MARCH 2013 JMSMA by Journal MSMA

March

VOL. LIV

2013

No. 3

Insurance issues pushing your medical practice

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MISSISSIPPI STATE MEDICAL ASSOCIATION

The physicians who care for Mississippi.

Hattiesburg: Friday, April 26 Oxford: Friday, May 3 Metro Jackson: Friday, May 10 Register now! Visit MSMAonline.com or scan the code below.

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

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Official Publication of the MSMA Since 1959

MARCH 2013

VOLUME 54

NUMBER 3

Scientific Articles

Clinical Problem-Solving: Snake, Rattle, and Roll

Jeremy B. Wigginton, MD

Concepts in End-of-Life Care: Palliative Care Medicine

Vicky D. Pilkington, MD; W. Mark Meeks, MD; Sharon P. Douglas, MD; B. Gwen Windham, MD, MHS

Editorial How Doctors Die

Ken Murray, MD

In Support of POLST: Better End-of-Life Care for Mississippi

Andre Barthelemy, M4

Related Organizations Mississippi State Department of Health

President’s Page A Balanced Life

Steven L. Demetropoulos, MD, MSMA President

Departments

From the Editor: Remember, You too are Mortal Poetry in Medicine Asclepiad: Thomas Steven Parvin, MD

62 80 92

About The Cover: “Cathedral Ceiling” – Robert B. Brahan, MD, photographed the ceiling at St. Mary Basilica in Natchez. He used a fisheye lens and developed the image using high dynamic range (HDR) software. Notice the altar and the backdoor can be seen in the same photo. It is a fitting cover image as the papal conclave elected a new pope for the Roman Catholic Church on March 13, 2013. Argentine Jorge Bergoglio takes the name Pope Francis I succeeding Pope Benedict XVI. Recognized as an architectural masterpiece among Catholic churches in the South, the basilica is the spiritual home of a vibrant St. Mary Catholic community of approximately 2,000 Roman Catholics. Construction of this place of worship was begun in 1842 as the Cathedral of the newly established Diocese of Natchez. The city of Natchez, on the Mississippi River and the birthplace of Mississippi, is a tourist destination because of its historic antebellum homes. St. Mary Basilica, also antebellum, is the city’s central landmark. No longer the Cathedral of the diocese, St. Mary congregation sees its mission not only as serving the local community but also as a support and resource for the ministry of smaller Catholic communities in southwest Mississippi. Much of St. Mary’s ministry is carried out by a cadre of dedicated volunteers. The St. Mary congregation takes pride in the basilica’s colorful and prayerful setting. Inspirational liturgies, sacramental celebrations, the observance of important feast days, and leadership training for congregation members are highlights. It has provided Catholic education through the Cathedral School system since 1853. The school’s (K-12) enrollment at present is approximately 600 students. Dr. Brahan is board-certified in internal medicine and geriatric medicine and practices at the Hattiesburg Clinic. r March

VOL. LIV

2013

No. 3

MARCH 2013 JOURNAL MSMA 61

From the Editor: Remember, You too are Mortal

ast night in Magnolia, as I was driving home from late night nursing home rounds, I received a call from the chief nurse at my rural hospital to come pronounce a DNR patient who had just died with end-stage liver and renal disease. I wasn’t on call, but this nurse recognized that I had a relationship with the patient and his family and would want to be involved. After years of alcohol and drug abuse, this 69-year-old male had suffered much over the last few months, requiring many hospitalizations before being placed on hospice. He also suffered persisting pain, nausea, and agitation, which proved difficult to control. Utilizing comfort measures, his terrible symptoms were finally stabilized, and he died without significant pain or suffering. During my consolation of the family after his death, they expressed how appreciative they were that he had “slipped peacefully away” with family members at his bedside. “This was what he wanted,” his son said, noting his father’s frequently stated fear that “he did not want to die hooked up to a machine.” This patient experienced “a good death,” and a physician plays a critical role in providing such quality at end-of-life. Hippocrates spoke to our own mortality in a phrase from his first aphorism: vitae brevis, life is short. Hippocrates was telling

his fellow physicians never to forget that “you too are mortal.” He emphasized the physician duty to empathize with the sick, whose ranks all physicians will eventually join. Physicians must provide our patients the same kind of quality death physicians want for their own families and themselves. I direct you to Dr. Ken Murray’s brilliant essay on “How Doctors Die” in this issue. Murray’s reflections have stimulated much discussion on death and dying across the country. This Journal also brings you the second part of “Concepts in End-of-Life Care.” Written by Drs. Sharon Douglas, Mark Meeks, Vicky Pilkington, and Gwen Windham, this series provides Mississippi physicians with up-to-date and comprehensive strategies for providing exemplary end-of-life care. Three more are to come in this series which will better arm state physicians for the important task of caring for our patients at this time they need us most. Dying is a dirty business: difficult, emotionally exhausting, humiliating, and painful for the one experiencing it. Physicians must serve our calling to make this inevitable part of life as good as a very bad thing can be. Contact me at lukelampton@cableone.net. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

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Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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• Clinical Problem-Solving • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Snake, Rattle, and Roll Jeremy B. Wigginton, MD

50-year-old white male presented to the emergency department with a 12-hour history of excruciating left arm, shoulder, face, and flank pain as well as accompanying dizziness at the peak of the pain. He also complained of left arm weakness and tingling. He was conservatively treated for a presumed non-venomous snakebite of the left wrist approximately 6 days prior to the onset of his symptoms. At the time of the bite, he was given morphine and discharged home with hydrocodone (Lortab), as his tetanus status was current. He reported initially having pain only in his left wrist at the site of the bite for about 24 hours, and he had been virtually pain free until these new symptoms began. Poisonous snake bites in Mississippi most commonly occure from rattlesnakes, water moccasins, and copperheads (referred to as crotalids).1 Bites from coral snakes are less common but more likely to be fatal. Initial management of crotalid bites includes local wound care and assessment of the need for antivenom. Antivenom is indicated only for patients with a confirmed crotalid bite and signs of severe toxicity because of the risk for anaphylaxis or serum sickness.1,2 This patient was appropriately not given antivenom at his initial presentation as his symptoms were only local pain, he had no autonomic instability, and the type of snake could not be confirmed. Patients with puncture wounds should also receive tetanus vaccination if not up-to-date.2,3 Upon further questioning, the patient stated he had been seen twice after the bite at a local clinic where lab studies were performed. He sparingly used hydrocodone to control local pain for the initial 24-hour period. He was discharged to follow up only as needed since he had no signs of venom toxicity and his lab values were stable. Monitoring patients with suspected crotalid bites includes Author Information: Dr. Wigginton practices with Singing River Health System Outpatient Family Practice, 2819 Denny Avenue, Pascagoula, MS 39581. Corresponding Author: University of Mississippi Medical Center Department of Family Medicine, 2500 North State Street Jackson, MS 39216. 601-984-5428

64 JOURNAL MSMA MARCH 2013

a complete blood count and coagulation profile for approximately 1week after the bite. This is due to the nature of crotalid venom, as it can cause a secondary coagulopathy and thrombocytopenia. Monitoring should also include assessment for increase in local symptoms or development of new symptoms indicative of autonomic instability or neurological deficits.3.4 In the emergency department, he reported that the new pain was unlike the pain initially experienced. His home dose of hydrocodone did not provide pain relief during the recurrent episode. Pain was worse in his left wrist at the site of the bite, and the pain radiated upward toward his shoulder, face, and chest. He denied shortness of breath, difficulty with speech or vision changes. He did admit to feeling “dizzy and faint” when the pain was severe as well as intermittent “tingling” of his left arm. His vital signs were stable, and his exam revealed only faint puncture wounds to the left volar wrist and pain with light touch of the skin extending from the left wrist to the left arm, shoulder, face, and thorax. A complete blood count, cardiac enzyme profile, coagulation studies, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), and electrocardiogram (EKG) were all normal in the emergency room. Additionally, a chest radiograph and non-contrasted computed tomography (CT) scan of the brain were also normal. Despite this patient’s history of a snakebite, the differential diagnosis for any adult presenting with unilateral symptomatology and chest pain includes acute coronary syndrome, stroke, injury, local or systemic inflammation or infection, or neuropathic causes. Studies to evaluate for causes of unilateral symptoms can include a CBC, ESR, and CRP to assess for inflammation or infection. Cardiac causes can be initially evaluated by serial cardiac enzymes and EKG. Structural and neurological causes may be seen through the use of CT scan or magnetic resonance imaging (MRI) of the brain or the affected area. However, a careful history and physical exam should always supersede any testing in order to guide the differential. The patient was again given morphine and hydromorphone in an attempt to control his pain. His symptoms persisted without any relief despite multiple doses of analgesics. He also continued to report “tingling” and “shooting pain”

