DON'Ts for Long Term Care Patients: #ChoosingWisely Canada

I have been a serious fan and also a concerned critic of Choosing Wisely Canada (CWC) over the years. Overall the campaign is excellent, encouraging conversations between patients and providers to help prevent harmful and unnecessary tests, treatments, and procedures.

While I love the new emphasis on the high-level message "More is not always better," my feelings have always been lukewarm on the lists of Choosing Wisely Canada (CWC) recommendations, created by (mostly) physician associations not by Choosing Wisely Canada, as they vary in strength, currency, and courage. For example, the CAEP (Emergency physicians) list is quite clear, direct, and practice changing. The Orthopedics list is irrelevant, and not wisely chosen at all, lacking the moral fortitude to tackle common, high-paying procedures that have limited/no evidence to support them.

The most recent lists reinvigorate my interest! It is exciting to see a list from the Canadian Nurses Association (CNA), as nurses have an incredible role in advocating for patients and in helping patients make decisions. Hospital-based nurses usually know their patients well and might even have a better sense of their goals and needs than would a physician; a nurse's advice can easily sway a patient to see "too much" medicine, but it can equally reassure that patient that a test or other intervention may not be right for them.

  Image from unknown source on twitter; quote from an interview with the  Centre for Advancing Health

Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

Because most mornings I work in a program that is designed to help frail elders avoid unnecessary/ unwanted admissions to hospital, the Choosing Wisely list for Long Term Care (LTC) is extremely relevant to my practice. #1 (see below) resonates particularly with me, so I'm glad to see it is the first on the list. I see countless patients who could (and should) be looked after in their full-care facility but unfortunately they have turned up at the hospital. There are a number of reasons this happens, including the inability of the facility to contact the GP or the GP's inability to attend the patient in an urgent fashion, the family's 'insistence' that the patient be "checked out" at the hospital, a lack of clarity on the patient's goals, unclear understanding of the natural history of their disease, insufficient staffing at the care facility, etc. And sometimes these patients really do need to be at the hospital.

We clearly have a lot to learn both in how we communicate and in how we approach care for patients in long term care. This list is a great addition to the tool kit that might help us give LTC patients the right care for them:

  1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

  2. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. 

  3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

  4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 

  5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 

  6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
     

See the list here or download the PDF.

Source: http://choosingwiselycanada.org/recommenda...

If lobsters had doctors...

Comfort with uncertainty is an essential part of medicine, particularly in family practice and other generalist pursuits. There are many labels, lab tests, pills, and therapies, but not everything has an answer.

We must not only tolerate uncertainty, but embrace it.

Dr Rabbi Abraham Twerski, a man who marries psychiatry and spirituality, suggests that discomfort is essential for growth. This applies not just to physicians but to patients as well. Facing adversity can be the key to developing resilience. 

Source: https://www.youtube.com/watch?v=3aDXM5H-Fu...

VIDEO: It's just life (not a disease). Así es la vida [subtítulos inglés] - YouTube

 "Thisislifix 1 g There is no pill that can solve the reality of not being sick."

"Thisislifix 1 g
There is no pill that can solve the reality of not being sick."

The idea that any normal, bad thing that happens to our bodies is a disease state is called "medicalization." When we label normal aspects of life in this way, it seems to degrade coping mechanisms and increase dependency on the health care system.

Perhaps a bit silly, but certainly on-point, this video reminds people that some things are just a part of life. There is no pill to fix getting a cold, feeling sad after a breakup, or getting older; these are things we have to accept and work through.

Source: https://www.youtube.com/watch?v=mqxuxN5Fw3...

When the nurse told me "less is more"

I was called to the emergency room to admit a very ill patient. With sepsis and an MI, this frail elder probably wasn't going to do so well.

“He’s pretty sick, eh?”
“Yah. Poor guy.”

The nurse and I paused, resigned to the fact that this elderly man was nearing his end and there was little we could do to change that. I think we both sighed at the same time.

I entered the room and talked to the patient and the family at length. They showed me a photocopy of the DNR form he had signed years ago. He didn't have any kind of advance directive, and had rarely talked about the process of dying, aspects of medical treatment, or what his goals might be for the remainder of his life.

At home, he spent most of is time in bed. Mobility was a bit shaky with a walker so it was safer to stay put. Poor hearing, shoddy vision, and mild dementia made it nearly impossible for him to read or watch TV or to do much of anything, really. He still beamed during visits from the grandkids. His daughter told me that she thinks he had been depressed for a long time; every second day he would say that he was ready to die.

I stepped closer to him. The laboured breathing didn’t look any better close up. He did have the breath to tell me, “I’m dying.” When I discussed the various range of treatments from comfort care (treating pain and respiratory distress), to medical management (antibiotics, blood thinners), to aggressive medical therapy (maybe some non-invasive support for breathing), he said that he wanted to die.

Was he just feeling terrible because his heart had jammed from the strain of fighting off a systemic infection, something that would be exhausting and uncomfortable even on its own? Or was this an expression of considered hope for an end to his now languid existence?

