Are Your Health Wishes Known?

By Dr. John Ropp | Family Physician | Hartsville

When my wife and I married seventeen years ago, our eight grandparents attended the wedding on a warm May evening.  A picture of them together stands as one of our most treasured memories from that special day.  What is even more special, however, is that five of them remain with us today and our children have grown up knowing them well.   The years have not passed, though, without some very difficult discussions and decisions about their well-being, medical care, and other plans if and when they need additional attention.  In the last several weeks alone, I have advised my parents and in-laws concerning matters with their parents, and I sat with neighbors around their dining room table to consider alternatives for their aged mother.  Many of you know what hard talks these can be with family members and other special people in our lives.  Often, we delay speaking until a problem arises that forces us to face a reality- that there will probably come a time when our loved one’s health will not improve or when they cannot take care of themselves any longer.  What then? 

This month we celebrate National Health Decisions Day and as a family physician, I encourage you to take several actions to insure that you and your family have communicated your wishes with one another throughout various life stages.  As a doctor who cares for many seriously ill patients, I cannot tell you how important these discussions are for the peace of everyone involved in a person’s life.  First, please identify a health care power of attorney for yourself and ask other adult members in the family to do the same.  A local attorney can help you with this and other advance directives that may be helpful as well.  Second, when you are diagnosed with a medical condition that you will live with for the rest of your life, please establish and maintain good communication with your primary care physician through the years.  This step will insure appropriate care is provided no matter how long you live with the condition as you continue efforts to cure the malady.  Finally, when a disease process becomes overwhelming or when care needs are extraordinary in a person who is nearing the end of life, consider the appropriateness of more direct palliative care in discussions with your doctor.  Goals to relieve pain and suffering, while honoring patient wishes and dignity, are a hallmark of this care. 

Additionally, we are very pleased that the start of the South Carolina Physicians Order for Scope of Treatment (SC POST) pilot study coincides with NHDD this year.  Our state coalition has worked long and hard to insure that all seriously ill patients in South Carolina and their families have an active voice in their health decisions and communicate these wishes with their physicians and other providers.  I hope you will help join us in this effort by taking the action steps suggested so that we can deliver the best care to our most vulnerable patients.

A Message from The President: Health Care Decisions

Bruce A. Snyder, MD | SCMA President

Today marks the Seventh Annual National Healthcare Decisions Day. As physicians, we often spend a great deal of time talking with our patients about end-of-life-care issues, but today I want to remind you that it is equally important that we take the time to also make those decisions for ourselves.

The goal of National Healthcare Decisions Day is to ensure that all adults with decision-making capacity in America have both the information and the opportunity to communicate and document their future healthcare decisions.  The first years’ results were impressive—over 750,000 people obtained resources to make their health care decisions known.

My siblings and I have experienced the advantage of our parents open discussions and planning for their futures.  We were pleased that both of our parents completed Advance Directives with the advice of their physicians.  Twenty years ago my mother chose to not again be placed on a ventilator because of her day to day struggles due to severe emphysema.  Likewise two years ago my father died without aggressive intervention or CPR.   Both understood their need to make the decision that was most appropriate for them, and to share that with their loved ones.  My mother was confined to the home, required a walker, slept poorly, and was constantly short of breath even with oxygen.  Two years earlier she spent five days on a ventilator and was able to return home, but saw her health steadily deteriorate and therefore eventually chose comfort care.  My father at age 85 started dialysis and for over two years was able to drive himself back and forth for treatments three days a week, have an active social life, and remain active in his church.  Then as his health deteriorated, he required transportation for his dialysis treatments, required an electric scooter, and became short of breath with minimal activity.  He discussed his options with his physicians, family, and friends; and then he also decided not to undergo more extensive care. I had served as his health care agent with his wish for me to make healthcare decisions if he could not make them for himself.  Having completed both his Advance Directive and Health Care Power of Attorney gave him and all of his children assurance that his wishes would be followed and when confronted with his final illness, I was able to honor his wishes.