starting at the left wrist and extending to the entire left side of his upper body. The physical exam remained unchanged during the persistence of these symptoms, and his vital signs remained normal. Given his symptomatology and test results, the differential is narrowed to non-ST elevation myocardial ischemia, ischemic stroke, and neuropathic pain. He was placed on a cardiac monitor, and a consult to neurology was placed to investigate the cause of his unusual unilateral symptoms. Neurology noted that the patient’s pain and paresthesia type symptoms did not cross the midline of his body, suggesting an organic cause. The most likely diagnosis was neuralgia secondary to envenomation, even though his initial snakebite was presumed non-venomous. Neurology recommended anti-convulsant therapy for his neuropathic pain. He was given an initial dose of 500mg of divalproex sodium (Depakote) in the emergency department along with his narcotic analgesics. There are few reports documenting the existence or treatment of neuralgia secondary to envenomation.4,5 However, there is abundant evidence that neuralgia of any type may respond to anticonvulsant therapy if short-term opiates are ineffective.7 The agents most studied have been phenytoin, carbamazepine, valproic acid, gabapentin, and pregabalin. The goal of using these medications is to achieve pain relief with the smallest possible dose and only monitor concentrations (if available) to avoid toxicity.7 The mechanism of action is still not well understood, but a trial of therapy is initiated for this patient given his refractory pain. In order to further monitor his symptoms and to 1de2 termine any other causes of his pain, the patient was admit3 ted to the hospital service for further neurologic assessment 4 and continuation of serial cardiac enzyme testing. He was continued on divalproex sodium 500mg twice daily, and5af6 ter approximately 24 hours, his pain and paresthesias were 7 significantly improved. His cardiac enzymes were normal. 8 In order to monitor for toxicity, divalproex sodium con9 centrations were drawn 12 hours after the first dose. Divalproex sodium requires approximately 2-4 days to reach steady state, 10 but the goal for pain control is solely to avoid toxicity. 11 His concentration was sub-therapeutic for anticonvulsant therapy. 12 However, his pain was adequately controlled so he was contin13 ued on the same dose. 14 Cardiac enzyme panels were drawn every 6 hours15 for 18 hours to adequately assess for myocardial infarction, 16 and neurological checks were done every 4 hours, which17 revealed no progressive symptoms indicative of stroke. The 18 patient remained stable with almost complete resolution19of pain and was discharged home approximately 36 hours20 after presentation of the recurrent pain. He was instructed21to continue the divalproex sodium at 500mg twice daily and 22 follow up with neurology in 1 week. 23 The patient did not return for his follow-up appointment,

but his primary care physician stated that the patient discontinued the divalproex sodium on his own accord once the pain was relieved, assumed to be only a few days after hospital discharge. Although secondary neuropathy is an uncommon finding in non-venomous snakes as well as venomous snakes such as the crotalid, it was apparent that this patient experienced neuralgia likely due to his snakebite. The patient’s report that opiate analgesia was ineffective further confirms the diagnosis of neuralgia. Using anti-epileptics as an adjunctive therapy for neuropathic pain proved effective in this puzzling case.

Key Words: Neuralgia, Envenomation, Pain management Resources 1.

Mississippi Poison Control. Treatment of snakebites. Available at: http:// poisoncontrol.umc.edu/educational.html. Accessed February 15, 2011.

PE McKinney. Out-of-hospital and interhospital management of crotaline snakebite. Ann Emerg Med. 2001. 37(2):168-174.

Seneviratne U, Dissanayake S. Neurological manifestations of snakebite in Sri Lanka. J Postgrad Med. 2002; 48:275-279.

Allegrante JP. The role of adjunctive therapy in the management of chronic nonmalignant pain. Am J Med. 1996;101:33S-39S.

Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med. 2002;347:347-356.

FG Walter. Epidemiology of severe and fatal rattlesnake bites published in the AAPCC Annual Reports. Clin Toxicol. 2009Aug;47(7):663-669.

Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11:203-217.

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• Editorial •

How Doctors Die Ken Murray, MD

My friend, Ken Murray MD, Clinical Assistant Professor of Family Medicine at USC, is a retired California family physician. He wrote this brilliant essay in 2011, and it was posted on the internet magazine Zocalo Public Square. (www.zocalo publicsquare.org) The essay soon went viral, generating a national conversation on end-of-life issues. He kindly allowed the JMSMA to share it with its readers. The article was recently included in “The Best American Essays, 2012” edited by David Brooks. Dr. Murray’s email is kmurray@dr.com. —Ed.

ears ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-yearsurvival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him. It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently. Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right). Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that

you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo. To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice. How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system. To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not. The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

MARCH 2013 JOURNAL MSMA 67

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment. Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital. Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was a prominent attorney. She had severe diabetes and terrible circulation, and, at one point, she JNLMSMed-BW2 developed a painful sore on her foot. Knowing the hazards of

hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died. It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble. Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I

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arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later. Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment. But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me. We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20. Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors. r

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MARCH 2013 JOURNAL MSMA 69

• MSDH • Mississippi Reportable Disease Statistics

January 2013 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR ﬁgures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

70 JOURNAL MSMA MARCH 2013

• Editorial •

In Support of POLST: Better End-of-Life Care for Mississippi Andre Barthelemy, M4, Tulane School of Medicine

Introduction to POLST

Advance Directives (AD) refer to a variety of methods designed to help patients retain control of their medical treatment decisions at the end-of-life, even while they are unable to communicate those decisions to their caregivers and loved ones. Traditionally, these methods have included completion of orders of Do Not Resuscitate (DNR), Living Wills (LW), or identification of a Health Care Proxy (HCP), but unfortunately, for all the potential promised by each, our patients have yet to realize the benefits. Documented shortcomings include a paltry utilization by patients, poor portability between health care settings, vague instructions to health care providers, or inadequate understanding of the patient’s wishes by the HCP.1 Recognizing the crucial importance of ensuring patient autonomy at the end-of-life and the flaws preventing its implementation, a group of health care professionals, at the Center for Ethics in Healthcare, Oregon Health and Science University (OHSU), designed the Physician Orders for Life Sustaining Treatment (POLST) Paradigm Program. Implemented first in Oregon, the Program was soon applied by the Regional Ethics Network of Eastern Washington and has since been replicated in established or developing programs in 40 states.2,3 The Program is easily recognized by the POLST Form, a distinctively colorful set of physician orders. The Form explicitly refers to the patient’s wishes for or against cardiopulmonary resuscitation (CPR), cardioversion, hospital transport, intensive care unit (ICU) admission, invasive or non-invasive ventilation, antibiotics, intravenous fluids, or artificial feeding. There are sections for additional orders, expression of the patient’s goals of care, and identification of a health care proxy. The forms differ by states, but most forms require a patient or surrogate decision maker signature as well. The Form is constructed so as to consolidate the other ADs, benefiting from each of their strengths within a single document.1,4 Like DNRs, the POLST form is a set of physician orders. It delineates clear actions to carry out the patient’s wishes, removing the difficulty of translating such vague statements as “no heroic measures” or “no artificial life support,”

while removing the burden from loved ones to decide between complex treatments. In can alleviate fears for patients who might otherwise distrust advance planning due to uncertainty regarding eventual interpretation. Like a LW, however, the POLST Form addresses a far wider set of situations than the DNR, which addresses only situations where the patient has no pulse or breathing. POLST is generally for patients with serious health conditions. Physicians should consider consulting with the patient about completing a POLST Form if the patient wants to avoid or receive life-sustaining treatment, resides in a long-term care facility or requires long-term care services, or might die within the next year. Encompassing the functions of a DNR, a LW, and identification of a HCP on a single, easily recognized document allows recognition across health care settings and promotes integration into electronic medical record systems. A wallet-sized version is even available so that patients may carry with them at all times.2 Understandably, many of our patients may still be concerned that any of these documents could be used to limit their care. Providers can explain to patients that participation is always voluntary and that comfort care (O2, suction, pain

control, positioning, hygiene, wound care, and feeding by mouth) are never excluded. Hospitalization, even when limited, is still ordered when this comfort care cannot be provided in the current setting. A patient requesting the full level of care on the POLST Form will receive full care as would those without POLST orders. While traditional advance directives refer to future care plans, POLST explicitly addresses immediate care based upon one’s current condition. As such, it may be amended or revoked at any time by verbal or written statement. In short, every possible effort is explicitly made to represent the patient’s wishes as accurately as possible. The growing popularity of the POLST Paradigm Program is not without endorsement in the literature. Patients who use the POLST Form were far more likely to have physician orders regarding life sustaining treatment (96% vs 16%) or orders regarding hospitalization (97% vs 14%), the majority MARCH 2013 JOURNAL MSMA 71

HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS & ELECTRONIC REGISTRY AS NECESSARY FOR TREATMENT

Physician Orders for Life-Sustaining Treatment (POLST) Follow these orders until orders change. These medical orders are based on the patient’s current medical condition and preferences. Any section not completed does not invalidate the form and implies full treatment for that section. With significant change of condition new orders may need to be written. Guidance for Health Care Professionals. http://www.ohsu.edu/polst/programs/documents/Guide book.pdf.

A Check One

Patient First Name

Patient Last Name: Date of Birth: (mm/dd/yyyy)

Gender:

Middle Int.

Last 4 SSN:

Address: (street / city / state / zip)

CARDIOPULMONARY RESUSCITATION (CPR):  Attempt Resuscitation/CPR  Do Not Attempt Resuscitation/DNR

Patient has no pulse and is not breathing.

When not in cardiopulmonary arrest, follow orders in B and C.

B Check One

MEDICAL INTERVENTIONS: If patient has pulse and/or is breathing.  Comfort Measures Only (Allow Natural Death). Relieve pain and suffering through the use of any

medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.



Limited Additional Interventions In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: Provide basic medical treatments.

POLST in Mississippi

Full Treatment In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including life support measures in the intensive care unit. Additional Orders: _________________________________________________________________



C Check One

ARTIFICIALLY ADMINISTERED NUTRITION:  No artificial nutrition by tube.  Defined trial period of artificial nutrition by tube.  Long-term artificial nutrition by tube. DOCUMENTATION OF DISCUSSION:  Patient (Patient has capacity)  Parent of minor  Court-Appointed Guardian

Offer food by mouth if feasible. Additional Orders:

__________________________________________ __________________________________________

 Health Care Representative or legally recognized surrogate  Surrogate for patient with developmental disabilities or significant mental health condition (Note: Special requirements for completion. See reverse side.)  Other

Signature of Patient or Surrogate Signature: recommended

Name (print):

Relationship (write “self” if patient):

This form will be sent to the POLST Registry unless the patient wishes to opt out, if so check opt out box

SIGNATURE OF PHYSICIAN / NP/ PA My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s current medical condition and preferences.

