living your best to the end
Dr. Michael Fratkin is an enabler

Dr. Michael Fratkin is an enabler

“Most of my healing has little to do with medicine.” “My approach has more to do with being there, listening and helping people with a different approach.” Fratkin, entrepreneur creator of Resolution Care,  is a Palliative doctor whose conversations enable people to see things differently The 37-year old alcoholic He gives me an example: “A 37 year old guy who’d almost drunk himself to death – and not for the first time. I knew this patient because he came to us for Rehab. After 10 months of sobriety, he fell of the wagon: Shit happens.” A week ago, this 37 year old had a 75% chance of dying. Two weeks ago, his doctor wanted to change hospitals: “That’s what the family wants.” I was told. Fratkin thought it was crazy, and not medically indicated. “But I didn’t know enough about the situation, so I checked in on him. He was doing better, but was still high risk. I spoke to his mom via video. His mom loves him, and understands him as an alcoholic. Almost killed his liver with hepatitis, but she loves him.  So I asked: What do I need to know – as a parent – to better understand what’s going on, what you’re feeling. And I determined what the family really wants is for him have to have another chance, they want to know how they can help him to survive. Nobody explored that until I spoke to her. 45 min later, he and his mother were able to see things differently. There was healing in the space: if he dies today, there is healing in...

Extreme Measures: Dr Jessica Zitter on a Palliative mission

“I’m going to call 911: a doctor is torturing a patient.” So said Nurse Pat Murphy to Dr Jessica Zitter  – just as Zitter was about to plunge a syringe into the neck of a patient with a host of health issues. Tho the 911 call wasn’t made, it was a turning point for Zitter – who trained as a critical care doctor, and for whom going gently into that good night felt like she was abandoning a patient, a failure. That encounter with Nurse Murphy led her to completely change her own medical ‘mandate’ – becoming a Palliative doctor – the specialty that embodies the philosophy of ‘patient-centered’ medicine. I first ‘met’ Dr Zitter in a New York Times essay in which she admits on her first night on call as a Palliative doctor she hadn’t yet completely relinquished her ‘critical care save the life at all costs’ ‘tude. A healthcare team in conflict The patient ­– a Holocaust survivor ­– was sleeping peacefully. She’d been admitted with pneumonia, but it hadn’t responded to treatment. As she got sicker and her breathing harder, she was made comfortable. The doctor attending the patient told the team gathered that she had clearly said she didn’t want a breathing tube, but the respiratory therapist wasn’t comfortable not intubating: “I’m not really sure she ‘got it’ she was pretty out of it.” Zitter was also unsure. The compromise was to strap on an oxygen mask overnight and re-assess in the morning. The morning found the patient ‘delirious and terrified, her mask off center and totally ineffective.” Confirmation of commitment to Palliative Care...

Dying in the operating room? Rarely happens.

Dying after the operating room is a different story. “People worry about ‘dying poorly’, so one of the reasons for agreeing to surgery is the mistaken belief they’ll likely die – peacefully – in the Operating Room. This rarely happens.” Dr Gretchen Schwarze To understand what can happen even if the surgery or operation is successful, Palliative doctor, Toby Campbell and Surgeon, Gretchen Schwarze feel stories are necessary to paint a picture for ‘consent’.               To illustrate, Dr Schwarze tells this story: “She’s in her late 70’s, with chronic kidney failure and COPD. She’s making it a home with lots of support – but just barely. Now she has an aneurysm, that’s likely going to lead to a medical crisis. Should she have surgery for the aneurysm to prevent the medical crisis?” Using statistics to describe success or failure, her family’s told: 50% chance of not surviving surgery 60% going to need dialysis for renal failure 80% chance going to need ventilator (breathing machine) What the family hears is: 50% chance of survival 40% chance of NOT needing dialysis 20% chance of NOT needing “So, they went for the surgery, took about 8 hours, overall doing well, as best as could be hoped for. When her family came to see her in the ICU, you can imagine what they saw. She was puffy with a breathing tube, with lines and wires and machines. They said, ‘this is not what she would have wanted’ and asked the team to withdraw all supports.” We’ve been so good with innovating in so many areas, communication is...