I encourage you to visit www.nationalhealthcaredecisionday.org for a variety of free information (including free advance directives forms for every state) and tools to assist you with your own thoughtful reflection on your healthcare choices.

I also encourage you to check out the work being done by our very own SC Coalition for the Care of the Seriously Ill (CSI). Their mission is that all persons in South Carolina with serious, chronic or terminal illnesses will have an active voice in the care decision process.

I hope you will take the time to spread the word to your patients, as well as make your own wishes known to your loved ones---- remember, your health care decisions matter, too.

Colonoscopy Ps and Qs

By Dr. March Seabrook, Gastroenterologist, SCMA Board Member

March is known for being "National Colorectal Cancer Awareness Month". Dr. March Seabrook, a gastroenterologist and an advocate for early screening and prevention, shares with us the "Colonoscopy Ps and Qs".

There are several things that everyone should know before having a colonoscopy. I call this the Colonoscopy Ps and Qs.

Patient Selection – Colorectal screening is generally recommended for everyone over the age of 50.  However, it is important to discuss this with your physician because all patients are different and though colonoscopy may be the preferred strategy, perhaps it may not be the appropriate test for you.  It is best to talk to the physician performing the procedure to go over your medical history as that may affect your preparation, where the procedure is to be performed and the type of sedation.  Colonoscopy is NOT just a simple test.  

Physician – Who is actually performing the procedure?  A gastroenterologist clearly has the most training and experience.  Many gastroenterologists have at least three years of advanced training and perform well over 1000 colonoscopies per year.  This is what they do every day.  The physician performing your colonoscopy may not be a gastroenterologist.  Make sure you know their training and experience.  Also find out if they are credentialed to perform this and other procedures at the local hospital. 

Preparation – Most will say this is the worst part of the entire procedure.  Yes, you do have to get “cleaned out.”  It is critical to the quality of the procedure that the colon is well prepped.  There are a number of effective preps and the one that is chosen may be determined by your specific medical situation.  None of the preps are particularly pleasant.  However, going though this is probably better than having surgery or receiving chemotherapy.

Proper Facility – The majority of these procedures can be performed in convenient outpatient endoscopy centers.  The entire experience usually takes no more than a couple of hours. Make sure the facility is certified and accredited.  However, there may be reason that your physician believes it should be performed in the hospital based on other medical factors.  The cost at an endoscopy center is usually substantially less than a hospital.  When you come in for your procedure, a nurse will get you ready for the procedure and place an IV.  During the procedure you will be on your left side in somewhat of a fetal position. The procedure usually takes approximately 20 minutes to perform.  After the colonoscopy you will spend about 30 minutes in the recovery area depending on the sedation.   There will be some restrictions about activities for the rest of the day and perhaps some restrictions for medications (especially blood thinners) and other activities if polyps are removed. 

Proper Sedation – Your comfort is important and sedation is a critical part of the procedure.  With proper sedation you should remember virtually nothing about the examination.  There are two major forms of sedation.  First, patients may receive a combination of drugs (usually Demerol and Versed) and this is called conscious sedation.  It works well but wears off slowly. The patient is not totally asleep, but doesn’t have any memory of the procedure.  A small percentage of people are difficult to sedate with these drugs primarily because of other medications they may be taking.  Secondly, many patients are now sedated with Propofol (the “Michael Jackson drug”).  This drug works quickly and wears off quickly.  You are asleep with this medication.  Using this drug requires either an anesthesiologist or nurse anesthetist and does add a cost to the procedure.  Regardless of the type of sedation, you need to have someone responsible to take you home after the procedure.

Pathology – If polyps are removed or if biopsies are obtained for other reasons, they are sent for examination under the microscope. The lab and the pathologist play an important part in this process.  Most specimens are sent to local pathologists.  You should be notified of the results of any specimens sent for evaluation.  This usually takes a week or so.  Your doctor will generally be able to tell you if anything is very concerning just by examining the tissue at the time of the procedure.