Print Signing Physician / NP / PA Name: required

Signer Phone Number:

Physician / NP / PA Signature: required

Date: required

Signer License Number: (optional)

Office Use Only

S E N D F O R M W I T H P AT I E NT W H E NE V E R T R A NS F E R R E D O R D I S C H A R G E D , S U BM I T C O PY T O R E G I S T R Y

HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS & ELECTRONIC REGISTRY AS NECESSARY FOR TREATMENT

Information for patient named on this form

PATIENT’S NAME:

The POLST form is always voluntary and is usually for persons with advanced illness or frailty. POLST records your wishes for medical treatment in your current state of health. Once initial medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can address all the medical treatment decisions that may need to be made. The Oregon Advance Directive is recommended for all capable adults, regardless of their health status. An Advance Directive allows you to document in detail your future health care instructions and/or name a Health Care Representative to speak for you if you are unable to speak for yourself.

Contact Information Surrogate (optional):

Relationship:

Phone Number:

Address:

Phone Number:

Date Prepared:

Health Care Professional Information Preparer Name:

Preparer Title:

All three major types of Advance Directives are recognized in Mississippi– Out-of-Hospital DNR (OHDNR), Power of Attorney for Health Care (PAHC), and Living Wills (LW) – but as mentioned earlier, ambiguity, lack of portability, and the necessity for interpretation are among the reasons that Advance Directives fail to impact patient care.1 This remains true in Mississippi. It is encouraging to note, however, that there are no significant legal barriers to implementation of the POLST Paradigm Program in Mississippi,1 though we must remember that the expected challenges to any end-of-life planning remain. As a largely rural state, Mississippians already struggle to attain adequate access to health care due to long distances to facilities, relatively lower rates of higher education, greater poverty, and distrust of the health system as a whole. Traditionally, minorities are far less likely to complete AD.10,11 The challenge will be to present POLST to patients as a communication tool and means of assuring a future level of care rather than a means of limiting care. We can also reassure patients that palliative care has received the approval of major religious organizations, among them, the Catholic Church and most Protestant denominations.12,13

Phone Number:

PA’s Supervising Physician:

Next Steps

Primary Care Professional:

Directions for Health Care Professionals Completing POLST Completing a POLST is always voluntary and cannot be mandated for a patient. Should reflect current preferences of persons with advanced illness or frailty. Also, encourage completion of an Advance Directive. Verbal / phone orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy. Use of original form is encouraged. Photocopies, faxes, and electronic registry forms are also legal and valid. A person with developmental disabilities or significant mental health condition requires additional consideration before completing the POLST form; refer to Guidance for Health Care Professionals at http://www.ohsu.edu/polst/programs/documents/Guidebook.pdf.

Sending to Oregon POLST Registry (Required unless “Opt Out” box is checked) For the Oregon POLST Registry the following must be completed: Patient’s full name Date of birth Section A MD / DO / NP / PA signature Date signed

of which indicated for less than full hospitalization or ICU admission. Most importantly, these patients had lower rates of unwanted hospitalizations,5 none received unwanted resuscitation, and only 2% who only wanted comfort care were hospitalized.6 Several studies have confirmed that the POLST Form led to an increased compliance with patient end-of-life wishes.1,6,7,8 The POLST Form has been well regarded by professionals and helped fulfillment of patient wishes in a variety of health settings, from hospice to long term care facilities to prehospital EMS.4,6,9

Send a copy of both sides of this POLST form to the Oregon POLST Registry. FAX or eFAX: 503- 418-2161 or Mail: Oregon POLST Registry CDW-EM 3181 SW Sam Jackson Park Rd. Portland, OR 97239

Date Submitted

MAY PUT REGISTRY ID STICKER HERE:

Registry Phone: 503-418-4083 *Please allow up to 10 days from receipt for processing into the Registry. Mailed confirmation packets may take four weeks for delivery.

Reviewing POLST

This POLST should be reviewed periodically and if: The patient is transferred from one care setting or care level to another, or There is a substantial change in the patient’s health status, or The patient’s treatment preferences change, or The patient’s primary care professional changes.

Voiding POLST A person with capacity, or the valid surrogate of a person without capacity, can void the form and request alternative treatment. Draw line through sections A through E and write “VOID” in large letters if POLST is replaced or becomes invalid. Send a copy of the voided form to the POLST Registry as above (required). If included in an electronic medical record, follow voiding procedures of facility/community. For permission to use the copyrighted form contact the OHSU Center for Ethics in Health Care. Information on the POLST program is available online at www.polst.org or at polst@ohsu.edu. S E N D F O R M W I T H P AT I E NT W H E NE V E R T R A NS F E R R E D O R D I S C H A R G E D , S U BM I T C O PY T O R E G I S T R Y © CENTER FOR ETHICS IN HEALTH CARE, Oregon Health & Science University

72 JOURNAL MSMA MARCH 2013

June 2011

This is the good news: Mississippi is wonderfully positioned to take advantage of the POLST Program for its own patients. We have a clear opportunity to improve and simplify documentation of end-of-life preferences, there are no significant legal barriers to implementation in Mississippi,1 and the necessary resources are waiting. Caregiver awareness must be a primary goal at this stage. Physicians and other health professionals can gain a wealth of information at either the POLST Program website (www.ohsu.edu/POLST.org), or by visiting the Louisiana Mississippi Hospice and Palliative Care Organization (www. lmhpco.org). Next, the movement will need a physician champion to represent the movement to other health professionals as well as to legislators, financial donors, and eventually, the public. This should be a local figure who can navigate the culture and political climate of Mississippi. Again, these websites provide

resources for designing, implementing, and monitoring a POLST Progam, a list of grants available for every stage of research, development, and implementation, as well as consultation and mentoring by POLST Task Force members with a wide variety of backgrounds. An excellent review of current state program implementation and identified challenges exists in a recent AARP study: “Improving Advanced Illness Care: The Evolution of State POLST Programs.”14 The POLST Paradigm Program impels and informs a profoundly positive impact at a time when a person may feel most powerless, fearful, and unsupported. It is precisely the type of advancement needed in our current health system. It truly addresses the deepest needs of a patient while simultaneously lowering costs and protecting from needless physician ordered pain, suffering, and loss of dignity. We must seize the opportunity to learn about our patients’ end-of-life wishes, and equipped with the right tools, we can do more than treat disease. We can care for our patient.

References 1.

Hickman SE, Sabatino CP, Moss AH, Nester JW. The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation. J Law Med Ethics. 2008 Spring;36(1):119-40:4.

Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58(7):1241-8.

Meyers JL, Moore C, McGrory A, Sparr J, Ahern M. Physician orders for life-sustaining treatment form: honoring end-of-life directives for nursing home residents. J Gerontol Nurs. 2004;30(9):37-46.

Lee MA, Brummel-Smith K, Meyer J, Drew N, London MR. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly. J Am Geriatr Soc. 2000;48(10):1219-25.

Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59(11):2091-9.

Schmidt TA, Hickman SE, Tolle SW, Brooks HS. The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians’ practical experiences and attitudes. J Am Geriatr Soc. 2004;52(9):1430-4.

10. Reynolds KS, Hanson LC, Henderson M, Steinhauser KE. End-of-life care in nursing home settings: do race or age matter? Palliat Support Care. 2008;6(1):21-7. 11. Kwak J, Haley WE. Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist. 2005;45(5):634-41. 12. Bülow HH, Sprung CL, Reinhart K, Prayag S, Du B, Armaganidis A, Abroug F, Levy MM. The world’s major religions’ points of view on end-of-life decisions in the intensive care unit. Intensive Care Med. 2008;34(3):423-30. 13. Louisiana-Mississippi Hospice and Palliative Care Organization. Available at: http://www.lmhpco.org. Accessed July 10, 2012.

Center for Ethics in Health Care, Oregon Health and Science University. Available at: http://www.ohsu.edu/polst. Accessed June 28, 2012.

14. Sabatino CP, Karp N. Improving Advanced Illness Care: The Evolution of State POLST Programs. AARP Public Policy Institute. April 2012.

Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012;79(7):457-64.

Author Information: Andre Barthelemy, M4, will receive his

Hickman SE, Nelson CA, Moss AH, Hammes BJ, Terwilliger A, Jackson A, Tolle SW. Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting. J Palliat Med. 2009;12(2):133-41.

MD from Tulane School of Medicine in May and afterwards begin a General Surgery residency at the Hennepin County Medical Center in Minneapolis.

Wishing the physicians of Mississippi a

Happy Doctors’ Day – March 30th The following members of the MSMA Alliance have made contributions to the MSMA Alliance Scholarship Fund in honor of Doctors’ Day 2013.

Marsha Avara Amy Gammel Jean Hill Danita Horne Ann Blair Huffman

Louise Lampton Nancy Lindstrom Anne Love Karen Morris Sondra Pinson

Mollie J. Pontius Merrell Rogers Susan Rish Donna Witty Heather Wood

Synonymous with the Southern Medical Association Alliance, Doctors’ Day was first observed on March 30, 1933. Through the efforts of SMA Alliance members across the country, and led by Alliance Presidents Mrs. A. J. Campbell and Mrs. Jim Barnett, March 30, 1991 was designated as National Doctors’ Day by President George H. W. Bush.

MARCH 2013 JOURNAL MSMA 73

MSMA Annual Session August 16 – 17, 2013 Jackson, Mississippi

Visit MSMAonline.com and select the Annual Session link for details. 74 JOURNAL MSMA MARCH 2013

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76 JOURNAL MSMA MARCH 2013

• President’s Page • A Balanced Life

Steven L. Demetropoulos, MD 2012-13 MSMA President

octors, it seems, are especially predisposed to having imbalance in their lives. Our profession demands so much of our time that often we neglect other aspects of our life. This month’s President’s Page is devoted to finding the balance. Our work is very important and we give ourselves to others on a daily basis. In order to keep ourselves at our highest functioning level, we need to make sure that we balance other aspects of our life.

