Introduction to Bad Medicine Podcast
- Hosts: Anu Sim (Board Certified Functional Health Coach) and Dr. Nicholas Canelo (Board Certified Family Medicine Physician).
- Mission: Empower listeners on their journey to optimal health by demystifying healthcare and guiding through wellness information.
- Focus: Importance of lifestyle factors, evidence-based medicine, and moving beyond symptomatic treatment for true healing.
- Disclaimer: The podcast is for informational purposes only and should not be considered professional medical advice.
"Welcome to Bad Medicine, healing medicine one episode at a time. I'm Anu Sim, a board-certified Functional Health Coach, and I'm Dr. Nicholas Canelo, a board-certified Family Medicine physician. We believe in the importance of lifestyle factors, evidence-based medicine, and moving beyond symptomatic treatment for true healing."
- Introduction to the episode's focus on advanced directives and Do Not Resuscitate (DNR) orders.
Communication in Emergency Situations
- Notification through the electronic medical record (EMR) when a patient is in the ER.
- Dr. Canelo reads along with the patient's care progress and intervenes if necessary.
- Seamless communication if using the same EMR system; otherwise, involves phone tag.
"It's come up maybe a handful of times last year or two where I get notification through the electronic medical record and I read along usually as their care progresses and usually they don't hear anything from me because the care is good and adequate."
- Importance of communicating specific patient wishes in emergency situations.
"I had a patient where it wasn't clear to me that the advanced directive DNR was that they had access to it if they had the ER that the hospital patient was already admitted and this patient had very specific wishes."
Understanding DNR and Advanced Directives
- DNR (Do Not Resuscitate) is a patient’s decision but requires a physician’s sign-off.
- Discussion between doctor and patient to ensure understanding before signing.
- POLST (Physician Orders for Life-Sustaining Treatment) form used for DNR, includes questions about the aggressiveness of care and tube feeding preferences.
"A patient cannot make themselves DNR. I have to sign off on it and I think most doctors are like this we're not just going to sign off on it if you prefill it. We need to have a conversation, make sure you really understand what you're signing up for."
- Different levels of DNR: comfort care, selective care, or full care.
- Explanation of the POLST form and its components.
"The DNR form that we use is called a POLST form P-O-L-S-T. It's not just DNR; it has a question about the aggressiveness of your care once you're DNR."
Nuances of DNR Orders
- DNR does not equate to no care; it can include full care without resuscitation.
- Comfort care DNR means no hospital visits unless for comfort.
- Specific wishes regarding tube feeding can be included in the DNR.
"You could be DNR and have full care. You would have an intubation in the ICU. That's still a DNR because you have not died and been brought back to life."
- Importance of discussing and challenging patient understanding to ensure informed decisions.
"I usually say like what I play a little Devil's Advocate whatever they say so I can challenge their understanding of make sure they get what they're signing up for."
Age and DNR Decisions
- DNR decisions can vary significantly depending on the patient's age and health status.
- Physicians provide recommendations but ultimately respect patient autonomy.
"This totally depends on the age of the patient too, right? Let's say you have a patient in the 90s, I mean this takes on a different Avatar completely."
- Physicians may recommend DNR for older, sicker patients, but the choice remains with the patient.
"I pretty much always try to give my recommendation but acknowledge that it's their choice."
Case Example
- Example of a patient with specific wishes regarding withdrawal of care after seven days of tube feeding.
- Importance of having detailed and specific advanced directives to ensure patient wishes are respected.
"I had a patient where it wasn't clear to me that the advanced directive DNR was that they had access to it if they had the ER that the hospital patient was already admitted and this patient had very specific wishes."
- Highlighting the importance of communication and documentation in respecting patient autonomy in critical care situations.
"We were like, we're going to fax it over right away but I wanted you to know now here's what it said. It was very specific about withdrawing care after seven days of tube feeding."
These notes provide a comprehensive overview of the key ideas and topics discussed in the transcript, formatted to serve as detailed study notes.
Advanced Care Planning
- Advanced care planning involves preparing for future medical decisions and is essential for individuals starting at age 65 or younger if they have significant health issues.
- It includes discussing and documenting preferences for medical treatment in case the individual is unable to make decisions for themselves.
- The process is normalized and reviewed annually, similar to how medications are reviewed.
"The category is called Advanced Care Planning. So starting age 65, I address it once a year just like I review the meds once a year."