It wasn’t easy to communicate clearly or in detail. I asked more questions, but he said little. Even with a raised voice, I don’t know if he could hear me. His family was uncertain about what he would want done. It was clear that anything aggressive was not right. With failed kidneys, I’d have to give an IV blood thinner (heparin infusion) with up to 4x a day lab tests to prevent worsening of the heart attack. His breathing might get worse and if so, could be helped by strapping a machine on his face to push and pull air in and out of his lungs. That seemed cruel.

But, should I still offer some minimally invasive things that might improve both quality and quantity of life? Antibiotics might help the breathing to get easier and give him a chance of surviving. But this might also just delay the inevitable, prolonging suffering.

I try not to be wishy-washy and give patients and families clear recommendations, but it is hard. When people’s values vary so widely, and there are several avenues that might be appropriate, I don’t feel I can make the decisions for them.

I try really hard not to push my belief in “less is more medicine” too far. I don't want patients to be denied opportunity for healing and improvement. Just as I feel very strongly about doing less of the unnecessary things and interventions that will give more harm than benefit, I also feel very strongly that patients should have timely and meaningful opportunity to have the tests and treatments that might really benefit them.

“What do you think he would want? Is that consistent with his wishes? . . . ”

After I finished talking to the patient's family, I confirmed the plan with the nurse. We would keep the antibiotics and a few heart medications, but for the most part emphasize comfort. I left orders for adequate medications for pain, respiratory distress, and restlessness, to be used regularly if needed. If he got worse, we would stop the antibiotics. I didn’t think they would really help him but his family wanted to try. Although they would not want to extend his distress, it was all pretty sudden and not treating potentially reversible things was different than ensuring he was comfortable while dying (when no reversible causes remained).

It felt like we had arrived at some understanding of the medical reality, the patient’s wishes, and the substitute decision makers’ needs. As I discussed this and explained to the nurse that it wasn't maximum medical therapy but that it seemed a reasonable approach. Nurses, especially those who've got experience under their belt, seem to have a kind of wisdom that comes from the direct care of patients like these.

She looked at me and said "well, you know, less is more."

My colleague, an ER-physician who was in the same residency program as me and knows my passion, was within earshot. She chuckled.

A big smile stretched across my face, and I started looking at my list to find the next patient.

Pre-Osteoarthritis: Do we really need another "Pre-" disease?

This Spring, Dr Annemarie Jutel (RN, BPhEd(hons), PhD) from the Victoria University of Wellington shared with m some of her work on Social Issues in Diagnosis.

Dr Jutel is a social theorist and clinician interested in finding an understanding of just how diagnosis works, whether from the historical, linguistic, social, literary, clinical, or other angle. 

She explained: 

I am most interested in the “diagnostic moment” and the power of the diagnostic utterance; there is nothing that fundamentally changes in your soma from the moment you walk in to the doctor’s rooms, and the moment you get your diagnosis, but at the same time, if the diagnosis is a difficult one, everything has changed. 

I started following her posts on the Facebook Group, Social Issues in Diagnosis, which explores why and how we create these labels and what impact they have on patients and the course of medicine.

The most recent post is about pre-diagnosis, stimulated by this 2015 paper in Cartilage. If we can detect osteoarthritis before it starts, maybe we can stem the epidemic. Or, maybe we can turn a bunch of healthy, naturally aging, well-people into frightened patients?

In response to the article, Jutel asks:

What is a prediagnosis and what are its consequences? 

If pre-diagnosis states are, potentially, windows of opportunity, wherein individuals can adopt healthy, disease-avoidance behaviours, is there an advantage to calling these states "pre-whatever" as opposed to identifying them as healthy states, wherein health can be further improved?

What are the consequences of being given a pre-diagnosis? For some it may be a scary moment which marks their identity forever more. For others, it may be a wake-up call.

What would it be for you?

Take a look on the FB Group to participate or to learn more, see her book, Social Issues in Diagnosis.

Source: http://www.ncbi.nlm.nih.gov/m/pubmed/26175...

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

MOVIE: Knock (1951): Foreshadowing Medicalization

A first for Less is More!

No, we are not making a movie. It's the first "pop culture" feature of the problem of medicalization, where healthy people get labeled as sick.

Those of you who know I speak a bit of rusty, fragmented french will be aware of the page of French-language resources [français] on this site. I would love for the entire site to be better organized and to have the whole thing translated. But with a budget consisting of the coins I find in my couch, that is unlikely to happen soon.

In the meantime, I am proud to tell you about this french film.

"Dr Knock," is a french comedy film from 1951 in which a physician who, in need of work, convinces an entire healthy village that they are all ill so that he can treat them. Originally a play in 1923 by Jules Romains, called Knock ou le Triomphe de la médecine (The triumph of medicine), this film had some kind of foreshadowing!

Theatre 625 (BBC) did an English adaptation in 1966 but I have not been able to find a video of it.