Let me first talk about the physical aspect. It is very important that we carve out thirty to forty-five minutes at least three times a week to get some exercise. If you can do it more often, that is great. It is important for our physical wellbeing. It is important for us to stay fit as a good example to our patients. It is also important as a good form of stress management whether you choose to lift weights or do some cardiac work or a combination of the two. If you enjoy walking or riding a bike and are able to do that thirty or forty-five minutes before you go in to work on weekdays, then try to do it on the weekend as well. It will help to keep your weight in check, will make you feel better, and give you more stamina on your job. It is essential for our personal wellbeing. The second aspect is mental. We do this in our workplaces on a regular basis. Most of us keep up with CME as well as reading new articles or receiving inservices about new medications or new procedures, so I think for the most part we do a good job in that aspect of our lives. I will include here taking out a little time each month to be engaged in the issues that face medicine in general. You can do that by being a part of your local county medical society and by being engaged in the state medical association. I have said this multiple times, but if each of us just contributed a very small amount of our time, our cumulative effect would be so much greater than a small number of people committing even larger amounts of time. Emotional wellbeing is something that we often neglect. Whether it is taking time out for family activities, coaching our children in sports, or going to one of their performances, your emotional health will benefit. We often think that we will have another opportunity to do those things but the fact is that opportunity is very limited. The window of opportunity to spend time with our children before they graduate from high school and go off to college, a job, or the military is very short. You wake up one morning and they are little and then turn around in just a few years, and they are already out of the house. Make time to spend with the children so that when you get older you won’t have regrets about it. Make time to spend with your spouse. Have a date night once a week where you can give them your undivided attention. Include your spouse in your exercise program when you are going for a walk or a bike ride so that you can have thirty or forty-five minutes to debrief about the day and the week and about what is going on with your family. Pick out an activity that you enjoy doing together whether it is gardening, working in the yard, playing tennis, or exercising. Also, make time for friends. Combine it with your children’s school or musical events where you can spend time and visit as you watch them perform. Invite people over for a casual cookout. Have them bring their family. Be intentional about engaging both your family and your friends. If you are not, weeks go by and soon it goes into months and you are not spending time with the people you care about and that care about you. Don’t neglect your spirituality. The Bible asks, “What profit a man if he gain the whole world and lose his own soul?” Be engaged in your church. Try to carve out some time each day for prayer and meditation. Try to allocate some time to serve others outside your job whether it is a medical mission or a volunteer health clinic or soup kitchen.

MARCH 2013 JOURNAL MSMA 77

Burnout can be very high among doctors and it is essential that we live balanced lives so that we do not experience that or, if we do, that we can reduce the effects of it. Often there just does not seem to be enough time in the day but we need to be intentional about the way that we organize our days. We have to be able to say no to some things whether it is in our work or other community, hospital, or business functions so that we can prioritize the important things in our lives: our faith and our family and then friends and work. We have to understand that our lives go through different seasons as well. When our families are young they require most of our time and we have very little time for our community or ourselves so we have to be selective about what we take on. As our kids get a little bit older, we have more time so that we can take on more projects and still have balance within our family. Then as our kids leave our home, we have even more time. At that point, we need to decide how we want to use the extra time that we have available to ourselves. Nevertheless, regardless of what your stage of life, please keep four principles in place – that you do need physical, mental, emotional, and spiritual balance in your life and that for you to function at your very best, you will need to find the balance in each of these. Finally, do I have all the answers to having a balanced life? No. These are just my observations from twenty-six years of doing a lot of things wrong and a few things right. I hope they are helpful.

ust what the doctor ordered

SPAGHETTI SQUASH

ately, I have provided side dish recipes because those are often more difficult to come by. This week we are going to do a spaghetti squash. I know I just did a recipe with sweet potatoes but there are still a lot of other great winter vegetables we can use. One of them is spaghetti squash. I like to poke some holes in the squash and put them in a warm oven with the skin on and let them get soft for about 20 minutes. Take out and let them cool. Remove the seeds, cut them in two, and scoop out the inside. The inside is like spaghetti and so it comes out in little strands. You can then put that in a Pyrex baking dish. I put a couple of teaspoons of garlic with When your medical office is short-staffed, it. Chop up about half an onion, dice it up, and mix it in with you get frustrated. the squash. Then I spread it in a layer across the bottom and When you get frustrated, sprinkle Romano cheese over the top. you dread going to work Bake this in the oven for about 40 minutes on 400 degrees and you start playing hooky. until the top is browned and toasted. Take it out, cut it in small When you start playing hooky, squares, and serve it that way. the bills pile up. It makes a great accompaniment to any type of meat. It’s When the bills pile up, also good for a couple of days afterwards as leftovers. You can Mama ain’t happy. replace the spaghetti squash with butternut or acorn squash, and When Mama ain’t happy, use the same recipe as well. ain’t nobody happy. That’s all for winter vegetables. Next edition, we will try something to celebrate the springtime. Bon Appétit!

KEEP MAMA HAPPY. When your office is short-staffed, use the MSMA Online Job Bank! Learn more: www.MSMAonlinejobs.com

78 JOURNAL MSMA MARCH 2013

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• Poetry in Medicine • [This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician and JMSMA’s unofficial poet laureate. This poem, written recently, is a reflection on the importance of parents reading to their children. McEachin relates that this poem was “inspired by a lesson from a McGuffey’s Reader.” For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

On Reading to Children

ow do you read to your youngster, And what are good books to be read? A very important question, For reading welds the heart to head.

Are lying and cheating held high, And fornication glorified? Are villains made into heroes, And licentiousness justified?

First rules for reading to a child: You read aloud; child feeds it back! Then you read aloud together; Once more you ask, “Please say that back!”

Does the book present characters Who have due respect for all men, Whose actions are always wholesome, Who are steady through thick and thin.

Then parent and child read again, In silence they perform this task. Now we close the book up tightly, “Tell me what you’ve read, I must ask?”

Little brains are oh, so fragile, With computers planted inside. It’s important to remember Once seen, once heard, facts will abide!

Repetition, name of this game, So make it a daily habit. Your child will look forward to it, Progress comes— “turtle or rabbit”!

So parent, check out the grammar, The story, the language, the style. But be alert to the ethos, Well before you expose your child.

As the young one improves in skill, Parents again have much to say. Who are the people in this book? Are they role models on display?

80 JOURNAL MSMA MARCH 2013

—John D. McEachin, MD Meridian

• Scientific Articles • Series: Concepts in End-of-Life Care Palliative Care Medicine Vicky D. Pilkington, MD; W. Mark Meeks, MD; Sharon P. Douglas, MD; B. Gwen Windham, MD, MHS [This is the second article in the Series: Concepts in End-of-Life Care. Future articles will address following patients wishes, do not resuscitate orders, and advance directives. The final article in the series will address grief. The series is edited by Richard D. deShazo, MD, Associate Editor.]

bstract

The goals of palliative care are to provide the best quality of life for the patient and family at a critical time in the patient’s life. Ethical principles of patient autonomy, beneficence, and justice are very important at this time. Good communication is paramount in respecting patients’ values and preferences. Appropriate surrogates, as directed by the patient, should be included in discussions and decisions. Physical, social, emotional, and spiritual suffering must be addressed.

Key Words: Palliative Care, Approach, Hospice Introduction

Palliative care is a multidisciplinary approach to “provide relief from pain and other distressing symptoms; affirm life and regards dying as a normal process; intending neither to hasten or postpone death; integrate the psychological and spiritual aspects of patient care; offer a support system to help patients live as actively as possible until death…”1 The goal of palliative care is to relieve suffering and maximize quality of life with or without life-prolonging treatments. Although “hospice” and “palliative care” are often used interchangeably, palliative care is distinct from hospice as it provides care to patients who still wish to have life-prolonging treatments while hospice is a specialized form of palliative care at end of life when life-prolonging treatments are no longer desired.1 Palliative care is patient centered and focuses on controlling pain and non-pain symptoms; making decisions Author Information: Dr. Pilkington is a geriatric physician at King’s Daughters Medical Center in Brookhaven, MS. Dr. Meeks is a geriatric physician and a Professor of Medicine. Dr. Douglas is a pulmonary physician and a Professor of Medicine. Dr. Windham is a geriatric physician and an Associate Professor of Medicine. All three are at the University of Mississippi Medical Center in Jackson, MS.

Corresponding Author: Beverly Windham, MD, MHS, University of Mississippi Medical Center, 2500 N State St., (Geriatrics), Jackson, MS 39216-4500, Jackson, MS, 39216, Phone: (601) 984-5610. (gwindham@ umc.edu)

concerning life-sustaining interventions; planning end of life care; and providing psychosocial support to the patient and caregivers. Palliative care helps patients, families, and physicians with decision making throughout disease progression and addresses patients’ and families’ emotional, spiritual, and social suffering.2 This article describes end of life palliative care and interventions physicians can implement to meet goals for the patient and family during the dying process.

