November 2016 by San Francisco Marin Medical Society

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

ETHICS IN MEDICINE

Reports from the Field and Frontiers VOL.89 NO.9 November 2016

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

November 2016 Volume 89, Number 9

Ethics in Medicine FEATURE ARTICLES 11 End of Life Without Options: A View from Bioethical Retirement Albert R. Jonsen, PhD

13 Reflections on Opting In: Physician Aid-in-Dying Monique Schaulis, MD, MPH 14 Clinical Ethics Committees: A Long, Strange Trip William Andereck, MD

16 California’s End Of Life Option: Preparing for PAD Ruchika Mishra, PhD 17 Somebody’s Somebody: Representing the Unrepresented Patient W. Donnie Nelson, RN, and Kathleen Jordan, MD

18 Ethics Beyond the Bedside: Three Realms of Theory and Practice Carol Bayley, PhD 20 Last Rights: A Personal and Professional Reflection Steve Heilig, MPH

22 So Long, Hippocrates: Medical Students Choose Their Own Oaths Melissa Bailey 23 End of Life at Laguna Honda

24 California’s Opioid Epidemic: Turning the Tide Sandra R. Hernández, MD, MPH

25 PAD and Fidelity to the Patient: As Future Clinicians See It Nate Hinerman, PhD 26 Providing Longitudinal Primary Care in Rural Haiti: Short-Term Personal Commitment and Long-Term Community Health Gains John Brown, MD Editorial and Advertising Offices: San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org

MONTHLY COLUMNS 4

Membership Matters

President’s Message Richard Podolin, MD

Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

32 Medical Community News 33 Classified Ads 34 Upcoming Events

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

SFMS Networking Mixers a Success Bay Area group practice physicians, administrators and professionals attended a mixer with SFMS and Medical Group Management Association (MGMA) members recently. The event provided an opportunity to network with peers and build referrals, while enjoying drinks, hors d’oeuvres and city views from the rooftop patio at Mechanics Bank in the Financial District. SFMS thanks Mechanics Bank for their generous support of SFMS and for sponsoring this social event. Local physicians participated in SFMS’s October Networking Mixer at Belga Restaurant in Cow Hollow. Attendees took advantage of the opportunity to meet SFMS leaders and connect with colleagues from a wide range of specialties and practice settings. SFMS would like to acknowledge the Cooperative of American Physicians (CAP) for their support of SFMS and our networking mixer series. SFMS remains committed to serving the professional needs of our member physicians and their professional staff. Our door is always open. Stop by for a visit or call to share challenges you are facing. We hope to see you at our next mixer!

Dinner with First and Second Year UCSF Medical Students

The University of California, San Francisco (UCSF) chapter of the AMA/CMA hosted a dinner recently to introduce SFMS leaders to first and second year medical students interested in health policy. SFMS leaders shared their perspectives on how to shape public health policy through participation in organized medicine. We thank UCSF medical student liaisons, Amy Pugh and Steve Herron, for organizing this enlightening and interactive event. Here’s what SFMS physician leaders had to say about their participation: “Always a pleasure to experience the enthusiasm and insight of those beginning their journey in medicine.” -Benjamin Franc, MD, MS, CPE “It is really refreshing to see so many students interested in policy development and organized medicine. There is nothing more inspiring than watching younger colleagues as they explore their interests and grow into their careers.” -George Fouras, MD

SFMS to Launch New Leadership Council

As a way to engage early career physicians interested in getting more involved with SFMS, a New Leadership Council is being formed. The group will consist of physicians in their first ten 4

years of medical practice or those forty years of age and younger, as well as medical students, residents, and fellows. The purpose of the New Leadership Council is to identify and cultivate new SFMS leaders. The group will be tasked with generating new ideas to advance SFMS programming to meet the needs of young physicians. It’s also a way for young physicians to gain recognition amongst their peers and serves as an outlet for career advice and leadership development. As SFMS President, Richard Podolin, MD, states, “We hope to have these individuals help guide the medical society into the future. We want to get better at meeting the needs of young physicians, and ensure a vibrant medical community in San Francisco.” An informational dinner will be held on November 9th for prospective Council members who are interested in participating. For more information, contact Erin Henke at ehenke@sfms.org or (415) 561-0850 x268.

CMS Eliminates Penalties for First Year of MACRA and Offers “Pick Your Pace” Options

The Centers for Medicare and Medicaid Services (CMS) announced that it will allow physicians to choose the level and pace at which they comply with the new Medicare Access and CHIP Reauthorization Act (MACRA) payment reforms. Participating at any level in 2017 will ensure that physicians will not be hit with payment penalties in 2019. The welcome announcement comes after the California Medical Association, American Medical Association, and other physician stakeholders urged CMS to ease the burdens and delay the first MACRA reporting period to give physicians more time to prepare. CMS will begin measuring performance for eligible clinicians in 2017, with payments based on those results beginning in 2019. Details about participation options may be found on the SFMS MACRA resource page, www.sfms.org/forphysicians/macra-resources-for-physicians.aspx..

Nondiscrimination Notice Posting Requirement

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) recently finalized new nondiscrimination rules intended to advance health equity and reduce health care disparities. The rule, which implements section 1557 of the Affordable Care Act, includes important protections for individuals with disabilities and enhances language assistance for people with Limited English Proficiency (LEP), including new requirements with respect to nondiscrimination postings and grievance procedures. Physicians were required to be in compliance with the rule by October 16, 2016. A CMA FAQ resource which helps guide members regarding compliance with these requirements may be found at http://www.cmanet.org/resource-library/ detail/?item=section-1557-nondiscrimination-final-rule.