 The full film is available (legally, I believe) on YouTube. French speakers, enjoy!

Source: https://www.youtube.com/watch?v=OVBnhTEoiv...

Quaternary Prevention, P4

We still lack a unifying name, but initiatives like "Right Care," "Choosing Wisely," "Preventing Overdiagnosis," "Prudent Healthcare," and others all seek to describe, categorize, confront, or improve upon the status quo of what's being done: too much medical stuff and too little caring for people.

   
  
 
  
    
  
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    Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

 

Quaternary Prevention

You may have read lately about Quaternary Prevention (Prévention quaternaire) or P4, a major initiative of this movement. This – in the words of Ray Moynihan – "awkwardly titled" idea came originally from Dr Marc Jamoulle (@jamoulle), a Belgian GP, almost 30 years ago.

He coined the term "Quaternary Prevention" to describe 'an action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are ethically acceptable.' Essentially, it is a process that explicitly considers and thus enables avoidance of iatrogenic harm. 

"Quaternary prevention should take precedence over any alternative preventive, diagnostic and therapeutic, as dictated by the principle of primum non nocere." (Wikipedia)

P4

*NB*: Be careful not to confuse Jamoulle's term P4 with the more popular P4; predictive, preventive, personalized, and participatory (P4) medicine, with a focus on detecting and dealing with disease before it even exists, may (arguably) be the antithesis to Quaternary Prevention.

Jamoulle's idea came first, anyway. His original 1986 article Information and computerization in general practice (en français) started the discussion around quaternary prevention, with a particular focus on how information technology can dehumanize healthcare. He has refined the idea, with presentations at WONCA world conferences and many publications (listed here).

View Dr Jamoulle's page on Quaternary Prevention "P4" or read more

Although the cumbersome title will probably dissuade related initiatives from taking the name and falling under the umbrella of 'quaternary prevention,' we are all united in the spirit of our efforts. I remain in awe that Jamoulle and others had the wisdom to begin the discussion of harms of overdiagnosis in a time while mammography was just gaining momentum, ADD was rarely diagnosed and yet to be redefined as ADHD, and I was still in diapers.

Doctors warned not to encourage young women to freeze their eggs

Aging is a normal part of human existence.

Screen Shot 2015-04-19 at 11.04.38 AM.png

As we age, parts of our body change the way in which they work - or stop functioning all together. For women, natural aging means a slow down and then a stoppage in our ability to be fertile.

With women increasingly devoting the early part of their lives to establishing a career, many are delaying pregnancy. Some are freezing their eggs for later use. Physicians, employers, and society as a whole are starting to encourage this practice.

This is troubling in a few ways. Drs Petropanagos and colleagues write (in the CMAJ) that it raises some significant social implications, reinforcing that "motherhood is a central aspect of womanhood." 

Egg freezing as a way of preserving women’s reproductive options reinforces the social norms and expectations that construe motherhood as a central aspect of womanhood. Women are encouraged to freeze their eggs as a way to “have it all” (that is, to have both a family and a career), implying that for those women who want both these things, egg freezing makes this possible. Although individual women may benefit from egg freezing to satisfy their reproductive desires, physicians should not assume that having a genetically related child is equally important to all women who ask about social egg freezing.

Our bodies do things for a reason. Delaying pregnancy and then using frozen eggs exposes women (and their new children) to greater and greater risks, due to complications of pregnancy and childbirth. 

Fighting the natural changes makes aging a 'medical problem' rather than a part of our existence that we can embrace and accept. I agree with the authors' suggestion that there are better solutions, like funded child-care, that could enable women to really have a choice when it comes to balancing motherhood and a career.

Read the National post article here, or the original CMAJ article here.

Source: http://news.nationalpost.com/health/doctor...

VIDEO: How To Become Gluten Intolerant: The lighter side of medicalization

You are going to have to watch this genius video to understand. When the human condition becomes a medical condition, it can be very very funny.

JP Sears (@AwakenWithJP) explains that "being gluten intolerant is a fantastic opportunity for you to assert your dominance in the life everyone around you, which helps improve your life."

His video contains amazing tips on how to achieve the gluten intolerant lifestyle, among them:

Give expert medical advice. Once you take your gluten free vows, you'll need to have an automatic understanding that every medical condition in caused by gluten. Depression: it's always caused by gluten. Obesity: that's 100% gluten. Every single case of cancer is caused by gluten. I swear, gluten's what killed Gandhi. . . 

Seclusion makes gluten healthier. Understand that when no one's around, you somehow become less gluten intolerant. How does this happen? Well, based on medical evidence that's yet to be discovered, there's a direct correlation between how many people are around and how gluten intolerant you are."

See for yourself, and become enlightened in the ways of the gluten free: 

Being gluten free used to be a luxury only reserved for those who are intolerant to gluten. With this cutting edge gluten educational video, you can become gluten intolerant too, whether or not you're actually intolerant to gluten.

Source: http://devour.com/video/how-to-become-glut...