Communication

Approach Medical education is often geared towards a cure with limited training in managing terminally ill patients, particularly in areas of communication and pain relief in whom cure is an unrealistic goal.3,4 This can result in invasive procedures offering little or no benefit while increasing patient discomfort and family distress. When life prolonging therapy is no longer the best option, the physician should be straightforward, assuring the patient and family that the alternative is not “do nothing” but to provide aggressive palliative care. Identification of Patients Who Can Benefit from Hospice Care Although palliative care can be implemented at any stage of a progressive disease, patients who will benefit from hospice care should be identified early in the terminal stages. Certain characteristics of some diseases in terminally ill patients with life expectancy < 6 months may prompt hospice consideration (Table 1).5 To ease fears about palliative care, physicians can initiate discussion by addressing pain and non-pain symptoms, assisting with difficult medical decisions, and using a multi-team approach to provide medical, psychosocial, and spiritual support.6 Confirmation of Understanding It is important to know what patients understand about their condition, prognosis, and expectations for endof-life care so that their values and preferences guide treatment. This requires engaging the patient and family in end-

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Table 1. 1. Disease-Specific in Terminally Ill Patients (Life(Life Expectancy <6 months) That May Table Disease-SpecificCharacteristics Characteristics in Terminally Ill Patients Expectancy <6 months) That May Prompt Hospice Prompt HospiceConsideration Consideration Heart Disease ¥ Cardiac ejection fraction < 20% ¥ Stage IV heart failure despite optimal medical management ¥ Symptomatic arrhythmias ¥ Frequent visits to the emergency room ¥ Cardiac arrest Pulmonary Disease ¥ Dyspnea at rest ¥ Oxygen saturation < 88%, PaO2 <55 mmHg, PaCO2 >55 mmHg ¥ Unintentional weight loss >10% in 6 months ¥ Cor pulmonale End Stage Renal Disease ¥ Those who are not candidates for dialysis or who wish to discontinue dialysis ¥ Have a creatinine > 6 mg/dl if diabetic or > 8 mg/dl if non-diabetic or ¥ Creatinine clearance <10 ml/min (<15 ml/min if diabetic) ¥ Uremia ¥ Intractable fluid overload ¥ Oliguria (<400cc/24 hours) Liver Disease ¥ End-stage cirrhosis ¥ INR > 1.5 ¥ Albumin < 2.5 ¥ Refractory ascites ¥ Bacterial peritonitis ¥ Hepatorenal syndrome ¥ Recurrent variceal bleed ¥ Malnutrition and muscle wasting Primary diagnosis of Dementia* ¥ An inability to walk or ambulation that requires significant assistance ¥ Incontinence of bowel and bladder ¥ Fewer than six intelligible words ¥ Dependent in activities of daily living ¥ Albumin <2.5 g/dl or decreased oral intake with > 10% weight loss over 6 months ¥ Frequent hospitalizations and/or emergency room visits ¥ Multiple, progressive Stage III or IV pressure ulcers ¥ Aspiration pneumonia *Patients with dementia who do not meet these criteria may be considered under a separate diagnosis such as failure to thrive when ongoing and unintentional weight loss develops.

Common Domains of Physical Suffering:

Domains of Emotional Suffering:

1. Nausea and vomiting

1. Delirium

2. Diarrhea

2. Anxiety

3. Pain

3. Depression

4. Anorexia

4. Grief

5. Pressure Ulcers 6. Constipation 7. Dyspnea 8. Oral secretions

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of-life discussions. Conversations might begin by asking patients to describe their understanding of the diagnosis and prognosis. Additional questions such as “What worries you the most?” or “What is the hardest part for you?” may also reveal patients’ unaddressed needs and misconceptions about prognosis.7 Delivery of Bad News When delivering bad news, the physician should be prepared and choose a quiet, comfortable setting. The patient should decide who should be present. The legal decision maker should be present if the patient does not have decision making capacity. Pagers and cell phones should be handed off. The physician may include the nurse, chaplain, social worker or others. A medical interpreter, in person or using phone translation services, is required for hearing impaired or non-English speaking patients.2 It is prudent to avoid using family members or friends of the patient as interpreters. Advance Directives Advanced care planning allows a patient with decision-making capacity to make choices about potential future care decisions. This may include the completion of a health care directive (instructional directive), the designation of a health care agent (proxy directive),6 or often the patient’s verbal wishes to the physician or surrogates, even if not recorded in statutory documents. Advance care planning can address the patient’s wishes regarding intubation, cardiopulmonary resuscitation, artificial nutrition and hydration, and other potential life sustaining interventions.8

Suffering Domains and Treatment Responses

Suffering is a “specific state of distress that occurs when the intactness or integrity of the person is threatened or disrupted. It lasts until the threat is gone or integrity is restored.”9 Suffering is an individual process, varying in intensity and duration with each patient. To assess suffering, simply ask, “Are you suffering?” Palliative care distinguishes four paradigms of suffering: physical, emotional, social, and spiritual suffering, each with treatment responses.

• Physical Suffering

This section discusses the aggressive palliative management of common physical symptoms. Nausea and Vomiting In palliative care, nausea and vomiting are common and very distressing symptoms. Treatment depends on the etiology. If opioids are the source, it is better to treat the nausea than to stop opioids since most develop tolerance within a few days. If symptoms persist, switching to a different opioid may resolve the symptoms. Patients should take opioids with food and use anti-emetics as needed. If nausea and vomiting are caused by intestinal obstruction, surgery may be the best option. Sublingual (SL), subcutaneous (SC), or rectal routes of medication administration may be required. Patients need not stop eating or drinking but should

be encouraged to take small sips or ice chips as tolerated.5 Diarrhea Diarrhea can cause fatigue, dehydration, electrolyte imbalances, skin breakdown and pressure ulcers. The most common cause of diarrhea in palliative care is laxative use for constipation.5 Other causes include fecal impaction, intestinal obstruction, infections, chemotherapy, radiation, pancreatic insufficiency, and inflammatory bowel disease. Treatment includes encouraging oral clear liquids, unless dehydration is severe, in which case intravenous fluids or hypodermoclysis should be considered. Avoid lactosebased products and introduce simple carbohydrates, e.g. toast. Infectious diarrhea may be treated with antimicrobials, but loperamide should be avoided as it reduces peristalsis, promoting retention of toxins. Bismuth is useful and has some antimicrobial effect against E. coli. Kaolin-pectin can provide modest benefit but may take up to 48 hours to provide relief. Psyllium, aspirin, and cholestyramine together can reduce the amount of diarrhea in radiation-induced enteritis.2 Pain Types and Patient Feedback In palliative care, pain relief is the goal but some patients prefer to tolerate some pain to balance undesirable medication side effects such as sedation. Patient feedback is the most reliable way to gauge pain. Assessment of pain includes describing its location, radiation, character, duration, intensity, precipitating and relieving factors. Pain is categorized as neuropathic or nociceptive, which may be somatic or visceral. Neuropathic pain results from damage to the peripheral or central nervous system including diabetic polyneuropathy, post-herpetic neuralgia, compression radiculopathies, phantom limb pain and pain from thalamic strokes. It is described as burning, shooting or tingling. Somatic pain originates from soft tissues or the musculoskeletal system from disorders such as arthritis, metastatic bone disease or fracture, soft tissue tumors or wounds. It is usually well localized and described as achy, throbbing, or stabbing. Visceral pain originates from intra-abdominal or intra-thoracic sources such as bowel obstruction, myocardial ischemia, liver metastases or urinary retention. It is usually poorly localized and described as cramping, squeezing or pressure. Pain assessment scales should be completed by the patient. Examples include numeric pain intensity (0-10) or pictorial scales such as the Wong-Baker FACES Scale or Pain Thermometer.10 Patients with dementia may also be able to self-report pain and should be asked about pain. Family and caregivers should be asked about behavioral indicators such as grimacing, moaning, agitation or changes in functional status. Assessment tools for patients with advanced dementia include the Assessment of Discomfort in Dementia, Dis-

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Table Starting Doses, Doses,Routes Routesofof Administration, Miscellaneous Caveats of Common Table2.2. Starting Administration, andand Miscellaneous Caveats of Common Narcotic NarcoticMedications MedicationsUsed Usedfor forPain PainControl* Control* Medication

Initial Dose, oral (PO) or intravenous (IV), frequency**

Miscellaneous***

Morphine IR

5-30 mg po every 3 hours prn

Solution: 2, 4, 10, 20mg/ml

2-5 mg IV q 2 hours prn

Suppository: 5, 10, 20, 30 mg

5 mg per rectum (PR) q 4 hours prn

Caution if renal or hepatic impairment

Morphine ER

15 mg po every 8 or 12 hours

Caution if renal or hepatic impairment

Oxycodone IR

5mg po q 4 hours prn

Caution if renal or hepatic impairment

Oxycodone ER

10mg po q 12-24 hours

Caution if renal or hepatic impairment

Fentanyl transdermal

12 microgram/hour patch

¥ 12 mcg/h patch delivers 12.5 mcg/h; recommend ordering 12 mcg/h to avoid misinterpretation as 125 mcg/hr

Available 12, 25, 50, 75, 100 mcg/h Increase dose q 3-6days

¥ Best absorbed by adipose tissue; absorption reduced in cachectic patients ¥ Preferred in renal or hepatic impairment ¥ Do not cut patches ¥ Requires short-acting medication for acute pain during initial 12-24 hours; when rotating to new opioid, wait 12 hours after patch removed to start new opioid

Hydromorphone

2 mg po q 3 hours prn 0.2-0.6 mg IV q 2 hours prn 3 mg per rectum q 6 hours prn

Codeine

¥ Expensive, may have better side effect profile ¥ May be preferred if renal or hepatic impairment, not in severe renal failure (GFR<30ml/min); reduce dose and frequency

15 mg po q 4 hours prn No intravenous dosing

Meperidine

Not recommended

¥ Multiple drug and disease-drug interactions ¥ Poor oral absorption ¥ Toxic active metabolite

Propoxyphene

Not recommended

¥ Effect equivalent to acetaminophen with adverse effects such as sedation, confusion, hallucinations in elderly

*Adapted from references 5 and 8 **Consider lower starting doses of all opioids in elderly, very thin persons, or those with renal or hepatic impairment ***Begin a bowel regimen simultaneously with sennosides, bisacodyl, polyethylene glycol, or sorbitol daily

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comfort in Dementia of the Alzheimerâ&#x20AC;&#x2122;s Type and Pain Assessment in Advanced Dementia scale.11 Physical pain may be caused by conditions other than the terminal diagnosis such as constipation, arthritis, and pressure ulcers.

