4-16-13 National Healthcare Decisions Day

 

Working in healthcare the frequency of poor decision making when it comes to end of life decisions and choices has made many a good healthcare provider change careers. It becomes an ethical dilemma when patients are coerced into major procedures when the outcome will be poor regardless of the intervention. Many times it is because of poor communication between the patient, their family and the caring physicians.  This can largely be prevented through advanced care planning. Effective communication between the patient or legally designated decision-maker and health care professionals ensures decisions are sound and based on the patient’s understanding their medical condition, their prognosis, the benefits and burdens of the life-sustaining treatment and their personal goals for care.

The discussion should include what interventions would you agree to, what do you want to avoid? What do you want your family to know. Decisions include CPR, life support, respirators, tube feedings, surgical procedures, pain management, medications, skilled nursing facilities, hospice. How do you choose to spend your final days? At the bottom of this post you will find many wonderful resources to help you in decision making, and communication with family and physicians.

Photo: Learn more about advance care planning resources as we get closer to National Healthcare Decisions Day. http://www.nhdd.org/public-resources/Photo: Sometimes getting started is challenging! Check out some great family conversation starters: http://www.nhdd.org/public-resources/Photo: Speak up! www.nhdd.orgPhoto: Speak up with NHDD! http://www.nhdd.org/Photo: Advocate with NHDD! www.nhdd.org/joinPhoto: Two weeks until NHDD! Learn more facts about advance care planning http://www.nhdd.org/facts

advance care planning to keep healthcare centered around patient goals.

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Diabetes and Your Heart

Know your family history, does it include diabetes?

If so make sure you know your numbers. A blood sugar greater than 1oo when fasting  140 for someone two hours after eating is considered high. When you go to your health care professional for blood tests do you ask for a copy of the results, or do you simply get a call from the nurse saying it is normal? I recommend always getting a copy of your results. Over the years many are told there blood sugars are normal when in fact they are prediabetic. This should trigger either a conversation or a referral for education on how diet and exercise can help to avoid having full blown diabetes. Unfortunately this piece is often missing in many health care visits. Make sure you advocate for yourself. The infographic below is posted to help you advocate for yourself or your loved one.   Keep records of your lab reports track and trend them, are they improving or worsening. You know best how well you have adhered to a healthy diet, but the numbers give you concrete data.

Heart patients need to be more aware than most as several heart medication can pre-dispose one to diabetes.

Great fix the heart but then get diabetes! Yes, it is a real issue, but again through tracking, diet and exercise, medications hopefully we can prevent this from occurring.

Type 2 diabetes #infographic #diabetes

There  is a strong link of heart disease  in people who  have high cholesterol and are diabetic.  Cardiovascular disease  is much more prevalent if their  Hemoglobin A1c is chronically elevated. This significant contribution by elevated HbA1c to increased CVD is independent of statin therapy (cholesterol lowering medications), and thus requires appropriate HbA1c management in addition to lipids reduction. It is vitally important that any individual with known heart disease and diabetes gets their hemoglobin A1c measured approximately 4 times per year by their primary health care provider. Once a year is not enough. Tight control is imperative. If the blood sugars are constantly running high the vessels that deliver blood to the heart are constantly inflamed setting the stage for further heart issues.

There are many hemoglobin A1c calculators can be found on the internet. Here is Medscapes version

http://reference.medscape.com/calculator/hemoglobin-a1c-est-plasma-glucose

Health Devices

Today’s technology allows heart patients to monitor their own health changes and be proactive in caring for themselves. I believe we are on a medical breakthrough using the internet and new technologies. In the past one would have to go to their doctor and report transient changes in blood pressure, heart arrhythmia – (palpitations) out of range blood sugars, etc.  The modern healthcare approach is to then order several very expensive tests in hopes of capturing the data and then making changes to the patients care plan once there is evidence of the changes. Today’s rapidly emerging technologies now allow patients to capture this information with home devices which cost much less than the tests ordered by our modern healthcare system.

Let’s look at heart rhythm monitors as an example. Atrial fibrillation is a very common heart rhythm problem, and for many patients they will go in and out of this rhythm. They may feel the heart racing, skipping beats, or feel shortness of breath and fatigue when the rhythm is abnormal. If A fib is dangerous immediate care can be initiated and then  managed with blood thinners to decreased risk of stroke. Therefore it is worth monitoring and catching it earlier vs. later.   There are now  monitors one can purchase for about $200 that would capture the rhythm put it to memory, then you can send to your physician electronically. Other heart arrhythmia that can be detected and managed this way  include heart blocks, abnormally slow heart rhythms, tachycardia –  fast heart rhythms.  The modern course is to order a holter monitor or an event monitor. The holter monitor is worn for 24 hours or more, then it takes up to two weeks for it to be interpreted  dictated and the reports received and acted on by the ordering physicians. Event monitors are placed below the skin and worn for 30 days or more. Consider given the progressive nature of heart problems, that these tests are not  usually run only one time on an individual over the course of their life.

HOLTER MONITOR SCANNING $312.00
HOLTER MONITOR RECORDING $345.00

Handheld home devices purchased for about $200 can be used by the patient with  little education,and a plan of care is devised  between the patient and the physician..  This could potentially allow you to  manage their issues more in a much more convenient and timely manner. The device is owned by you and thus can be used over many years. Below is the typical physician algorithm for managing arrhythmia’s.

 

Figure.

 

With today’s hand held monitors available at a cost of approximately two hundred dollars, patients can capture the irregular rhythm when it occurs, save the data, report it to physicians and have their care evaluated much quicker – provided they can get an appointment with their healthcare practitioner. Wouldn’t it be even better to be able to transmit the information to the physicians email, and then be triaged based on the data?

The problem is $$$$$$$, and the medical system in the US is slow to adopt change. If it cuts in to the profit of healthcare it isn’t likely to be adopted.  This a role where I believe mid level practitioners like PA’s, CNA’s can play a role in triaging care, as the current work demand doesn’t allow most physician the time to undertake electronic care of patients. It may take patients to make the change, those who are under insured, uninsured, or have significant financial obstacles which impede access to traditional care.

On a side note I really enjoyed Eric Topol’s book The Creative Destruction of Medicine. It makes one think about how medicine can change practice models.

With personal technology, doctors can see a full, continuously updated picture of each patient and treat each individually. Powerful new tools can sequence one’s genome to predict the effects of any drugs, and improved imaging and printing technology are beginning to enable us to print organs on demand. Topol offers a glimpse of the medicine of the future—one he is deeply involved in shaping.

Below are a couple of examples of how patients can control and manage their health data:

http://www.misfitwearables.com/health_device_at_a_glance

health_device_at_a_glance.jpg

http://online.wsj.com/article/SB10001424052702303404704577311421888663472.html

TOPOLcollage

http://www.favoriteplus.com/easy-ecg-handheld-monitor-fp180.php