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

Measure V (Soda Tax) Films Ad with SFMS’ John Maa, MD

November 2016 Volume 89, Number 9 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA

A November local ballot measure will tax distributors of sugar-sweetened beverages a penny-per-ounce. These revenues can be used to support health education programs and efforts to improve children’s health across San Francisco. Soda and other sugary drinks are the number one source of added sugar in the American diet, and are linked to increased risk of obesity and diseases such as diabetes, heart and liver disease, and the most common chronic disease among children, tooth decay. SFMS’ own John Maa, MD, participated in a television ad that was aired in San Francisco. For more information, visit www.sfunitedtoreducediabetes.com.

CMA’s Practice Manager Tip of the Month

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Join or Renew Today!

When you join the San Francisco Medical Society, you join more than eighteen hundred members in San Francisco who are actively protecting the practice of medicine and defending public health. Working together with you, SFMS unites physicians to champion health care initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone.

Join SFMS/CMA Today

New members who join and pay full 2017 dues will receive the remaining months of 2016 membership for free. Join today to start receiving your benefits. Visit www.sfms.org/membership for more information about SFMS membership and benefits, or to join online.

Renew Your Commitment to Medicine; Renew Your SFMS Membership Today

Make sure you continue to receive the benefits of SFMS and CMA membership by renewing today. Full dues-paying members enjoy a five percent Early Bird Discount* if your renewal is received by December 15, 2016. There are three easy ways to renew your dues: • Mail/fax your completed renewal form when you receive it in the mail; • Renew online at www.sfms.org with your credit card; or • Enroll in Easy Pay Automatic Dues Renewal Plan** (quarterly installments) by contacting SFMS at (415) 561-0850 or membership@sfms.org. *Five percent Early Bird Discount applies to 2016 full dues-paying members only who are renewing at the same level for 2017; renewal form and payment must be received by December 15, 2016. **Easy Pay Automatic Dues Renewal Plan (quarterly installments) is available to full dues-paying members only; renewing members receiving the Early Bird Discount are not eligible for Easy Pay. WWW.SFMS.ORG

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

NOVEMBER 2016 SAN FRANCISCO MEDICINE

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PRESIDENT’S MESSAGE Richard Podolin, MD

“I Know Exactly How You Feel” Twenty years ago, the Chief of Surgery at a teaching hospital in New York was visiting San Francisco when he developed complete heart block. I took him to the cath lab and inserted a permanent pacemaker, which should have corrected his problem. When he returned to the telemetry unit it was clear that the pacemaker wasn’t working. A chest x-ray confirmed my suspicion the atrial lead had become dislodged. This had never happened to me before, and of course, it would happen when I was working on a prominent physician. I sheepishly entered his room and explained that I would have to take him back to the lab, re-open the incision, and correct the problem. His response was: “I know exactly how you feel.” All these years later, I still remember the kindness of those six words. One way or another, all physicians struggle with the consequences of our human imperfection. We make errors; there’s a whole literature devoted to classifying the mental traps that lead us awry. Even when we do our best, sometimes it’s not good enough. Patients who have entrusted their care to us have bad outcomes. At those times, in addition to sadness for our patients and their families, we can feel disappointment in ourselves, embarrassment, and sometimes shame. While thankfully infrequent, I suspect that this is a universal experience over the course of a medical career and yet we rarely, if ever, acknowledge these feelings to our colleagues. During training, no one talks about this internal toll, or how to manage it. In fact, it is made abundantly clear that our profession values emotional toughness. But that toughness can become an impediment when it diminishes our ability to construct and maintain empathic relationships with our patients. What physicians really require is not emotional toughness, but emotional resiliency. Toughness is an attribute of an individual. Resiliency can be fostered by the shared experience of a community. I regularly attend morbidity and mortality conferences, and I’ve served on peer review and credentialing committees. Physicians are generally fair to their colleagues. They understand that not all unexpected adverse outcomes are avoidable and that even the best physicians make mistakes. They make a diligent and honest effort to distinguish between isolated errors and patterns of poor care. But what I have never heard in these settings is: “I know how you must feel.” It goes without saying that our overriding responsibility is for the well-being of those under our care, and I’m not suggesting any equivalence between the dysphoria of the physician and an injury suffered by a patient. I am only arguing for acknowledgement of our experience, and for understanding its potential costs—to us as physicians, certainly, and also to our patients. A patient who has suffered a bad outcome is likely to have even greater need for the physician’s support, but just as it is difficult for a starving person to provide nourishment WWW.SFMS.ORG

to others, a physician who feels emotionally depleted may be ill equipped to provide the comfort and closure their patients need. Some may contend that my concern is misplaced. They believe a physician should experience discomfort when a patient does poorly; it motivates the physician to strive for excellence. Most of us probably encountered that sentiment during our training. But acknowledging a colleague’s feelings doesn’t erase them, it only offers the comfort of dispelling the mistaken notion that one is alone. The foundation of our profession is medical science, but the practice of medicine requires continued emotional presence as well. Yet this daily aspect of our professional lives receives little attention. Now, as the stresses on all of us increase, as physician burnout has become an increasingly recognized problem, it’s time we extend the gifts of presence and understanding to our colleagues. For those of us in teaching programs, we need to model the caring we hope our students will carry forward in their careers. It is our professional responsibility to foster an environment that promotes emotional health among physicians so that we, having received kindness from our colleagues, have greater empathy to offer our patients. Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff. Connect with him via the SFMS LinkedIn Group or send him an email at podolin@sfms.org.