Analgesic Ladder

When prescribing pain medication, the World Health Organization (WHO) analgesic ladder recommends a nonopioid (acetaminophen, non-steroidal anti-inflammatory drugs [NSAID]) for mild pain; a low-potency opioid (codeine, hydrocodone) or low dose of high-potency opioid (morphine) for mild-to-moderate pain; and higher doses of a high-potency opioid for moderate-to-severe pain. Adjuvant analgesics can be used for all steps of the ladder.12 Methadone pharmacokinetics are complex, requiring a specialized approach and its dosing will not be addressed here.

Initial and Ongoing Dosing of Opioids

When initiating opioids, begin with a low dose immediate-release (IR) oral formulation such as morphine, oxycodone, or hydromorphone every 4 hours. Opioids can be titrated up 25%-50% for mild-to-moderate pain and 50%100% for moderate-to-severe pain daily until pain relief (Table 2). Immediate-release formulations can be increased every 2 hours. Slow-release tablets or patches should not be used for rapid dosage titration. Once a stable daily dosage is achieved, a long-acting formulation can be prescribed with short-acting formulations for breakthrough pain. Long-acting formulations and transdermal fentanyl patches can be increased every 24 hours. Since the elderly are more susceptible to adverse drug effects, start with half the standard adult dosage. When patients can no longer take oral medications or are hospitalized for acute pain crises, other routes of administration of opioids are necessary. Intravenous and SC administration can be used, but intramuscular injections should be avoided due to pain and variable absorption. Figure 1 shows an algorithmic approach to managing acute pain. No ceiling exists for opioid titration.13 Pain relief or adverse effects determine maximal doses. Addiction is rare and should not dissuade physicians from providing pain relief in terminally ill patients.

Breakthrough Pain

Breakthrough pain occurs in 40-80% of cancer patients. If taking opioids orally (PO), an appropriate dosage for breakthrough pain would be 10%-20% of the 24-hour dose given hourly as needed for PO/PR formulations, every 30 minutes for SC administration, and every 15 minutes for IV administration. For patients on opioid infusions, the breakthrough dose is usually 50-100% of the hourly infusion rate.14 If 4-5 breakthrough doses are required daily, increase the baseline slow-release opioid dose.

Opioid Rotation

Opioid rotation is important when the current opioid is ineffective or there are persistent adverse effects.13 The first step is to determine the oral morphine equivalent daily dosage (MEDD) of the current opioid, including slow-

Table 3.3. Equianalgesic DosingDosing Chart Table Equianalgesic Chart

Drug

IV orSC dose (mg)

Oral (mg)

Duration IR 3-4 hours SR 8-12

Morphine

Hydromorphone

1.5

7.5

3-4 hours IR 3-4 hours SR 8-12

Oxycodone

Fentanyl IV

0.1

30-60 minutes

Hydrocodone

3-4 hours

Not recommended

200

3-4 hours

Codeine

Fentanyl 25mcg transdermal patch every 72 hours approximates morphine sulfate ER 50 mg twice a day.

release and immediate-release formulations given over 24 hours. The second step is to convert one opioid dosage to an equipotent dosage of another using an equianalgesic dosing chart (Table 3).5,8 An example of opioid conversion is provided (Figure 2). The third step is to reduce the dose of the new opioid by 25â&#x20AC;&#x201C;50% to account for incomplete crosstolerance among opioids.

Monitoring Opioid Use

Treatment with daily opioids requires monitoring adverse effects and initiating a scheduled bowel regimen. Nausea and vomiting occur in 10%-40% of patients taking opioids, but tolerance often develops within 3-7 days. Symptoms can be managed by dose reduction if pain is controlled, prescribing metoclopramide, haloperidol or prochlorperazine for a few days until tolerance to nausea and vomiting develops, or opioid rotation.15 To avoid acetaminophen or aspirin overdose, doses of these medications from all sources should be monitored closely. Opioid induced neurotoxicity is most often seen when patients have received chronic and/or high doses especially in the presence of dehydration or renal impairment.16 It is due to morphine-3-glucuronide metabolites that cause myoclonus, hallucinations and agitation and is treated with opioid rotation. Rotation to methadone may be optimal because it has no active metabolites. Opioid-induced hyperalgesia, although infrequent, results in increased nociceptive sensitization after exposure to opioids. Pain worsens as the opioid dose is increased.17,18 Treatment is opioid rotation. Respiratory depression is rare when opioids are titrated,5 with attention to level of alertness. Sedation usually precedes respiratory depression and may signal the need to reduce dose or frequency. If hypoventilation occurs and the patient is arousable, stop the opioid, wait for the effect to wear off, and restart opioid at a lower dose. If the patient is not arousable with hypoventilation, naloxone should not be administered at usual doses as it is likely to produce a severe pain crisis. If partial reversal is desired, an option would be to dilute 0.4mg of naloxone in 9 ml of saline and give 1 ml (0.04 mg) every 5 minutes until partial reversal. Mild sedation is common when patients first begin opioids,

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Adjuvant Therapy

Figure Figure 1. 1. Algorithm for Treatment of Acute Pain ¥

History and physical examination ¥ Diagnostic studies if needed

1. IV opioids every 15 minutes (e.g. morphine sulfate 2-5mg) 2. Oral opioids every 4 hours as needed (e.g. morphine IR 10-30mg) 3. Calculate 24 hour total dose of each pain medication in #1 & #2 4. Convert 24-hour required doses (of #3) to morphine equivalent daily dosage (MEDD) for maintenance medication using dose equivalent conversions. MEDD dose equivalents: Morphine oral 30mg = oxycodone oral 20mg = morphine IV 10mg = hydromorphone oral 7.5mg = hydromorphone IV 1.5mg (30:20:10:7.5:1.5 rule) 5. If changing to a different opioid, reduce the calculated 24-hour oral dose requirement by 25-50% because of incomplete cross tolerance. Give in divided doses 6. Calculate 10% of the calculated 24-hour oral dose requirement and give this amount as immediate release every 1-2 hours for breakthrough pain 7. If more than 3 breakthrough doses required, increase maintenance dose (by 25-50% for mild-moderate pain, 50-100% for severe pain)

Consider adjuvant analgesics: Somatic pain Steroids Bisphosphonates NSAIDs Opioids Heat/Cold Massage

Neuropathic pain Visceral pain SNRI antidepressants Treat underlying causes. Anticonvulsants Acetaminophen Tricyclic antidepressants* Opioids NMDA receptor antagonists Topical analgesics (lidocaine patch, ketorolac cream) Alpha-2 receptor agonists

Undetermined Antidepressants Antianxiety agents

*Amitriptyline is not recommended in older patients. Nortriptyline may be preferable if tricyclic is needed due to relatively less anticholinergic properties SNRI=serotonin norepinephrine re-uptake inhibitors; IV=intravenous; NSAID= non-steroidal anti-inflammatory drugs; NMDA=N-Methyl-D-aspartate

Figure 2.2. Example of Dose Conversion Among Opioids Figure Example: Patient is taking Morphine ER 30 mg twice a day PO and requires morphine IV 5 mg 3 times in 24 hours; physician wishes to switch to oral oxycodone. Based on conversion ratios the equation would be:

Step 1: Calculate oral morphine equivalent daily dosage (MEDD). (Note here that IV morphine is converted to po morphine [see Table 3] by equianalgesic dosing chart) (30 mg x 2) + (5 mg x 3 doses) x (30mg po/10mgIV) = 60 mg + 45 mg = 105 mg morphine PO in 24 hours

Step 2: Calculate amount of oxycodone (“x”) that is equivalent to the current 24 hour oral morphine dose also using equianalgesic dosing chart (Table 3): “x” mg oxycodone = 20 mg oxycodone 105 mg oral morphine 30 mg oral morphine “x” mg oxycodone = 70 mg oxycodone in 24 hours

Step 3: Reduce the dose by 25 - 50% due to incomplete cross tolerance among opioids 24 hour total oxycodone dose would be approximately 35 – 50 mg

but tolerance occurs over a few days.8 Other side effects may include constipation, delirium, urinary retention, medication diversion, and withdrawal/physical dependence.

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Certain painful conditions require adjuvant analgesics. Pain from bone metastases may respond to NSAIDs, bisphosphonates, calcitonin, dexamethasone, radioisotopes (strontium -89) or external beam radiation. Brain metastases causing increased intracranial pressure may benefit from dexamethasone. Pharmacologic management of bowel obstruction can include any of the following: anticholinergic agents (hyosycyamine, oxybutynin) for colicky pain, octreotide to decrease peristalsis and gastrointestinal secretions, and glucocorticoids to reduce edema and inflammation. Neuropathic pain may respond to certain antidepressants (tricyclics, SNRI’s), anti-epileptics (gabapentin, pregabalin) or antiarryhythmics (lidocaine patch). Acute pain is considered a palliative care emergency. Sometimes an evaluation including diagnostic studies may be required. Physicians may consider consultation with a pain management or palliative care expert if available. If the patient continues to suffer severe pain despite aggressive measures, sedation to unconsciousness may be considered.8 Anorexia Anorexia is distressing to caregivers and family but not usually to the patient. Reversible causes should be sought including xerostomia, dental caries or abscesses, thrush, constipation, depression, medications, or nonpalatable foods. Dietary restrictions, including salt, may be removed. Anorexia is a natural part of the dying process; more than half of patients with incurable cancer report anorexia and weight loss.2,19 Enteral feeding in dying patients who are unlikely to feel hunger can worsen suffering by causing discomfort, aspiration, infection, or choking and can shorten life.5,8, 20 Physical restraints used to protect lines or tubes may cause discomfort or