- Advanced care planning consists of two main components: the advanced directive and the DNR (Do Not Resuscitate) order.
Advanced Directive
- An advanced directive is a legal document that designates who would make medical decisions for an individual if they are unable to do so themselves.
- It is also known as a power of attorney for healthcare or durable power of attorney for healthcare.
- The document should include contact information for the designated person and a backup person to ensure that someone can be reached in case of an emergency.
"Advanced Care Planning is two things. There's a lot of misconceptions about it. One is an advanced directive...that designates who would make medical decisions for you if you were unable to make them for yourself."
- The advanced directive is critical in situations where the patient is unable to communicate their wishes, ensuring that their preferences are respected.
"A good Advanced Directive has the phone number or phone numbers for the person, has a backup person and their phone numbers."
DNR (Do Not Resuscitate) Order
- A DNR order specifies that no attempts should be made to resuscitate the individual if they stop breathing or their heart stops beating.
- It is particularly relevant at the moment of death, whether in the street, emergency room, or hospital.
- The DNR order is not about ongoing treatment decisions but rather the immediate response to a cardiac or respiratory arrest.
"The main time a DNR matters is right when you die...you don't know the diagnosis, you don't know the prognosis...you just know patient bed five just coded and died."
- The DNR order needs to be prominently displayed, such as on the fridge, where paramedics and firefighters are trained to look for it.
"You must put this DNR form pulse form p o LST pink on the fridge because that's where the paramedics firefighters are trained to look for it."
Interaction Between Advanced Directive and DNR
- The advanced directive can override a DNR order if the designated decision-maker is present and requests resuscitation.
- The DNR order is useful when no one is present to make decisions or if there is uncertainty among the decision-makers.
"The advanced directive always trumps the DNR always. So the patient has DNR, but the advanced directive person is in the room and says I want a resuscitation, that person wins."
- The advanced directive provides clarity and relieves the burden from family members or designated decision-makers during critical moments.
"A lot of this is taking the burden off of the person."
Legal Requirements for Advanced Directive
- The advanced directive requires two witnesses or a notary to sign and date the document.
- Witnesses cannot be the person designated to make medical decisions.
- The document must be properly signed and dated to be valid.
"You do two witnesses, or a notary...The witnesses have to watch you sign and date it."
- Ensuring the document is correctly completed is crucial as it can be a matter of life and death.
"This is life and death. I don't want to mess it up, so I say nope, fix it right. We got to fix this lack of a date."
Surrogate Medical Decision Maker
- A surrogate medical decision maker can be chosen without their permission or signature.
- The chosen surrogate does not need to be informed immediately.
- It is illegal for a healthcare provider to be designated as a surrogate decision maker.
"You don't need the permission or signature of the person you're picking to be your surrogate medical decision maker."
- You can choose a surrogate without their consent.
"I had a patient who said, 'Dr. Canal, I trust you over her closest family member, so I put you.' I eventually realized like, oh wait, that's illegal."
- Healthcare providers cannot legally be surrogate decision makers.
"What you could always do is designate person X and just instruct person X to ask Dr. Canal, but the final decision maker, the spokesperson, Final Call is made by someone who is not your healthcare team."
- The final decision must be made by someone outside the healthcare team, although they can consult the healthcare provider.
Importance of Discussing Advanced Directives with Older Patients
- Discussing advanced directives with patients aged 65 and older is crucial.
- Advanced directives should be included in the patient’s medical records.
- Some patients may choose DNR (Do Not Resuscitate) even if they are in good health, often influenced by past experiences with family members.
"When a patient comes to the doctor, there's so many things. How do you even put this as an important topic to talk about?"
- It's challenging to prioritize discussing advanced directives during medical appointments due to time constraints and other pressing issues.
"My practice is everyone 65, and the reason I do that, well, I started doing that maybe ignorantly. I just said, oh 65, let's do it."
- The speaker routinely discusses advanced directives with patients aged 65 and older, initially started without specific guidelines.
"I've had a few patients who want DNR at that age. They're healthy, they're well, they would otherwise be reasonable candidates for a resuscitation attempt."
- Some healthy older patients choose DNR due to personal experiences and the perceived burden on their families.
Legal and Practical Aspects of Advanced Directives
- Advanced directives must be accessible to the hospital team to be effective.
- Many advanced directives from lawyers may not be legally binding or properly understood.
- There is a need for better education for lawyers regarding medical directives.
"People will have them, and I say, well, your lawyer never got it to us, so you might as well not have it because it's not in your chart."