Quality Follow up –  If you have an excellent prep and a complete colonoscopy and you have no polyps and no family history of colorectal cancer, you may not need another colonoscopy for up to 10 years (or maybe never depending on your age and other medical factors).  This is quite a powerful test compared to a mammogram, Pap smear, or prostate exam that is generally performed annually.  However, many people do have polyps.  It depends on the number, size, and type of polyps that will determine when a follow up colonoscopy is recommended.  For instance if you have one or two small adenomatous (considered precancerous) polyps, the recommendations would be to repeat the examination in five years.  If you have three or more or if you have larger or more “advanced” polyps, you may need a repeat examination in three years. 

Quality Monitoring – All physicians want to deliver the highest quality care that they can for their patients.  However, no one cares more about the patient than the patient.  Make sure your physician is qualified to perform the procedure.  Make sure the endoscopy center is certified and accredited.  As part of accreditation, the facility is engaged in various programs to assess patient satisfaction and quality improvement.  A quality program will also be monitoring and submitting their data to a national registry to compare their physicians to the rest of the country.  Some of the data that is being evaluated is how often a complete procedure (“cecal intubation”) is performed, the number of polyps identified and removed and the timing of a follow up evaluation.  One of the best ways to find a good physician in your area is to ask other patients or even better, ask someone that works in the hospital in the same area where the physician works.  They have the opportunity to see all of physicians and how they perform technically and how they interact with patients, families, and staff.  Be careful if you are only relying on the internet for information as the main reason to see a certain physician.

Like many aspects of medical treatment, the future of screening will be individualized to each person’s own set of circumstances. These personal characteristics will help us define who and how often and with what method that patient should be screened.  But for now, the best way to prevent (not treat or cure) colorectal cancer is to identify and remove precancerous polyps.

March is National Colon Cancer Awareness Month

By Dr. March Seabrook, Gastroenterologist


The month of March is National Colon Cancer Awareness Month.  It first received this designation in 2000.  Colorectal Cancer (the term used when cancer begins in either the colon or rectum) is the second leading cause of cancer death and it is generally preventable.  In South Carolina, there are over 2,100 new cases and about 750 deaths a year from this disease.  The good news is that the number of deaths is actually decreasing despite the aging population. The major reason for this is thought to be an increase in screening colonoscopy.  Keep in mind that our goal with breast cancer and prostate cancer is to detect them early enough to cure them.  Our goal with colorectal cancer is to PREVENT it.  

Age is the major risk factor for developing colorectal cancer and over 90% of cases are detected after the age of 50.   A family history of colorectal cancer and certain other diseases such as inflammatory bowel disease can increase your risk as well.  Lifestyle can also affect the development colorectal cancer.  There is mounting evidence that factors such as high fat diet, obesity, smoking and lack of exercise can all increase your risk.  The cancer affects both genders and all races (although there is a slightly more frequent diagnosis in males and a higher death rate among African Americans).

The cancer generally begins as a benign growth called a polyp.  There are two common types of polyps: hyperplastic and adenomatous.  The adenomatous polyps (also called adenomas) are the type that is thought to develop into cancer.  You cannot predict which polyps will turn into cancer just by looking at them so it is best to try to remove all of them.

Polyps and even cancers may cause no symptoms at all.  That is why it is recommended that everyone get screened.  Concerning symptoms may include unexplained change in bowel behavior, blood in the stool, weight loss or abdominal pain.  Anemia or low blood counts may indicate a problem as well.

Screening (testing when there are no symptoms) for colorectal cancer is recommended for everyone beginning at the age of 50.  There are some reasons to screen sooner (usually a family history of colorectal cancer).  Some organizations recommend that African Americans should be screened at age 45.  There are a variety of tests that can be used for colorectal screening including:  colonoscopy, flexible sigmoidoscopy, x ray examinations or testing the stool for blood or other potential cancer markers.   Any of these tests may be appropriate for an individual but most experts would recommend a colonoscopy.