Say No To Big Soda

This letter was published in the San Francisco Chronicle Sunday, October 13, 2016. The cover story “Big Soda’s tax claim falls flat with grocers” (Oct. 9) provides compelling evidence that the soda industry is intentionally deceiving voters with false claims about the real impact of Proposition V. As the grocers in the story realize, the tax would be on soda only. It would help pay for a healthier community and is supported by a wide array of health and medical organizations. In fact, the state Constitution prohibits taxes on groceries. The San Francisco Medical Society protests this deceptive campaign, which reminds us of similar efforts by the tobacco industry in the past. Voters should not be fooled by such deceptive tactics. We urge a “yes” vote on Prop. V, for the health of all—especially children. —Richard Podolin MD, President, SFMS NOVEMBER 2016 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

A Means, an End, and the Evolution of Medical Ethics “Medical ethics” covers a very wide array of issues and concern; from birth to death and beyond (e.g., organ donation policies), and when we called on potential authors from each local hospital to write for this issue on an ethical issue of their choice, we expected a spectrum of issues. But a big majority chose to write on the same issue: PhysicianAssisted Dying, or PAD. This really isn’t so surprising, given the timing at a minimum. PAD became legal in our state just this year, after decades of debate. It was a high-profile event, landing on the front pages of paper and media sites nationwide, and San Francisco has long been a locus of attention and advocacy on the issue. The SFMS’s own survey of physician opinion on PAD over a quarter century ago, showing strong support in the profession for an ethical and legal option for the practice, was the first such poll, and was itself “media event”—but more importantly, it served as a sort of taboo-breaking publication. At least a dozen subsequent physician polls around the nation showed the profession was very divided, or even in favor of, a legal option for PAD. Then, as other states legalized PAD, careful monitoring indicated that not only were serious problems rare or nonexistent, but that it could serve as a stimulus to improving overall end-of-life care. Our decades of work to get the California Medical Association to allow PAD legislation to go forward finally paid off last year. And now comes the important task of making sure this landmark law is implemented so as to ensure the best possible outcomes at a difficult time —and perhaps, to improve end-of-life care overall, as has been the case elsewhere. In any event, in this issue we are honored to have a perspective from one of the world’s leading bioethicists, Albert Jonsen, about evolution of his own opinion on PAD. In the following articles and hospital reports, we learn how local hospitals and health systems have been hard at work developing their individual approaches to PAD. Constraints can range from Federal law to faith-based conflicts to concerns about the adequacy of the procedural and clinical “safeguards” contained in the new law. There is still uncertainty among many clinicians, administrators, and others regarding how legalized PAD can and should be implemented—and reported. The reports herein give hopeful indication that it need not be as burdensome as the new law might make it appear, but can be done in line with best clinical practices anyway. Interestingly, when first talking with some of this issue’s authors about their forthcoming articles, some reported actual numbers of patient requests for PAD in the first few months since legalization in June. But upon review by legal and public relations advisors, those numbers did not appear in the final arWWW.SFMS.ORG

ticles here. One can speculate about the reasons for this, beyond it being a still-controversial subject. But it is clear there was some “pent-up demand” for PAD, at least in terms of requests. If other states’ experience holds true here, the actual procedure will likely be rarer than the requests. And we will wait to see how many physicians actually participate in PAD with their patients. The intensive follow-up evaluation mandated in the new PAD law, and now in some institutional guidelines, is likely to be very interesting and instructive reading. Another common, alas, ethical issue in recent times has been how to make difficult, often end-of-life, treatment decisions for patients who have limited or no capacity to do so for themselves anymore, and nobody else to do that for them —who have come to be called “unrepresented” patients. We are glad to have a report on that troubling topic. And since the primary locus of many ethical discussions has long been our hospital ethics committees, we welcome the report on CPMC’s committee, among the longest-running and most active anywhere. On the education of future physicians, see the summary of how medical graduates take oaths of practice in our time, and the brief note from the undergraduate front. And the report from Laguna Honda, long our city’s largest facility for end-of-life care—in fact, once the largest in the nation—and fully rebuilt in 2010 via public support, shows that it is a valued resource to us all, and an example of what the City of Saint Francis can do best. On other notes, see the reports on how SFMS members are leading both the ongoing response to the opioid abuse epidemic and healthcare crises in Haiti. At some basic level these are ethical issues too, of course. We thank all of our contributors for taking the time to share their expertise and wisdom with our readers. Editor and cardiologist Dr. Fung is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMS President. Steve Heilig is Director of Public Health and Education for the SFMS, managing editor of San Francisco Medicine, Co-Editor of the Cambridge Quarterly of Healthcare Ethics, co-founder of the San Francisco End-of-Life Network, and has been an ethics consultant at numerous local hospitals.

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Ethics in Medicine

END OF LIFE WITHOUT OPTIONS A View from Bioethical Retirement Albert R. Jonsen, PhD On June 9, 2016, The End of Life Option Act (ELOA) became law in California. This new law allows a terminally

ill patient to request a drug from his or her physician that will end the patient’s life. The statute requires that the recipient must be an adult resident of California who is terminally ill, that is with a prognosis of six months or less to live, and who is mentally capable of making his or her own health care decisions and is physically capable of self-administering the prescribed drug. The State of Washington in 1991 and California in 1992 saw ballot measures to legalize what was then called “physician-assisted -suicide” fail by two point margins. Oregon in 1995 passed a “compassion-in-dying law.” Several other states, including a repeat effort in Washington, have now passed similar laws. Each of these legislative efforts has stimulated vigorous debate, with each side offering cogent reasons and telling moving stories of suffering. Since I was professor of medical ethics at University of California, San Francisco, and at the University of Washington in the 1990s, I was inevitably drawn into those debates. My stance on this issue has changed over time. At first, I was oppossed to any legislation that would relax the ancient Hippocratic prohibition, “I will give no deadly drug, even if asked to do so.” My reluctance stemmed not only from this ancient medical precept which protected the profession from accusations of murder as they worked in the dangerous activities of healing, but also from the Judeo-Christian prohibition of killing except in self-defense. Finally, I feared that even the most compassionate proposals would start a slide down the slippery slope toward mercy killing and the Nazi elimination of “useless eaters.” My position shifted during the Oregon debates. The proposed legislation had added statutory language that reflected both a diffenent moral premise and an unprecidented practice. The different moral premise was a move away from the prior absolute prohibition of killing to the centrality of patient autonomy. The practice was the requirement that the patient be competent at the time he or she requested aid, and at the time when it was implemented, and also that the patient be able self-administer the lethal drug. The physician’s role is limited to a prognosis of death from the patient’s underlying disease within six months and to prescribing a drug to effect death. These features of the Oregon legislation appear to have prevented any slide down the slippery slope to impermissable euthansia. Also, many patients who make the request never use the prescriptions, and physicians are legally permitted to decline a request. All these provisions are incorporated in the California law. My principal objections have gradually eroded. However, I now have a new perspective. I now live in a retirement community. We have a few youngsters in their seventies and several centenarians. Although walking sticks and walkers are prevailWWW.SFMS.ORG