worsen confusion. Palliative care patients may respond best when allowed to eat and drink without restriction. IV hydration

may prolong an inevitable death and increase suffering.2,5 However, small sips of liquids or moistening oral mucosa with applicators can alleviate symptoms of dry mouth or thirst. A recent review of parenteral nutrition and hydration in terminally ill cancer patients reported that most patients do not benefit from parenteral nutrition, although exceptions may include those with good functional status and non-functioning gastrointestinal tract or a slow growing tumor. Similarly, parenteral hydration did not appear to improve symptoms or survival although it may help reverse delirium in a subset of patients.20 Educating caregivers concerning artificial nutrition and hydration and reassuring them that aggressive care will be instituted to alleviate suffering even in the absence of artificial nutrition and hydration is essential.2,5 They should know that, at times, it may be best not to institute artificial nutrition and hydration. Once terminal patients stop eating and drinking, the average time to death is 10 days but could be 2-3 weeks. One study of patients who voluntarily stopped eating and drinking reported that 85% died within 15 days.21 Patients do not “starve to death” in this situation but die of progressive renal impairment. Pressure ulcers Pressure ulcers cause significant discomfort for patients and caregivers. Prevention is a priority. High-risk patients include those with decreased alertness, older age, delirium, immobility, incontinence, malnourishment, and impaired sensory perception.22 High-risk areas are the sacrum, heels, ankles, hips, ears, and knees or any other areas with direct contact on mattresses or other surfaces.5 The appropriate support structure is based on risk assessment. Nurses or other ancillary staff may be helpful in this regard. Round cushions, known as donuts, should not be used because they cause occlusion of blood flow and do not prevent pressure ulcers. Pad foams are also ineffective. Consults to physical therapy can be placed for special wheelchair cushions in patients confined to wheelchairs.2 Constipation Limited activity at the end of life reduces normal gastric reflexes. Almost all patients on opioids require bowel therapy. Other medications and concurrent conditions should be reviewed (Table 4). A rectal digital exam should be performed to evaluate for impaction. A bowel regimen of one or a combination of the following can be used: polyethylene glycol, bisacodyl 1-4 tablets daily with MOM 30cc daily, Senna 1-8 tablets daily, Fleet’s enema, bisacodyl suppository, or magnesium citrate.5 Dyspnea Dyspnea, a subjective feeling of shortness of breath, may be present at rest and worsened by physical activity. Oxygen may not relieve dyspnea, and a patient can have dyspnea without hypoxemia. Evaluate for reversible causes such as pneumonia, thick secretions, pleural effusions,

kinked oxygen tubing, inadequate oxygen supply, or anxiety due to other issues such as uncontrolled pain, volume overload, and imminent death. Treatment includes a semi-upright sitting position (80-90°) with knees bent or straight, increasing air movement with a fan or open window, and discontinuing intravenous fluids. Opioids are the medications of choice for dyspnea. The initial dose is 5-15mg of morphine orally or 2-5mg in IV or SC route, although lower doses may suffice for older or very thin patients or those with renal or hepatic impairment. For patients on chronic opioids, a higher starting dose may be needed. Controlled trials of nebulized morphine have not shown benefit over placebo.23 If hypoxemia is present, nasal cannula is preferred over face mask which can cause agitation. Anxiolytics are useful in treating accompanying anxiety. Treat underlying diseases as appropriate, e.g. bronchodilators in asthma.2 Death Rattle and Oral Secretions Ability to clear secretions decreases as level of consciousness decreases. Air moving over pooled secretions in the oropharynx and bronchi produces a “rattling” or “gurgling” sound, a predictor of near-death.2 Non-pharmacological treatment includes turning the patient on his side or in a semi-prone position to increase drainage, reducing fluid intake, and gentle suctioning. Avoid frequent deep suctioning that can make the patient uncomfortable. The Trendelenburg position may move fluids to the oropharynx, but there is a risk of aspiration. Anti-cholinergic medications are the mainstay of pharmacological treatment of hypersecretory states (Table 5). The quaternary amines (glycopyrrolate) do not cross the blood-brain barrier. The tertiary amines (i.e. scopolamine, hyoscyamine, atropine) cross the blood-brain barrier and can cause sedation and delirium. Scopolamine is available transdermally but due to its slow onset of action an additional medication is required for acute symptoms.2 Palliative Sedation in End of Life Care for Extreme Cases of Physical Suffering Physicians are obligated to relieve end of life pain and suffering. Palliative sedation is “the administration of sedative medications to the point of unconsciousness in a terminally ill patient.”24 It is considered the last option when other aggressive treatments have failed but is not to be used to cause death. This is an accepted and appropriate medical and ethical option in the proper setting. The current opinion of the Council on Ethical and Judicial Affairs of the American Medical Association24 has published guidelines for palliative sedation (Table 6).

• Emotional Suffering

Emotional suffering in palliative care encompasses numerous aspects of the dying process, including delirium, anxiety, depression, and grief.

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Table 4.4.Common Causes of Constipation Table Common Causes of Constipation MEDICATIONS  Opioids  Diuretics  Iron supplements  Antihypertensives, e.g. nondihydropyridines  Anticonvulsants  Zofran  Anticholinergics  Vincristine  Antacids containing calcium and aluminum DISEASES/ CONDITIONS  Hypothyroidism  Diabetes  Hyperparathyroidism  Hypokalemia  Hypomagnesemia  Diverticular disease  Hemorrhoids  Anal fissures

Table 5. Pharmacological Treatment Options for Excess Secretions

Table 5. Pharmacological Treatment Options for Excess Secretions Medication

Route

Initial dose

Time of onset

Atropine sulfate

SC, IV

0.1mg

1 minute

Atropine sulfate(1% ophthalmic solution)

1 drop

30 minutes

Glycopyrrolate

SC, IV

0.1mg

1 minute

Glycopyrrolate

0.2mg

30 minutes

Hyoscyamine

PO, SL

0.125mg

30 minutes

Scopolamine

Transdermal

1.5mg patch every 72 hours

6-8 hours

Table 6. Guidelines in Using Palliative Sedation from the Code of Medical Ethics of the American Medical Association. 1. Palliative sedation to unconsciousness is not to be used to cause death. 2. Document the rationale for offering palliative sedation to unconsciousness in terminally ill patients. 3. Consider palliative sedation to unconsciousness when other treatments have failed to relieve clinical symptoms. 4. Be sure that the patient and/or the surrogate has given consent. 5. Consult multidisciplinary team or expert in palliative care, if possible, to aid in determining that all other options have been exhausted. 6. Physicians should discuss with their patients the duration of the sedation. 7. Patients must be monitored appropriately. 8. Be aware that palliative sedation to unconsciousness is not an appropriate treatment for suffering that is primarily existential. Existential suffering should be addressed by other means.

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Delirium Delirium is associated with a 10-fold increased mortality risk in hospitalized non-hospice patients25 and carries a grave prognosis for dying patients. About 80% of patients in the final week of life experience delirium.5 Physicians should look for reversible causes and treat if the patient desires, including opioid rotation and discontinuing anticholinergic medications. Other common reversible causes include infection, hypotension, hypoxemia, hypoglycemia, hyponatremia, hypercalcemia, acute cardiac syndrome, increased ammonia level, alcohol withdrawal, drug toxicity, uncontrolled pain, and sleep deprivation. Non-pharmacologic management is central in treatment. Any underlying precipitant should be treated and contributing factors removed (e.g. unnecessary tethers, electrolyte imbalances, medications). Caregivers and staff should provide supervision, verbal comfort, reorientation, mobilization if feasible, noise reduction, uninterrupted sleep, and nighttime low lighting.25 Some patients will require pharmacologic agents to address frightening hallucinations or dangerous behaviors. Delirium secondary to alcohol or benzodiazepine withdrawal should be treated with benzodiazepines. Otherwise haloperidol generally remains the drug of choice although quetiapine and other atypical neuroleptics (e.g. risperidone, olanzapine) may be effective.2,25,26 Haloperidol can be administered in PO, IV, SC, SL, topical and rectal formulations.25-27 Pharmacokinetic data are lacking for SC and rectal forms but are used in palliative care.27 The starting dose is 0.5-5 mg although lower doses, for example 0.5-1 mg, are recommended if given IV or to older patients. Doses may be repeated every 1-2 hours for symptom relief.27 Once a twenty-four hour dose is established, it should be divided into 2 to 3 doses daily. In older patients, daily or twice daily scheduled dosing is often adequate with breakthrough doses of 0.5-1 mg, if needed, every 4 hours.25 When converting from oral to IV, the haloperidol dose should be halved.27 Haloperidol should be avoided in patients with prolonged QT intervals or with parkinsonism (e.g. Lewy Body Dementia) or Parkinson Disease.26 A benzodiazepine may be substituted in these cases25,26 but has been associated with prolongation and worsening of delirium symptoms.28 Alternatively, quetiapine may have lower risk of extrapyramidal effects.29 Anxiety Common causes of anxiety include dyspnea, pain, post-traumatic stress disorder, depression, and generalized anxiety disorders. Opioid withdrawal and medications such as caffeine, antiemetics, and albuterol may contribute. Unnecessary medication and/or treatment should be stopped. Selective serotonin reuptake inhibitors (SSRIs) have anxiolytic properties, but benzodiazepines may be required, especially for acute symptoms. Palliative experts or psychologists may be needed to employ relaxation and behavioral techniques.

Depression Depression is common, especially as patients approach death, and may be worsened by physical and social suffering. SSRIs and psychotherapy are recommended treatment.5 Psycho-stimulants such as methylphenidate can be useful while awaiting SSRI effects. Addressing physical and social suffering is important as these can worsen depression. Grief Grief is universal to any loss, may begin before the patient actually dies, and should be addressed for the patient, loved ones, and the healthcare team. The palliative care team can provide encouragement for the patient and loved ones. Support for the family and help in preparing for a future without the patient are important in the grieving process, beginning before the patient dies and continuing after the death of the patient.

