In This Issue

Your Odds of Landing in an ICU

The Health Care Power of Attorney

Living Wills -- and Some Questions to Ponder

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Who Speaks for You When You Can't Talk to the Doctor?

Dear Patrick,

Anyone tempted to stop reading this newsletter with the idea "it can't happen to me" should read these numbers first.  

Five million Americans are admitted to intensive care units every year. Most of them are unconscious or unable to communicate in any meaningful way.   ICU care is about the most expensive part of American health care -- accounting for about thirty cents of every health care dollar. ICU care is also prone to error and patient injury -- not because of incompetence, but because of the sheer intensity and number of things going on for each patient.  So every one of those five million Americans needs a good advocate for them in the ICU.

Elderly Americans are especially likely to spend time in an ICU.  On average, one in nine spends at least a week in the ICU in the six months before death,  and the numbers in some parts of the country are as high as one in four elderly persons spending a week in the ICU before they die. 

So if not you personally, then the odds are that at least through an elderly relative, you will experience intensive care in a hospital at some time in your life.   And decisions will have to be made. 

The Health Care Power of Attorney

There are two ways you can plan for the day when you cannot make your own health care decisions.  

One is to appoint someone to make the decisions for you.  That's called a health care power of attorney or health care proxy.

The other way is to prepare what's called a "living will." In a living will, you describe your goals for medical treatment, your religious or spiritual beliefs, and any guidance you want to give about your preferences for medical treatment in various circumstances.

You can do either or both.  But I recommend everyone fill out a health care power of attorney -- aka "durable power of attorney."  It's a simple form that accomplishes one basic important task: it appoints someone to speak for you if you cannot speak for yourself.  And it takes effect ONLY IF you cannot speak for yourself.

The format of the document couldn't be simpler.  In most states, you write something that says "I appoint [fill in name] to make health care decisions on my behalf when I am unable to make those decisions myself." You sign it and have two people witness your signature, and then you give copies of the document to various important people.   

Even easier: Download a free, state-specific form for the health care power of attorney from this website, a project called Caring Connections, from the National Hospice and Palliative Care Organization.

You should especially have this done if you're not close to your legal family members and someone else has a much better idea of what you'd want done for your own health care.     

Read the next section for some specifics you might want to consider adding to the power of attorney by way of a "living will." But these are optional.  If you trust the person you've designated to be your decision maker, you don't have to do anything more than appoint him or her.  

(And don't worry: It's easy to appoint someone else if you change your mind or circumstances prevent your first choice from doing the job.) 

The Living Will -- and Some Questions to Think About

Do we pummel Grandma with everything modern medicine has?   

Maybe so, if she's been alive and vibrant until a day or two ago.  Maybe not, if she has advanced dementia and several of her body's organ systems are already failing. It all depends, and Grandma can help us make the right decision by alerting us in advance about her wishes.   

It's called a "living will" -- and it's usually best set up as an advisory document that gives guidance but not hard-and-fast dictation.  Because "it all depends" on the actual circumstances, and it's hard to know that in advance.

Here's an excerpt from a "living will" form put together by the National Hospice and Palliative Care Organization. The idea of the form is to check off your preferences during a calm and considered time so that your family members won't be left to guess.   

If my doctors certify that I am in a persistent vegetative state, that is, if I

am not conscious and am not aware of myself or my environment or able

to interact with others, and there is no reasonable expectation that I will

ever regain consciousness:

_____ 1. Keep me comfortable and allow natural death to occur. I do not

want any medical interventions used to try to extend my life. I do not

want to receive nutrition and fluids by tube or other medical means.

((or))

_____ 2. Keep me comfortable and allow natural death to occur. I do not

want medical interventions used to try to extend my life. If I am unable to

take enough nourishment by mouth, however, I want to receive nutrition

and fluids by tube or other medical means.

((or))

_____ 3. Try to extend my life for as long as possible, using all available

interventions that in reasonable medical judgment would prevent or delay

my death. If I am unable to take enough nourishment by mouth, I want

to receive nutrition and fluids by tube or other medical means.

The person writing a living will might want to think about some related issues:

* Do we surgically implant a feeding tube into the stomach to take over for the swallowing mechanism that doesn't work any more?  

* Should a respirator be used to take over breathing?    

* Should CPR be used if my heart stops  -- shocking the heart with paddles, and pounding on the chest to squeeze blood from the heart, along with various medications? 