ing modes of transport, it is a remarkably cheerful place, with lots of laughter. Much of that laughter stems from jokes about lapses of memory, and therein lies the problem: many of us are slipping toward a time when those amusing lapses will become loss of memory, confusion and dementia. About a quarter of our companions, including my dear wife, reside in a section where they receive full time care needed for this condition. How will ELOA work in such a place? I know from many conversatioins that many, perhaps most, of my fellow residents strongly support aid-in-dying. They have lived long, good lives and now suffer from many discomfiting condition. They wish to die on their own terms and as comfortably as possible. The majority have signed living wills and Physician Orders for LifeSustaining Treatment (POLST). But few will meet the legal requirements of ELOA. They may become mentally incapacitated long before they have any health condition that promises their death within the six months specified in the law as a terminal condition. Even some who learn that they do have a terminal condition and can request aid-in-dying may no longer be able to utilize it as they approach a terminal state. Some will incur painful, severely debilitating conditions after falling into mental or physical incacacity. The compassionate framers of ELOA intended to enable persons to evade so wretched a death. But in their zeal to close the gate on the slippery slope, they exclude a remnant, perhaps a large one, from its benefits. This is not an argument against ELOA; it is a paradox. Albert Jonsen is one of the leading figures of modern healthcare ethics. He has been President of University of San Francisco, founding director of the University of California, San Francisco, ethics program and committee, Chairman of the Department of Medical History and Ethics, University of Washington School of Medicine, served on numerous Presidential and other panels, and authored many landmark papers and books, including the standard Clinical Ethics (with Mark Siegler and William Winslade), The Birth of Bioethics, and A Short History of Medical Ethics. He is currently Consulting Bioethicist, Program in Medicine and Human Values, at California Pacific Medical Center.

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Ethics in Medicine

REFLECTIONS ON OPTING IN Physician Aid-in-Dying Monique Schaulis, MD, MPH In October 2015, Governor Jerry Brown signed the Physician Aid-in-Dying Bill, the End of Life Option Act (ELOA), making California the fifth state in the nation to

allow terminally ill patients, who have capacity, to request a lifeending drug from their physician. In response, a multidisciplinary team from both The Permanente Medical Group and Kaiser Hospital/Health plan (KP) convened to develop our approach to operationalizing the law. A first step was to consult with our Northwest colleagues who have more than a decade of experience implementing a program to comply with Oregon’s Death with Dignity legislation. Our team has created policies, workflows, educational materials for patients and clinicians, and guidance on questions that may arise from physicians, managers, staff and patients. Each local area has a leadership team to oversee local communication, education, training, and implementation. We also heard from several patients and family members. Our team members spoke at length with Dan Diaz, the husband of Brittany Maynard, and Elizabeth Wallner, KP member, who also shared their stories on 60 Minutes. Northern California KP patients can now access a clear plan if they qualify for and desire physician aid-in-dying. Each medical center has a patient coordinator who receives electronic or verbal requests from providers. This coordinator explains the program and walks the patient step-by-step through the process, including finding local physicians to be consulting or attending physicians. As a result of this incredible front-end work, what looks to be an onerous process on paper is streamlined in practice. Patients can often get through the multiple steps required by the law in just over two weeks. Physicians can focus on whether the patient qualifies for assistance in dying, and/or needs more palliative or mental health services. The system supports physicians though the paperwork and provides mentoring and debriefing as needed. I was asked to be the consultant physician for a Kaiser San Francisco patient who asked for assistance in dying. This compelled me to do some soul searching. As an emergency physician, I have witnessed much suffering at the end of life. I see the cases where symptoms and suffering are uncontrolled, or when sudden trauma or family dysfunction makes death at home difficult. Wearing my other hat as a palliative care physician, I know that personal growth and closure often happen at the end of life, and can be key to a person’s legacy. There has been debate within the palliative care field about whether aid-in-dying is ethical and necessary, or just demonstrates the U.S. healthcare system’s failure to provide good access to quality palliative care. Some of WWW.SFMS.ORG