Colonoscopy is currently the Preferred Strategy for colorectal cancer screening.  It is the only test that can visualize the entire colon AND remove precancerous polyps at the same time.  It is clearly the best test but it is not a simple test and it is not a perfect test. If you are going to have a colonoscopy make sure it is the right physician in the right place doing the right procedure.  The risks associated with a colonoscopy are very low in experienced hands but they include bleeding, perforation of the bowel, reaction to medications and possibly missed lesions.  The likelihood of any of these is quite low and the benefits of preventing colorectal cancer far outweigh any of these risks. 

I am proud to say that South Carolina has been recognized as a national leader in some of the innovative programs that have been developed regarding colorectal cancer.  There are about 160 gastroenterologists in the state and the South Carolina Gastroenterology Association in collaboration with Blue Cross Blue Shield and The USC Center for Colon Cancer Research under the direction of Frank Berger have been instrumental in developing statewide awareness and screening programs. Most of this effort has been focused on the disparities that exist in health care in our state.  

The South Carolina Colon Cancer Prevention Network (CCPN) began with a grant from the Blue Cross Blue Shield Foundation in 2008.  It started with a clinic in Anderson and Greenwood counties.  In 2011 it expanded to 4 counties and today, thanks to a grant from the Duke Endowment and a state legislature proviso, the program is in 24 of the 46 counties and over half of the states board certified gastroenterologists are donating their time and expertise to this project.  The preliminary results are impressive.  Thanks to navigating support, over 800 individuals, the majority being African- American will be screened through this program this year.

In recognition of National Colorectal Cancer Awareness Month, there will be a number of awareness activities across the state.  The signature event, the Eight Annual Unmasking Colon Cancer Gala will be held on Saturday March 8 in Columbia.  This event will be a celebration of the survivors of this disease.  Our ultimate goal is to make this disease the number three or number four cause of cancer death and one day to just prevent it altogether!!

Stay tuned for the  Colonoscopy Ps and Qs later this month!

30 Years of Experience in Caring for the Seriously Ill

By Mark O'Rourke, MD | Member to the SCMA Bioethics Committee

For an older person, admission to a hospital is frequently a time of difficult, major medical decisions and a time of diminished capacity to make decisions.  Frequently, frail elderly persons need help to make important medical decisions when they are hospitalized.  A study published online in January in JAMA Internal Medicine documented just how often older persons admitted to the hospital had to make major medical decisions and how often they needed help in doing so[1].  In the study of 1598 persons age 65 years and older who were admitted to two hospitals in a Midwestern city, the researchers defined a major medical decision as (1) life-sustaining care such as CPR, (2) a procedure or operation that required informed consent, or (3) hospital discharge to a nursing home.  They found that two thirds (1083) faced a major decision.  I am impressed by the high fraction.

Of those making major decisions, 47% depended in part or completely on a surrogate, such as a spouse, son or daughter.  Of those who were transferred to the ICU at some time during the hospital stay, 71% depended on a surrogate.  I take from this study that spouses, sons, daughters and other family members had to make a lot of important decisions for patients with diminished capacity.  Of the 1,083 patients, only 7.4% had a living will and only 25% had a health care representative document.  It appears that these spouses, sons and daughters usually had to figure out what the patient wanted and/or what was best for the patient without a living will or a healthcare power of attorney.

My experience over the past 30 years of taking care of seriously ill persons in the hospital is consistent with the statistics in this report.  I regularly see patients and families in distress in the hospital struggling with major medical decisions.  I can offer a few suggestions that may help and reduce the distress for all concerned.

First, every adult should designate a surrogate for medical decisions and fill out the paperwork for a healthcare power of attorney. Forms for South Carolina are available in hospitals, physician offices, attorney offices and online at www.scha.org/shared-decision-making.  The form is short and simple.

Second, when a person has a number of interested family members, designating a single surrogate as power of attorney makes it clear to the surrogate and to the others who the patient ultimately wanted to make the decisions.

Third, everyone should discuss their health, outlook and preferences with their surrogate and other family or friends.  This means discussing one’s health condition, considering one’s life expectancy, weighing the benefit of CPR (cardiopulmonary resuscitation) and describing how one feels about care at the end of life, when that time comes.