* Should I be put on a dialysis machine to take over for my kidneys if mine have failed? (Dialysis is a particularly overused treatment for hopelessly ill patients in the last month of life, probably because Medicare covers the full cost of it.)  

 In every one of these particulars, one issue is going to be the prospects for recovering a normal or near normal life if heavy-duty care is provided. That's why my advice is not to place any specific hard-and-fast restrictions on what you want, but just outline general concepts for guidance, and rely on the good sense of your designated decision maker to make the right choices. 

We've moved!

Patrick Malone & Associates is in spacious new digs, four blocks north of the White House in downtown Washington, D.C.  Our building is at 1111 16th Street N.W., and is owned by the American Association of University Women. We're next door to the historic Soviet Embassy (now the Russian ambassador's residence -- that's a sliver of our building on the right edge of this linked photo), and just north of the intersection of 16th and L Streets.

If you look due south from 16th and L, you will see the main ceremonial entrance to 1600 Pennsylvania Avenue, with its distinctive triangular pediment supported by four columns.

Give us a call when you're in the neighborhood, and stop in.

Past issues of this newsletter:

This is issue No. 17 of our patient safety newsletter, now in its second year.

Issue No. 16 is all about talking with your doctor, especially when the doctor is stuck about what's the matter with you. One simple question can help cut through the fog help your doctor eliminate the possibility you have a life-threatening problem.

Issue No. 15 is also about conversations.  This one is about talking to your surgeon:  the "informed consent" discussion that so many of us misunderstand. It's not about signing a form to get surgery. It's about having an intelligent, adult discussion to build a bond of trust with a surgeon -- and to make the right decision about what to do.

No. 13 and 14 focused on doing your own health care research on the Internet. No. 13 opened the discussion of "separating fact from hype" in health care advice with a piece on HealthNewsReview, plus articles on the five most overrated prescription medicines and the Miranda warning you see on a lot of so-called natural health products.  Read No. 13 here. 

No. 14 featured a short list of reliable web sites for health care information. We also did a short expose of a very popular website that one writer memorably called "a hypochondriac time suck." As a bonus, one more click will give you an excellent food pyramid for a healthy diet. Read No. 14 here.

Here's a rundown of our newsletters in 2010:

Our first newsletter focused on the problem of conflicts of interest in medicine -- what you need to know in general, and how to find out if your doctor has a conflict that might affect the quality of your care. Click here to see that newsletter again.

Newsletter No. 2 expanded the discussion into the related topic of why experience counts -- especially when choosing a surgeon.  We focused on the story of minimally invasive prostate surgery with the device called the da Vinci robot. We explained how the lessons apply to any kind of surgery or medical procedure. To see newsletter No. 2 again, click here.

Newsletter No. 3 talked about why "more is not always better" in modern medicine. We focused on cancer screening, especially for breast and prostate cancer, and why you can feel not so guilty if you're a little less aggressive about getting the test. (But if you have any symptoms, you shouldn't wait!)   Click here to read it again.

Newsletter No. 4 talked about choosing a hospital, and why the best known rating systems such as U.S. News & World Report may not be all they're cracked up to be. I give some tips about other ways to make sure your hospital is up to par.  Click here to read it again.

Newsletter No. 5 talked numbers -- how it's important for all consumers of health care who want to make informed choices to learn a little bit about how statistics are used -- and misused -- in health care. I introduced readers how to read medical statistics in a straightforward way. To read it again, click here. 

Newsletter No. 6: Back pain and heart disease: how less can be more. The simpler approaches can work just as well as or better than more complex kinds of surgery. Here's the link to see it again.

Newsletter No. 7: Preventive care: what every adult American needs.  Here's the link.

Newsletter No. 8: Colonoscopy: two questions you must ask to make sure you get a competent screening exam. These questions can be a real life-saver when you know how often colonoscopies miss life-threatening lesions.  Read more here.

No. 9: Why getting and reading your own medical records can save your life -- and how to do it. The link is here.

No. 10: The joys of being a health care skeptic -- or, Why statisticians are our friends. And more on why most published research eventually turns out to be wrong. The link is here.

No. 11: Part one of preventing injury in the hospital, discussing why 24/7 bedside coverage is essential, and focusing specifically on bedsores and falls.  Read it here.

No. 12: Part two of preventing injury in the hospital: infections, blood clots and wrong medicine/wrong dose problems. Here is the link.

To your continued health!

Patrick Malone
Patrick Malone & Associates