Sadly, but with conviction, I recently removed breathing tubes from three patients in intensive care.
As an I.C.U. doctor, I am trained to save lives. Yet the reality is that some of my patients are beyond saving. And while I can use the tricks of my trade to keep their bodies going, many will never return to a quality of life that they, or anyone else, would be willing to accept.
I was trained to use highly sophisticated tools to rescue those even beyond the brink of death. But I was never trained how to unhook these tools. I never learned how to help my patients die. I committed the protocols of lifesaving to memory and get recertified every two years to handle a Code Blue, which alerts us to the need for immediate resuscitation. Yet a Code Blue is rarely successful. Very few patients ever leave the hospital afterward. Those that do rarely wake up again.
It has become clear to me in my years on this job that we need a Code Death.
Until the early 20th century, death was as natural a part of life as birth. It was expected, accepted and filled with ritual. No surprises, no denial, no panic. When its time came, the steps unfolded in a familiar pattern, everyone playing his part. The patients were kept clean and as comfortable as possible until they drew their last breath.
But in this age of technological wizardry, doctors have been taught that they must do everything possible to stave off death. We refuse to wait passively for a last breath, and instead pump air into dying bodies in our own ritual of life-prolongation. Like a midwife slapping life into a newborn baby, doctors now try to punch death out of a dying patient. There is neither acknowledgement of nor preparation for this vital existential moment, which arrives, often unexpected, always unaccepted, in a flurry of panicked activity and distress.
We physicians need to relearn the ancient art of dying. When planned for, death can be a peaceful, even transcendent experience. Just as a midwife devises a birth plan with her patient, one that prepares for the best and accommodates the worst, so we doctors must learn at least something about midwifing death.
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http://well.blogs.nytimes.com/2014/04/10/a-better-way-to-help-dying-patients/?
Thursday, April 10, 2014
Wednesday, April 9, 2014
Many Drug Prescriptions Go Unfilled - NYTimes.com
A Canadian study has found that almost one-third of patients never fill the prescriptions for the medicines they are told to take.
The analysis, published online in The Annals of Internal Medicine, was conducted in Quebec, where all residents are covered by health and drug insurance. There were 15,961 patients in the study.
Over all, 31.3 percent of prescriptions were never filled. But some types were filled more often than others. Prescriptions for headaches and migraines were filled more than half the time, but only 20 percent for bronchitis, and 25 percent for skin irritations. The more often a patient saw the doctor, the more likely the prescriptions would be filled, but medicines with high co-pays were less likely to be bought.
People under age 52 were much less likely to fill their prescriptions than older people, and men slightly less likely than women.
The lead author, Robyn Tamblyn, a professor of medicine at McGill University in Montreal, said the results sent several messages. First, the cost of drugs affects their use. Second, when patients are followed more closely by their doctors, they are more likely to take their medicine. And finally, she said, "chronic illness is the primary driver of ill health, and people who fill their prescriptions have a better rate of controlling their disease."
Tuesday, April 8, 2014
A Google Glass App That Would Be Hard for Even the Haters to Hate | Re/code
Many people have already made up their minds that they're uncomfortable with people wearing Google Glass.
But here's a use that's hard to argue with: An emergency room doctor at Beth Israel Deaconess Medical Center, a Harvard teaching hospital in Boston, Mass., was tending to a patient suffering from massive brain bleeding. Because the doctor was wearing Google Glass, he was able to see that the patient had severe allergic reactions to blood pressure medications. Normally that might have required running to a computer or grabbing a tablet, accessing the patient records and then scrubbing up again.
"Google Glass enabled me to view this patient's allergy information and current medication regimen without having to excuse myself to log in to a computer, or even lose eye contact," said Dr. Steve Horng.
Because he was able to start treatment immediately with that knowledge, Horng believes that Google Glass helped save the patient from the chance of permanent disability or death.
Horng is part of a pilot program at Beth Israel involving about five doctors using Google Glass. This isn't the normal Glass you can buy if you're selected for Google's "Explorers" program and pay $1,500. It's a version of the same hardware that has been modified by a company called Wearable Intelligence.
Wearable Intelligence strips and replaces the Google Glass software with a reformatted version of Android, so it can be locked down for specific uses and specific contexts. Doctors don't have the option to tweet photos of patients, check their Facebook, or even take the device off the hospital Wi-Fi network. Google's on-board speech recognition technology is replaced with a more specialized medical dictionary from Nuance.
Wearable Intelligence was founded by repeat entrepreneurs and former Google employees, and seed-funded by venture capitalists in the Glass Collective as well as First Round Capital.
It's one of a group of companies participating in Google's new Glass at Work program to bring the wearable computer to the enterprise. Others include Augmedix and APX Labs, as the New York Times reported today, and in addition to hospitals, Google is working on modifying Glass for broadcasters, NBA athletes and police officers.
Wearable Intelligence's largest deployment is actually not in a hospital, but out on the oil fields of Schlumberger, the multinational energy company, where employees are using 30 of the units to help them follow the complex checklists that allow them to do their jobs safely.
"With this ambient information stream, we start to blur the line between knowledge in your head and the institutional knowledge of the entire organization," said Wearable Intelligence CEO Yan-David Erlich.
Erlich thinks that all different sorts of enterprises — energy, medical, manufacturing, construction — face similar challenges for which Glass can be helpful, like implementing workplace procedures, offering remote assistance, recording best practices and serving context-aware alerts. And he'd also like to expand beyond Glass to other wearables, like Thalmic Labs' Myo and the Meta augmented reality glasses.
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