests and provide other services using mobile devices – allows doctors to offer a much higher level of care in the comfort of the patient’s home.

Conant, an associate clinical professor at UCSF, said she uses mobile devices to aid in her patient care, but she finds home visits offer other advantages like allowing her to see patients’ physical environments, meet their caregivers and better understand what kind of care they need.

“Not only does that improve medical care, but it’s based in reality,” she said.

The UCSF program is not the only home-based primary care program in the Bay Area. Kaiser Permanente, for example, serves some 370 members in San Francisco as part of its 13-year-old Community Care Program, which is handled by physicians, nurse practitioners and social workers.

Reinstituting and reinforcing in-home care, considering the significantly improved care for patients and the reduced cost to the taxpayer, would seem a no-brainer. But brains are losing out to politics a lot these days.

via UCSF program shows house calls’ time returning.

General interest
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Doctors, neckwear & the male brain

by Fran Johns
Bob-baldric
Dr. Liner in his Baldric

This space is happy to offer up-to-the-minute insights, today’s concerning connections between neckties, germs, the male brain and other organs.

First, reporter Rebecca Smith writes in today’s Wall Street Journal that neckties may be helping spread flu germs, and many people inside and outside the health care industry think they should go.

“The list of things to avoid during flu season includes crowded buses, hospitals and handshakes. Consider adding this: your doctor’s necktie.

Neckties are rarely, if ever, cleaned. When a patient is seated on the examining table, doctors’ ties often dangle perilously close to sneeze level. In recent years, a debate has emerged in the medical community over whether they harbor dangerous germs.

Several hospitals have proposed banning them outright. Some veteran doctors suspect the anti-necktie campaign has more to do with younger physicians’ desire to dress casually than it does with modern medicine. At least one tie maker is pushing a compromise solution: neckwear with an antimicrobial coating.

BUT HOW ABOUT JUST SWITCHING TO THE BALDRIC?

My friend Robert Liner MD, a distinguished physician/piano player/tango dancer/fellow board member of Compassion & Choices of N.CA and general Renaissance man, made this switch some time ago. In rather characteristic Liner fashion, he then established a company which produces Baldrics in order that others may enjoy them.

Earlier Baldrics were worn by most respectable Scots so they would have something handy from which to hang their swords. But for the 21st century, as Liner writes on his company web site:

We are re-inventing the Baldric for present day men and women on the go. I originally conceived the idea of the Baldric as a new fashion statement for men. Instead of a constricting necktie, a man could dress up with a Baldric. Instead of carrying a sword, the modern man could employ his Baldric to carry his sword equivalent: a cell phone, I-Phone, Blackberry or other p.d.a.. Additionally, in place of a bulky wallet, he could keep credit cards, folding money and small personal items easily accessible in a secret pocket in his Baldric. The Baldric is a hybrid: it’s a necktie alternative that performs like a sleek, modified, minimalist messenger bag.

Contacted today about the germ issue, Liner reports he had indeed heard of such. “Of course, it’s seemed to me,” he muses further, “that the more significant problem with neckties from the point of view of health and world peace is the possibility that neckties reduce blood supply to the male brain. This may account for a good deal of what looks like irrational behavior on the part of my sub-species. This can especially be a problem during adolescence and at other times (ie. most of the time) when demand is placed upon the male circulatory system to divert blood to an organ that is not the brain but sometimes functions in place of the brain. Under these circumstances, the male blood stream can hardly afford to have any restriction placed upon the “choke point” by a necktie so that what little blood is left available to go north to the “main brain” is impeded, resulting  in chaos on a global scale.”

Considering the problems of H1N1 and other viruses, and the potential for advancing world peace as Dr. Liner suggests might happen with fewer neckties, this space hereby blatantly endorses the Baldric.

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