my most respected palliative care colleagues told me they would not participate and this worried me. Also foremost on my mind was a family member who died from amyotrophic lateral sclerosis (ALS) in 2015. She lived in California but desperately wanted to travel to Oregon to receive medical aid-in-dying. Ultimately, she was unable to travel as her disease was too advanced. For our family, this legislation came just months too late. I decided to opt in. As it turned out, my patient requesting aid-in-dying was also a physician. The oncologist said the cancer would become highly symptomatic soon and that no more disease modifying treatment existed. My patient was clear, focused, and calm. There were no issues of coercion and no concerns of access or health care disparities. The patient understood the medical issues and the ramifications of the decision. The partner agreed. This was a simple request for aid-in-dying before total disability, on the patient’s own terms. Once in contact with my patient, my hesitations and doubts disappeared. We had a meeting at the patient’s home in which we met all of the requirements of the law, and discussed so much more. It was a conversation between two mortal colleagues facing death at different times. Ultimately, the decision to request aid-in-dying is a deeply personal one, as is the choice to participate as a physician. “I do not know what I would do if I were dying in prolonged and excruciating pain,” Jerry Brown wrote. “I am certain, however, that it would be a comfort to consider the options afforded by this bill. And I wouldn’t deny that right to others.” If you are asked to participate, do not look away, look inside. Monique Schaulis MD, MPH, practices emergency medicine and home based palliative care at Kaiser San Francisco. She graduated from University of Chicago Pritzker School of Medicine and did her Emergency Medicine residency at Highland Hospital in Oakland. She has done specialized communication training through the Palliative Care Education and Practice Program at Harvard and the Vital Talk program. She serves as a Vital Talk facilitator and is on the board of SFMS.

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Ethics in Medicine

CLINICAL ETHICS COMMITTEES A Long, Strange Trip William Andereck, MD Hospital Ethics Committees came into existence in the early 1980s. California Pacific Medical Center (CPMC)

has had one since 1985, and I have had the privilege of serving as its chair since inception. In the following few paragraphs, I hope to give the reader an idea of the climate from which these committees arose, what they became, and how I see the field of Clinical Ethics evolving from their groundbreaking work. Thomas Percival coined the term “medical ethics” in his text of the same name, published in 1803. His book, Medical Ethics, recognizes some of the general principles that promote the nobility of the profession and the physician’s duty to their patient’s general welfare. However, its focus is in a different direction. Most of the contents fall into what should be called “medical etiquette,” describing the role of the doctor in the community of healers. It addresses such things as the relationship between physicians and pharmacists, primary and consulting physicians, self-promotion to patients (advertising), and the relationship between competing physicians themselves. (This is the source of the admonition that doctors should not solicit patients who already had a relationship with another doctor.) In essence, patients were considered a commodity on which doctors would practice their noble craft. Percival proposed the rulebook for good practice etiquette within an exclusively paternalistic system. The arbiter of etiquette disputes was the local medical society, not the hospital. This was the tenor of the “ethical practice of medicine” until the early 1970s. Two things changed independently, but together they made the “good old boy” system unsustainable and refocused the idea of ethics from that of etiquette to grappling with the profound moral dilemmas that we face today. The first was a social revolution in America. The seminal book Our Bodies, Ourselves, published in 1971, gave voice to the deep social changes that swept our country in the decade before. The development of safe and effective means of birth control spurred young women to demand respect for their reproductive rights. The concept spread like wildfire, and patients quickly asserted that if their reproductive organs were due respect, so was the rest of their body. Patient values gained a place in medical decision-making. The previous culture of paternalism was under assault. The second development that thrust physicians into the realm of moral dilemmas was a product of our own success. Coronary Care Units (CCUs) appeared in the sixties and, along with them, cardio-pulmonary resuscitation. Early success in CCUs developed specifically to treat acute myocardial infarctions opened the door to the application of the technique, now called cardiopulmonary resuscitation (CPR), to every hospital bedside. And for those we could “return to spontaneous circulation,” our intensive care units could make sure they stayed that 14

way for at least a few more days. Resurrection was in our sights. In short, doctors gained the ability to be too good for their patient’s own good. This was the cultural milieu of the 70s, and the case to ignite it was Karen Ann Quinlan, a woman in what we now know as a persistent vegetative state. The decision to remove her from the respirator created a public clamor. In those days, whenever there was some public turmoil, the civilized response was to form a committee. Hospital medical staffs decided to call it the “Ethics Committee.” Throughout the 80s and early 90s, hospitals around the country, including my own, set up “ethics committees,” usually as a committee of the Medical Staff. Most of them were charged with three things: education, policy, and consultation. Many were formed, but few succeeded. After one or two impassioned medical staff conferences and a few visiting lecturers, many committees settled into a period of self-education. Since the consultations often were not rolling in, the committee turned its attention to such things as the hospital’s “Code Policy” or its informed consent documents. By the dawn of the 21st Century, it was clear that things were not working out as well as planned. Surveys showed that most hospitals that did have ethics committees were averaging around twelve consults a year. Unfortunately, over forty percent of doctors said they were hesitant to ask for an ethics committee consultation. Almost one third of the doctors surveyed felt it was too time consuming, and fifteen percent felt that it made the situation worse. Physicians did not find the consultations helpful and felt the consultants were unqualified. Published reviews of successful consultation programs reported only about one third of consultation requests coming from doctors. In 2003, Dr. Albert Jonsen and I decided there needed to be a better way. Thanks to the generosity of several wonderful people, we began the Program in Medicine and Human Values (PMHV) with the goal of bringing the lofty ideals of medical ethics to the bedside, redefining it as “Clinical Ethics.” We sought out philosophers, trained in the abstract, but well versed in the ethical concepts that validate the profession. A PhD from the finest university turned out to be not enough. Practical wisdom was harder to find. So we started our own Clinical Ethics Fellowship, introducing some of the brightest products of the academic world to the rigors of clinical medicine. After completing a fellowship embedded with the medical teams who have asked for ethical guidance, our clinical ethicists have developed a set of skills which enables them to help untangle the conundrums facing clinicians trying to do their best. The clinical ethicist is not a social worker, lawyer, chaplain, or palliative care specialist. There is a definite set of skills