The seventh annual Health Care Decisions Day will be observed on April 16, 2014.  This day after income taxes are due is chosen to remind us of the two certainties in life, death and taxes.  As physicians, we can help educate our patients and the public about the need to plan ahead for healthcare decisions.  We can speak up in our practices and in our hospitals.  We can speak up in our places of worship and in our various clubs and associations.  We can write letters in newspapers and newsletters.  I encourage SCMA members to check out the website, www.hcdd.org, and to make a special effort this year to spread the word on Health Care Decisions Day.

1.         Torke, A.M., et al., Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults. JAMA Intern Med, 2014.

Rule #5 will Make Them Raving Fans

By Deb Sofield, Public Speaking Coach

Over the next few months, join Deb Sofield as she goes through her series 15 Rules for the Physician Leader, where she outlines how a physician leader can be successful when speaking, no matter where they are... 

Rule #5: Talk about the audience – one mark of effective speaker is that they focus less about themselves and more on those who have come to hear them speak.

Most people want the speaker to know who they are and to have anticipated in some way the needs of those who are sitting in the audience. A speaker who tells stories for self aggrandizement or self congratulations (shocking but true) – will for the most part not impart great wisdom or leave the group with nuggets of truth that can help them in their life.

You, speaker, have a message or at least the title of your presentation led that audience to think you had something to offer – now you have to deliver. Talk to them, speak truth to power, and don’t be afraid. You never know when by your truth, knowledge or wisdom you change them.

Another way you can talk about the audience is to commend them for something good they have done…it will go a long way… Rotary, Sertoma, Elks…  do a great deal of community service and when you stand to speak and say thank you – you’re starting on safe ground.

A little twist to this topic is as the presenter you can take charge of the room – from where you stand you can tell if your audience is cold, hot, uncomfortable, or antsy… read and respond to their needs – that shows respect for them and they will appreciate it. I have never had an audience complain that they get too many breaks… to go the bathroom or stretch their legs.

By talking about the audience and caring for them – you will win them over.

Deb's Tip of the Month:

Be careful with Names: Let me share a new rule for the road many of us are incorporating in our speaking. If you can’t say the names of everyone in your audience – say no one’s name... people are more sensitive now than ever. So if you, speakers, call one friend over and over by name the others will wonder why you don’t call them by name. I know it is an odd comment, but I see it from the stage all the time. People want to be known and if you tend to call out the one or two people you know well and not the one you slightly know – you alienate them all.

WomenHeart Comes to South Carolina

By Providence Hospitals

When the Providence Hospitals’ South Carolina Heart Center cardiac specialist Dr. Norma Khoury was in Washington, DC last spring at a conference, she was impressed by the national group WomenHeart: The National Coalition for Women with Heart Disease. Connecting with some of the group’s leadership, she saw the potential for this group to dovetail with the already successful Red Dress campaign and other awareness activities in Columbia because it filled a real gap in the Midlands – the emotional recovery element of tackling heart disease.

 

Cardiac rehabilitation is common among heart disease survivors, but after years of connecting with her patients, Dr. Khoury was increasingly worried that there was no outlet for the emotional healing that is required to live with the looming spector of heart disease. Advocacy and education are also key elements that needed a more year-round approach for women to truly understand how heart disease could affect them, so Dr. Khoury approached Providence Hospitals leadership about buying into WomenHeart.

 

“This opportunity was too good to pass up – whether you are scheduled for heart surgery, have afib or some other heart condition, WomenHeart Columbia is a group to learn with, to grow with and is set for heart disease survivors to shape into an emotional recovery hub for all of South Carolina’s women.”

 

WomenHeart Columbia’s champion, Christine Gallagher, has worked hard with WomenHeart at the national level to launch the support network’s first Columbia meeting. Though the group is partnering with Providence Hospitals, patients who seek heart care at any practice or any hospital are welcome.

 

Please urge your female heart patients to check out this new group and try to attend one of their meetings. More information is available at their facebook page: www.facebook.com/WomenHeartSC.