Posts tagged #shared decision-making

Go ahead, hit "record" in the doctor's office

The elderly woman’s right knee was bright red and twice its normal size. Her doctor explained that her prosthetic knee joint was infected and would have to be removed — antibiotics alone couldn’t cure her.

Her doctor (T.L.) began discussing treatment options, but the patient stopped him. “Do you mind if I record you?” she said, picking up her cellphone.

Surprised, the doctor leaned back in his chair.

This simple request can elicit starkly different reactions from patients and clinicians.

To learn more, check out my new article (with co-author Glyn Elwyn) at STAT.

Posted on July 12, 2017 .

Wait for it

At 94, my patient V. was funny and flirtatious.  Her French accent made even the name of her life-threatening fungal infection sound poetic.

“DEE-seminated HEESTO-plasmo-sees,” she said, “Oaf the skin.”

I smiled.

I also admitted her to the hospital because our treatments were not working.  

What I did next, though, surprised both of us. To read more, check out my new article at the great blog Reflective MedEd.

Posted on September 18, 2016 .

Opioid contracts can backfire on patients

The US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients. My patient, Cindy was a perfect example.

To hear what happened, read my new article at The Boston Globe's new publication STAT.

Posted on July 26, 2016 .

Why it's getting harder to know if someone is dying

We tried our best, but CPR, an injection of epinephrine, and 360 joules of electricity all failed to restart Mrs. Melnyk’s heart. When everybody on the resuscitation team agreed that we could do no more, I said the words: 

“Time of death, 9:32.”

As we cleaned up, a young nurse began to tuck a clean white sheet around Mrs. Melnyk’s body—and then suddenly stopped. 

“Wait!” she shouted, pointing at the heart monitor. There on the screen, an electrical impulse registered and quickly disappeared, replaced by a flat green line. “It’s too soon to give up!” the nurse said. 

It turned out the young nurse had been fooled by a stray electrical discharge on an EKG machine. Together with her supervisor, we talked it through, and did not prolong the code blue.

That kind of confusion is getting more difficult to clear up, though. With newer technologies like PET scans and ECMO, the dividing line between life and death is getting harder to define. 

To read more, check out my new post in The Atlantic. 

Are families of people in the ICU silenced by the law?

Doctors rushed an ill-fated motorcyclist with severe injuries to the head and chest to the ICU.   

ICU.jpg

In the difficult weeks that followed, the prognosis was progressively more and more grim. Family members were sure the patient "would not want to live like that" on a mechanical ventilator. 

But the law prevented them from speaking on his behalf.  

Read my full article at Scientific American blogs.

I was also interviewed on NHPR about this story as part of a three piece series on end-of-life decision-making. 

Posted on August 2, 2013 .

Earlier Is Better

For years now there has been controversy about whether early HIV infection should be treated. Could the immune system be spared the ravages of the HIV virus through early therapy? Or does early therapy just make treatment last longer? The jury has been out, and might still be deliberating, but a new piece of evidence has emerged. 

HIV.jpg

 Deeks et al have shown that, compared to people treated later in HIV disease, those treated within 6 months of initial infection show less immune system damage over time. This might be a sign that early treatment is good.  

We still lack clear evidence that such benefits of early treatment outweigh the downsides of HIV treatment. The side effects, costs and other risks are real. So, we still await a clear sign. 

When face-to-face with a patient with early HIV infection, I tell them what we know, and what we don't, and we share the decision-making. Does the possibility of ongoing immune damage scare them enough to make taking an HIV pill or two daily worth it? Or  does the prospect of starting decades of therapy freak them out more? We talk through it, and most (but not all) start therapy. 

Someday, let's hope we know more.

 

Posted on July 28, 2013 .