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shared with these disciplines, however. Clinical knowledge is augmented by refined communication skills and an appreciation of patient centeredness that helps to foster a patient’s trust. What distinguishes the clinical ethicist is the ability to distill the value sets of significant participants and help them more clearly understand their aspirations, obligations, and professional responsibilities. The response to a professional bioethicist available to staff members has been overwhelming. Our consultation rate at CPMC increased from an average of about twenty per year to over one hundred. This can be attributed both to the quality of the bioethicist as well as their availability and work product. Previous ethics consults were conducted by volunteer members of the ethics committee, often after hours, and sandwiched in between other responsibilities. It was much easier to listen to someone else’s opinion than obtain the primary data yourself. A fivefold increase in the request for consultations that occurred after the introduction of our bioethicist quickly outstripped the ability of our volunteer committee members to respond. Our bioethicists spend hours analyzing each consult. Each patient is seen in person, and family or surrogates are often interviewed. The medical facts of the case are fully reviewed with the health care team and the specific ethical components of each situation are discussed. In every case, the clinical ethicist works with the advice and support of the ethics committee chair. If the chair feels it is appropriate, additional members of the hospital ethics committee are invited to participate in the formal consultation process. Where medical decisions are necessary, treatments that are not ethically appropriate are identified while appropriate treatments are also recognized. Each case is thoroughly documented in the medical record and the patient is followed throughout the remainder of their hospital stay. To date, we have accumulated a caseload of almost two thousand consultations. Analyzing these cases, we have been able to identify patterns and trends in our consultation experience that have resulted in specific actions that have had positive results. A hospital policy addressing requests for nonbeneficial treatment resulted in a better understanding by our physicians of their ethical and legal obligations, as well as better comfort in dealing with requests for things that will not benefit a patient’s condition. Increasingly, we are being consulted about medical decision-making for incapacitated and unrepresented patients. After over one year of evaluation, we have introduced a policy to help provide some order to the situation. Our advice is now sought on matters beyond the bedside. When Sutter Health chose to respond to the State law allowing Aid-in-Dying, PMHV was called to help formulate a coherent plan and response. The Program’s bioethicists offer more than a word from the wise. When catastrophic cases in the newborn intensive care unit have left nurses devastated, we have been there to help them decompress. Nurses tell us all they could do is cry . . . and now they have us. The clinical ethicist is a new entity in the modern hospital—not someone who is needed in most cases. They only get involved in the tough cases, the ones when the best course of action is not always so clear. We are still experimenting with how this individual should coordinate with the hospital’s ethics comWWW.SFMS.ORG

mittee but, for now, it should be a close collaboration. From the inception of our professional consultation service in 2005, Sutter Health and others have asked us to develop some metrics that demonstrate the value ethics consultation brings to the institution. Differing views of “value” as quality vs. reduced length of stay, and imprecise metrics have confounded the task. One reliable indicator of value does stand out however—utility. Physicians are not ones to spend time and effort on something if it does not contribute to a better way of doing things. A fivefold increase in our number of requests for consultation indicates that we are providing a service that the clinicians find helpful. The increase in requests for consultation is even more impressive when the source of the request is identified. National surveys of functioning ethics committees report that about one third of consultation requests are initiated directly by physicians. At CPMC last year, a high percentage of the ethics consults were requested by physicians. Clearly our efforts to help the doctor make the best medical decision have been accepted as a useful intervention in appropriate circumstances. Nothing remains the same, and that will be true for ethics committees. Over time, I see the hospital ethics committee becoming less involved in the day-to-day activities of an ethics consultation service. Instead, they should continue in an oversight function. The role of the ethics committee of the future is to keep its finger on the ethical pulse of the institution. Following the activities of an ethics consultation service is one way to do that. The challenge for the hospital committee will no longer be assisting in individual case decision-making. Instead, its task will be to translate the lessons of many case experiences to the organizational level. What a long, strange trip it has been. The cowboys and pioneers of the early days of well intentioned but unfunded bioethics efforts have persevered to see the rise of the professional model of Clinical Ethicist, complete with a defined set of skills and competencies. A clinical discipline is evolving to help us understand our own ethical obligations in an increasingly complex world. It’s about time. William Andereck, MD, is a longtime internist at CPMC and chair of the ethics committee and director of the Program in Medicine and Human Values there, which he co-founded with Dr. Albert Jonsen. He has co-chaired numerous ethics conferences, authored many articles, and is on the editorial board of the Cambridge Quarterly of Healthcare Ethics. He is a past Editor of San Francisco Medicine.

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Ethics in Medicine

CALIFORNIA’S END OF LIFE OPTION Preparing for PAD Ruchika Mishra, PhD On June ninth of this year, California became the fifth state in the country to implement a law that allows terminally ill patients to request an aid-indying medication from their physician. The state law

permits participation by organizations and providers to be optional. Most hospitals, hospices, physician foundations, outpatient practices, and health care systems in the Bay Area are currently in the process of developing policies to implement this new law. The practical application of the law raises several important ethical questions for our community of patients, their families, physicians, other health care providers, as well as institutions that deliver care to patients at the end of their life. What choice do people have to determine how they live and die when faced with a terminal diagnosis, and to what extent will society recognize and support the rights of these individuals? It highlights the intersection of patient rights, physician rights and duties, the foundation of the doctor-patient relationship, and the psychosocial dynamics of being terminally ill and caring for an individual in the last stages of life. In this article, I want to focus on some scenarios of ethical relevance that physicians and patients should be prepared for.

Physician Participation

Physicians should know the policy of the organization within which they work. For participating organizations, physicians would have the right to choose if they will participate in the law. This includes providing information to patients about California’s End of Life Option Act (ELOA) as well as prescribing an aid-in-dying medication. If they choose not to participate, they do not have an obligation to refer the patient to a participating provider. However, physicians are still obligated to notify the patient about their terminal diagnosis and their right to seek other end-of-life options, including palliative care and hospice. If the patient asks further information about end-of-life options, the physician is obligated to discuss available medical treatments and choices that the patient has.