• Social Suffering

Members of the palliative care team should be sensitive to the social needs of patients. The palliative response to social suffering begins with assessing patient goals and allowing time for the patient to experience and express feelings. Death does not happen to the patient alone but also to the family. Terminally ill patients need to know that loved ones will be cared for during their illness and after their death. Family finances are impacted by loss of income, insurance, savings, and assets. An estimated 40% of families become impoverished when caring for a terminally ill loved one, creating an additional burden for the patient and family.5

• Spiritual

Most patients embrace the idea of exploring their spirituality in their terminal illness. Physicians should recognize patients’ spiritual concerns and utilize non-medical professionals such as clergy and counselors. A format such as Faith, Importance, Community, Address or “FICA” can be used in assessing spiritual concerns and the identification of patient goals.5 (Table 7). Forcing personal religious or spiritual views on the patient or family or providing false encouragement is not recommended, but patients and caregivers appreciate physicians who are warm and genuine in their concern.5

Conclusion

The goals of palliative care are to provide the best quality of life for the patient and family at a critical time in the patient’s life. Ethical principles of patient autonomy, beneficence, and justice are very important at this time. Good communication is a key element to ensure the patient’s values and preferences are respected. Appropriate surrogates, as directed by the patient, should be included in discussions and decisions. Physical, social, emotional, and spiritual suffering must be addressed. Palliative care should be viewed as aggressive care, akin to that received in the intensive care unit, but with a

Table 7. Tools for Assessing Spiritual Concerns F Does the patient feel that faith is important, or does he consider himself a spiritual person? I

Is faith important to them? Have they received any comfort from their faith? This allows the physician to screen for the need for support sources.

C Is the patient part of a spiritual community? This will reveal isolation from their faith community and what spiritual support may be lacking. A Ask how to help address their spiritual issues. The patient may reveal cultural practices, rituals, beliefs that the physician can then be sensitive to in providing care and meeting those needs.

Table 8. Physician Resources for Palliative Care Resource

Website

National Hospice and Palliative Organization

http://www.nhpco.org/i4a/links/ ?pageid=3287&showTitle=1#Grief and Healing

Center to Advance Palliative Care

http://www.capc.org/

The American Academy of Hospice and Palliative Care Medicine

http://epec.net/resources.php

End of Life Physician and Education Resource Center (EPERC)

http://www.eperc.mcw.edu/EPERC

American Hospice Foundation

http://www.americanhospice.org/

Find a Hospice or Palliative Care Program in Mississippi

http://iweb.nhpco.org/iweb/ Membership/MemberDirectory Search.aspx?pageid=3257& showTitle=1

focus on comfort. Patients and their families do not want to feel abandoned by their physician during the final stage of life, when aggressive care may be needed the most. Perhaps there is no time in the patient’s course that he or she needs the physician more. Sometimes the best approach by the primary physician is just being there. This presence can be fulfilling for physicians and patients. With the growth in hospice care in the U.S., all primary care physicians need to

MARCH 2013 JOURNAL MSMA 89

develop expertise in providing high-quality care for their patients nearing the end-of-life. There are many resources for physicians wanting further guidance on providing palliative care (Table 8).

14. Hanks GW, Conno F, Cherny N, et al. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer. 2001;84(5):587-593.

References

18. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145-161.

The authors wish to thank Dr. Paul Low for his review of this paper. 1. World Health Organization. Palliative Care. World Health Organization Press. Available at: www.who.int/cancer/palliative/en/. Accessed October 12, 2011. 2. Emanuel L, von Gunten C, Ferris F. Education in Palliative and End-of-life Care (EPEC) curriculum. Robert Wood Johnson Foundation. Available at: http://epec.net/. Accessed June 26, 2012. 3. SUPPORT Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):15911598. 4. The Institute for Clinical Systems Improvement. Health Care Guideline: Palliative Care for Adults; 2011. 5. Bailey F. The Palliative Response. 2nd ed. Birmingham, AL: Menasha Ridge Press; 2005.

15. Herndon CM, Jackson KC, 2nd, Hallin PA. Management of opioid-induced gastrointestinal effects in patients receiving palliative care. Pharmacotherapy. 2002;22(2):240-250. 16. Lotsch J. Opioid metabolites. J Pain Symptom Manage. 2005;29(5 Suppl):S10-24. 17. Axelrod D, Reville B. Using methadone to treat opioid-induced hyperalgesia and refractory pain. J Opioid Manage. 2007;3(2):113-114.

19. Teunissen SCCM, Wesker W, Kruitwagen C, de Haes HCJM, Voest EE, de Graeff A. Symptom Prevalence in Patients with Incurable Cancer: A Systematic Review. Journal of Pain and Symptom Management. 2007;34(1):94-104. 20. Dev R, Dalal S, Bruera E. Is there a role for parenteral nutrition or hydration at the end of life? Curr Opin Support Palliat Care. 2012;6(3):365-370. 21. Ganzini L, Goy ER, Miller LL, Harvath TA, Jackson A, Delorit MA. Nurses’ Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death. N Engl J of Med. 2003;349(4):359-365. 22. Bergstom N. Strategies for Preventing Pressure Ulcers. In: Thomas D, ALlman R, eds. Clinicians in Geriatric Medicine. Philadelphia, PA: W.B. Saunders Co; 1997.

6. Eti S. Palliative care: an evolving field in medicine. Prim Care. Jun 2011;38(2):159-171.

23. Noseda A, Carpiaux J, Markstein C, Meyvaert A, de Maertelaer V. Disabling dyspnoea in patients with advanced disease: lack of effect of nebulized morphine. European Respiratory Journal. 1997;10(5):1079-1083.

7. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything”. Ann Intern Med. 2009;151(5):345-349.

24. Council on Ethical and Judicial Affairs. Opinion 2.201 Sedation to Unconsciousness in End-of-Life Care. Chicago: American Medical Association; 2010.

8. Quill T, Holloway R, Shah M, al e. Primer of Palliative Care. 5th ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2010.

25. Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165.

9. Cassell E. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press; 1991. 10. Holen JC, Hjermstad MJ, Loge JH, et al. Pain assessment tools: is the content appropriate for use in palliative care? J Pain Symptom Manage. 2006;32(6):567-580. 11. Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage. 2006;31(2):170-192. 12. Bial A, Levine S. Unipac 3: Assessment and Treatment of Physical Pain Associated with Life-Limiting Illness. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2008.

26. Marcantonio ER. In the clinic. Delirium. Ann Intern Med. 2011;154(11):ITC6:1-15. 27. Prommer E. Role of haloperidol in palliative medicine: an update. Am J Hosp Palliat Care. 2012;29(4):295-301. 28. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153(2):231-237. 29. Wood LD, Neumiller JJ, Setter SM, Dobbins EK. Clinical review of treatment options for select nonmotor symptoms of Parkinson’s disease.Am J Geriatr Pharmacother. 2010;8(4):294-315.

13. Dale O, Moksnes K, Kaasa S. European Palliative Care Research Collaborative pain guidelines: opioid switching to improve analgesia or reduce side effects. A systematic review. Palliat Med. 2011;25(5):494-503.

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 90 JOURNAL MSMA MARCH 2013

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MARCH 2013 JOURNAL MSMA 91

• Asclepiad •

Steve Parvin, MD, MSMA past president, was born on February 22,1942, in Corinth, Mississippi, to David Woodrow Parvin, Sr. and Bernice H. Parvin. The family moved to Starkville where Steve’s dad was a professor of ag economics at Mississippi State University (MSU). Young Steve graduated from Starkville High School and MSU before attending medical school in Jackson, graduating in 1967. After interning in Savannah, Georgia, he went to Flight Surgery School at the US Naval Base in Pensacola, Florida, for six months. Following, Dr. Parvin was assigned to a VP17 antisubmarine warfare squadron based in Hawaii for over three years. His tour of duty there included service in Thailand, the Philippines, and Vietnam. Next came general surgery training at Balboa Naval Hospital in San Diego, California, followed by reassignment to Florida. After completing his naval commitment in Pensacola, Steve returned to Starkville in 1976 where he practiced General Surgery for over 35 years. In the early 90’s Dr. Parvin was called up and operated for six months in a Combat Support Hospital during Desert Storm. After taking additional training, Dr. Parvin founded and ran the Breast Center at Okitibbeha County Hospital in Starkville from 2006 until he retired on January 1, 2012, at age 70. But there is more to life than medicine. In 1963 Steve married Martha Ruth whom he met while both attended MSU. They remain happily married almost 50 years later. Their daughter Allison is the senior pastor at Crossgates Methodist Church in Brandon. Son Steve is a veterinarian in Spanish Fort, Alabama. Together they enjoy four grandchildren ages 3-6. When asked to discuss memorable events in medicine, Dr. Parvin recalled Dr. James Hardy performing the first heart transplant from a chimp to a human while he was a medical student. The heart team developed their proficiency by performing heart-lung pump for those procedures. Dr. Parvin expressed concern about the future of medicine in this country. He opined that nobody addresses personal responsibility for health care without which we can never gain control of health care costs in the U.S. This issue includes obesity, smoking, drug and alcohol abuse, teen pregnancies, and STD’s. Another concern of Dr. Parvin is access to medical care for seniors and the poor. More and more physicians are refusing to accept new Medicare and Medicaid patients. He fears that we may be heading towards a two-tier system of “haves” and “have-nots” and that the medical profession of his time is morphing into a trade association. —Martin M. Pomphrey, MD Committee on Publications Mayhew homas

92 JOURNAL MSMA MARCH 2013

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