- Advanced directives need to be in the patient's medical chart to be useful during emergencies.
"I've only once seen a DNR from a lawyer, and I'm not sure that would hold up."
- Legal DNR forms are rare, and their validity may be questionable.
"She was working on educating lawyers about these because there's a lot of not understanding these concepts."
- Efforts are being made to educate lawyers about the nuances of advanced directives and DNR orders.
Importance of Discussing DNR (Do Not Resuscitate) Orders
- Discussing DNR orders is crucial in medical practice to ensure that patients' end-of-life wishes are respected and followed.
- Clear documentation of DNR orders can ease the burden on families during critical moments.
- Having conversations about DNRs and end-of-life care, although difficult, is considered good medical practice.
"I've only maybe had a few patients where they're in the hospital and they die in the hospital and the DNR is so clear it's on file it's in the chart and they allow a death and it's a very straightforward and simple."
- Clear DNR documentation ensures that medical staff can follow the patient's wishes without confusion.
"I was thanked for that like thank you so much for having that conversation because in the moment do you want to resuscitate she just died you know I mean can you imagine and they said they felt the burden taken off because I had this conversation."
- Families appreciate when these conversations have taken place beforehand, as it removes the burden of making difficult decisions during emotional times.
Cultural Attitudes Toward Death
- Different cultures have varying approaches to discussing and preparing for death.
- In some cultures, death is openly discussed and prepared for from a young age, whereas in others, it is often avoided.
"There are certain cultures who prepare for death from the day they were born it's completely different here it's like we avoid it we're almost like oh we're going to be here forever."
- Cultural differences in attitudes toward death can impact how patients and families approach end-of-life decisions.
Challenges in Medical Practice: Time-Crunched and Convenience Medicine
- Modern medical practice often involves time constraints and a focus on convenience, which can lead to suboptimal patient care.
- Following guidelines and conducting thorough workups is easier than having in-depth conversations about the patient's wishes and quality of life.
"In medicine, I guess if I have to point out the bad medicine it's a lot of bad medicine is really just time crunched medicine or convenience medicine."
- The pressure to follow guidelines and complete workups can sometimes overshadow the importance of understanding the patient's preferences and quality of life.
Quality Measures and Exceptions in Healthcare
- Quality measures are designed to encourage good care but can sometimes disincentivize personalized patient care.
- Doctors may face additional administrative burdens when applying for exceptions to these measures, leading to a preference for standardized procedures.
"First there's things called quality measures which is a great topic where they're trying to encourage good care and then there's exceptions that you can make so that you don't get dinged."
- Quality measures aim to standardize care but can create challenges for doctors who want to tailor care to individual patient needs.
"That is an extra step for the doctor got to make sure that right codes on there I don't make sure I applied for that exception correctly so they're disincentivizing this and again comes down to what's easier what's more convenient."
- The administrative burden of applying for exceptions can lead doctors to choose the path of least resistance, even if it is not in the patient's best interest.
Practical Advice for Patients Regarding DNR and Advanced Directives
- Patients should ensure their DNR orders and advanced directives are properly documented and accessible to their healthcare providers.
- Misconceptions about DNR and advanced directives can lead to situations where patients' wishes are not followed.
"If you think your DNR and you don't have a pink form on your fridge you're probably not DNR talk to your doctor that's the number one misconception."
- Patients should actively communicate with their doctors to ensure their end-of-life wishes are clearly documented and accessible.
"If you have an advanced directive with your lawyer and you think your lawyer got that to me they did not that's actually never happened you need to bring it and have it scanned into the chart properly labeled."
- Advanced directives need to be personally delivered and properly filed with healthcare providers to ensure they are followed.
Conclusion and Call to Action
- The podcast emphasizes the importance of patients taking an active role in their health journey, including end-of-life planning.
- Integrating medical insights with lifestyle changes can significantly impact one's health.
"We hope that today's conversation empowers you to take a more important role in your health Journey remember your path to Optimal Health is unique and integrating medical insights with lifestyle changes can make all the difference."
- Encourages listeners to subscribe and engage with the podcast for more insights and discussions on health-related topics.
"Don't forget to subscribe to Bad Medicine on your favorite platforms so you never miss an episode and we love hearing from you if you have questions topics you'd like for us to explore or stories to share please reach out to us on Instagram."
- Engaging with the podcast community can provide additional support and information for listeners on their health journey.