Patient Decision

There are several factors that need to be taken into consideration as a patient undergoes the process of receiving the aid-in-dying medication. This includes issues of capacity, coercion, and deliberation over one’s own preferences regarding how their last moments will be. Participating providers must ensure that the patient is able to understand their diagnosis, the treatment options available, risks and benefits, and make an autonomous informed decision regarding the option that best fits their value system. If there are any concerns about the patient’s decision making capacity or mental health issues that may im16

pact the patient’s ability to make their own decision, the patient must be referred to a mental health specialist. Physicians should know, however, that every patient who asks about the new law may not necessarily want to pursue obtaining the medication. Physicians should use effective communication skills to engage with patients to explore reasons for their request and discuss appropriate treatment options that may be available to address the patient’s concerns. The data from Oregon reveals that the majority of patients who want to exercise their right under the state’s Death with Dignity Act (DWDA) is due to loss of autonomy and control. It is in these compassionate conversations that the patient’s fears and anxieties come to light and physicians can build on their longstanding trust and relationship with the patient to provide care and support when they may need it the most. The other side of informed consent is informed refusal. A patient with capacity can provide consent for treatments but they can also make a decision regarding refusing indicated treatments. If a patient refuses treatments that may help manage a chronic condition, physicians should be prepared for a deterioration in the patient’s condition possibly making a manageable medical condition now terminal. If the patient meets other legal criteria allowing the individual to be qualified, they may be eligible under ELOA to receive an aid-in-dying medication.

Family Disagreement

It is important to recognize that the law brings about a cultural shift in how patients cope with the stressors of a terminal diagnosis and, ultimately, make medical decisions that are rooted in their values and wishes. While the law clearly upholds the patient’s right to autonomy for those individuals who meet criteria and are able to self-administer the medication, their families may still struggle with the patient’s decision. Though the Attending Physician is required to counsel the patient to discuss the pursuit of ELOA with their next of kin, it does not place a binding duty on the patient to follow through with this discussion. Many family members may experience guilt or seek answers for their emotional struggles. It would be appropriate to involve social work and spiritual care to help address family concerns and provide adequate support. However, providers must respect patient confidentiality in discussions with family members.

A Time and Place to Die

Patients may choose to ingest or not use the aid-in-dying medication prescribed to them by their physician. Ultimately, it will be up to every individual patient who pursues ELOA to decide when, where, and how their last breath will go. For many patients, it may be in the comfort of their home after having said

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Ethics in Medicine

SOMEBODY’S SOMEBODY Representing the Unrepresented Patient W. Donnie Nelson, RN and Kathleen Jordan, MD At home it hits me: I held the hand of a person who died today, same as I did two days ago. I wish the family

could have been there, to feel the roughness of his calloused fingers and hear the monitors beep should his heart go too slow or his blood pressure too high. With his waning level of consciousness he didn’t understand why he needed to be hooked to the dialysis machine. The lights were hard and bright. I file his memory in my mind and in my heart. As I assess patients like him for palliative needs, I look for someone who loves and cares for them or can speak to the patient’s wishes. I contact any known family or friends or a prior health care provider. Too often, I have a “John Doe” or I find family that stopped caring long ago. I do my best to find out details, because details are important. Did he have a job? What was his favorite food? Are those his children’s names tattooed on his forearm? Maybe they are names of friends he served with in the military. In these situations, our Ethics Committee convenes a hospital working group to help. We recognize that this person, ravaged by disease, drugs, alcohol, time, and neglect was once somebody’s baby, somebody’s father, mother, husband, wife, partner, grandmother, grandfather, brother, sister, or just somebody’s somebody. We act as family members to this stranger in a hospital bed. Occasionally our “John Doe” may finally have a name, often known in the community by various Department of Public Health agencies. But along the way nobody found out if he had any family, a spouse, a friend, or someone to speak to his interests. No durable power of attorney (DPOA) or emergency contact exists. Sometimes, we find family with the help of the Internet and the dedicated ICU social worker. We may find children who haven’t seen this patient in years. We convey to the family that, despite today’s technology in medicine, we can’t cure the patient and the best thing is to let them pass. I promise them we will do everything possible to make the patient as comfortable as possible and ease their suffering. We set up a time to stop all artificial interventions. I sometimes use my smartphone so the family can see the patient one last time. And I become the family’s surrogate. I hold the patient’s hand tight, as tightly as I would if it was my own loved one. I thank the patient for letting us care for them and tell them they can rest. The patient’s breathing slows, their heart rate and blood pressure drop. There have been many patients whose hands I have held in their last few moments. They may have suffered from mental illness, addiction, poverty, or a variety of situations that led them to be alone at the end. I can’t imagine the suffering they endured before coming to me. They had no one. WWW.SFMS.ORG

I am also grateful that I’m alive and healthy, and that I get to be somebody’s somebody.