Death and doctors who don’t want to talk about it

What happens when patients want to talk about death, but their doctors don’t? My 94 year-old father-in-law was relieved and delighted when I brought forth the subject of medical directions, in the event he couldn’t speak for himself. My brother in law – a paramedic – brought a standard Do Not Resuscitate (DNR) form. Although written in largely incomprehensible language for a mere non health care professional, I took it upon myself to discuss more than just the decision to resuscitate – shocking his heart back to life. He was right on board with ‘no heroic measures’ – and even more adamant when he understood what ‘heroic’ and ‘measures’ meant in the context of his quality of life.This form required signature from a doctor, so he brought it to his next regular visit to his long-time family doctor. His doctor was aghast. “Who put you up to this? I’m not going to sign this. I don’t think this is what you’d want.” What?! Not an isolated incident, as I’ve discovered. I’ve been conducting informal interviews with healthcare professionals of all stripes about their reaction to not initiating or discontinuing life-prolonging interventions. This includes supplemental feeding (Feeding Tubes) breathing (ventilators and tracheostomies) and dialysis. It’s as if you’ve asked them to condone murder. It’s as if you’ve asked them what they’d want for themselves.. Often these are the same healthcare professionals who purport to want to follow patients wishes, but who try to talk their patients out of their wishes. “If I do that, you know what it will lead to.” Well, yes. It’ll lead to the death, but possibly...

A new medical decision PATH for the frail elderly

Palliative and Therapeutic Harmonization: PATH In plain language PATH means an assessment and treatment recommendation that takes into account what’s going on with us as a whole person, rather than our specific parts.  A worthy goal for all of us, but with particular importance for those both elderly and frail, and who may have a dollop or more of confusion. Dr Laurie Mallery Dr Paige Moorhouse Dr. Laurie Mallery, head of the Division of Geriatric Medicine at Dalhousie University and Director of the Centre for Health Care of the Elderly at the QEII Health Sciences Centre in Halifax, Nova Scotia. and DrPaige Moorhouse with her Masters in Public Health, also practicing at the QEII, are like-minded in their concerns for care of the frail elderly. Together,  these two good doctors took the initiative to research and develop a  framework for medical decisions related to the frail elderly. The result is PATH: Palliative and Therapeutic Harmonization. Says Mallery: “We spent many years, looking at all factors related to the frail elderly.  Drs Mallery and Moorhouse  practice and teach at the PATH CLINIC . The approach has three parts: 1. Understanding “The frail elderly are often in and out and in and out of healthcare with many crises, assessed by many people – each of whom brings their own lens. There’s no  organizational plan to take this info and use it collectively and understand the significance, for example: is this person near end of life, and should we take that into account in discussing a medical procedure. Sometimes the patient seems frail but they really have a hearing impairment. 2. Clarity of Language “For those...

Multiple Medications: too many for too many of us

By age 65, two thirds of us are taking 5 or more prescription medications a day so reports the Canadian Institute for Health Information (CIHI). Not included in that total is the number of times a day meds are taken. And it doesn’t include whatever non-prescription therapies we take. That’s a lot of swallowing, a lot to remember, and that’s certainly a lot of chemistry and chemicals acting and interacting in our bodies. Many drugs cause side effects, that require additional drugs to manage them. And too many of certain drugs together can mimic symptoms of alcoholism, substance abuse and Dementia. The Centre for Addiction and Mental Health (CAMH) , Choose to Change: A Client-Centered Approach to Alcohol and Medication Use by Older Adults  details those outward appearances that can be the result of medications: Confusion, disorientation, recent memory loss,slowed thought process,loss of muscle coordination, tremors, gastritis, depression, irregular heartbeat, high blood pressure, malnutrition, dehydration. In my conversation with  Dr. Paula Rochon, VP Research at Women’s College Hospital in Toronto, whose passion is medications as relates to the elderly, her strong recommendation: “Get medications reviewed regularly by a pharmacist. Ask questions that will help fit these meds into your lifestyle. If a pill is so large it’s hard to swallow, ask about tips to make it swallowing easier. Get specific about how to take it: if you’re not a big breakfast eater, and the meds indicate ‘take with food’ – determine what’s considered ‘food’.” For my thoughts on medication confusion, check out 10-second...