W. Donnie Nelson, RN, is director of Palliative Care at Saint Francis Memorial Hospital. *****

This essay was written by W. Donnie Nelson, RN, the palliative care coordinator at Dignity Health Saint Francis Memorial Hospital. Saint Francis implemented a program in 2012 mandating that all patients in the ICU have an interdisciplinary meeting with physicians, the patient and their family or appointed surrogate within three days of their ICU admission. We are now having meetings within forty-eight hours of ICU admission. These meetings have been effective in discussing goals of care, symptom management issues, and advanced care planning. They have improved communication between the physician, patient, and family, and, at times, have introduced palliative care planning. These timely meetings, along with a multitude of other efforts around quality of care, have decreased the number of patient vented days in the ICU, decreased lengths of stay in the ICU, and have improved overall patient care. As noted in Donnie’s essay above, unrepresented patients have been particularly challenging. In the process of setting up these family meetings, we find that some patients have no one to speak on their behalf. All clinically reasonable efforts are made to allow the patients to improve and/or come off sedation to make their own decisions. When this is not possible, we search for a surrogate medical decision maker, a previously documented durable power of attorney (DPOA), annotation of verbally appointed surrogates, a family member or spouse (sometimes estranged), or, at times, find a primary care physician that knows the patient. Some patients still have no one that can be identified to speak on their behalf. In these cases, our ethics committee will convene to aid in decision making. We have an average of fifteen ethics consults a year to aid in decision making for unrepresented patients. In an effort to eliminate the need for unrepresented decision-making and to aid patients in identifying their own health advocate and completing a DPOA, we have partnered with local nonprofit agencies and the Department of Public Health (DPH) to bring education on Advance Directives and Physician Orders for Life-Sustaining Treatment (POLST) forms to the members of the San Francisco community. We have focused on groups in highrisk situations that are most likely to be unrepresented; residents who do not have a next of kin, have been estranged from their legal next of kin, have psychiatric diagnoses, and/or have sub-

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Ethics in Medicine

ETHICS BEYOND THE BEDSIDE Three Realms of Theory and Practice Carol Bayley, PhD In 1994, Jack Glaser, an ethicist in Southern California, published a book entitled Three Realms of Ethics. In it, Glaser describes a concentric circle of ethics, with individual ethics at the center, institutional or organizational ethics at the next level out, and social ethics at the outer ring. As an organizing model for thinking about a variety of ethical issues, Glaser’s concentric circles have a great deal to tell us about how to understand a concept of ethics that is broader than ethics consultation at the bedside. As the great (sinking) ship of American health care turns to become a more integrated system that values wider access to preventive care as a rational use of limited resources, this model illuminates ethical responsibilities beyond the bedside. For the most part, when we think of ethics in regard to health care, it’s the realm of individual ethics that forms the backdrop in our minds. Whether to withdraw mechanical ventilation from a patient whose daughter is protesting (or insisting . . . ), whether the “non-compliant patient” can be ethically discharged from a home care agency’s service when he is unable to follow a plan of care designed for his safety and well-being, whether it is right to discharge a patient from the hospital to home when “home” is a tent under a freeway overpass—these questions about what it is right or best to do for an individual person are the questions that appropriately concern us at the individual level. These questions about actual human beings in front of us are more vivid and real than the abstractions we may find ourselves facing at the other levels of ethics. Questions about what contributes or will contribute to the flourishing of a person, about the rights and duties that exist between individual persons, or about the virtues and behaviors of “good” persons are not necessarily easy to answer, but they are intelligible and familiar ethical questions. They are also questions we have mechanisms to address, in the form of ethics consultants or ethics committees. In Glaser’s model, the middle ring, situated between individual ethical questions and those that reside at the level of society as a whole, is the realm of organizational or institutional ethics. At this level we find an institution’s systems, structures, and policies that constrain and direct the actors within it. Here we see, in management decisions, strategic plans, and choices an organization makes, evidence of its priorities for accomplishing good. Sustaining itself as an institution, growing in the ability to serve the public, maximizing returns in both the long term and short term for shareholders—these are all measures of the flourishing of an institution. At this level, though, the role of ethical inquiry is less clear. It is not enshrined in law, to the extent that, for example, advance directives or informed consent are, both of which have greatest effect at the level of the individual. The Joint Commission does not review an organization’s investments, employee benefits, or environmental practices the way it does policies on patient’s rights. The conflict of 18

values that mark an ethical issue are by and large less examined at an institutional level. But they are not difficult to find. The final realm of Glaser’s model is at the outermost ring. It is that realm of ethics that deals with the social conditions that contribute to what we might broadly call the common good. With a wider lens than institutions or organizations, this level sets the parameters for both individual and organizational flourishing. Probably the most important learning from Glaser’s thought is his insight that the pressure in this system comes from the outside in: the outer realms of ethics define and either enable or prevent ethical action at the interior levels. Working in Catholic health care institutions his whole professional life, Glaser often said, for example, that it was easier to find the biblical value of equality in a German secular hospital than in the most Catholic of hospitals in the United States. That is because German social ethics sees a basic guarantee of the good of health care as fundamental to the right working of society, whereas in the United States, society as a whole has not made this a priority. A hospital in the United States, regardless of how committed it is to equal access to its services no matter who the patient is nor her ability to pay, will always be constrained by a system that sees health care as a benefit of employment, incarceration, or destitution. So where does this vision of three realms of ethics leave the ethically minded practitioner or administrator? Although no one will say that there are ready answers to every clinical ethics issue at the bedside, the truth is that many of the early ethical issues have been settled, in best practice if not in all cases. We now agree that the desires of a patient for limited treatment, whether these are stated by the patient while he or she has capacity or in an advance directive or Physician Orders for Life-Sustaining Treatment (POLST) after the patient has lost it, must be respected. We know that respecting the dignity of persons means we must own up to errors in treatment and compensate a patient who has been harmed. We have learned that it is a serious ethical issue to either under- or over-treat pain. Even if all these things are not perfectly executed in practice, we do have basic and widespread agreement on what is right to do in principle. And when we have a live case with a wrinkle not anticipated in policy, we have ethics committees and ethics consultants who are skilled in negotiating the real facts of any given case to give a recommendation that is warranted. It is the other two realms of Glaser’s ethics model that genuinely need attention. If the questions are intelligible and familiar at the individual level, the questions at the organizational level may be intelligible but the systems of dealing with the ethical issues involved are not always recognized. And the questions at the social level of ethics are sometimes not even recognized as ethical issues, but have been channeled, unhelpfully sometimes, directly into political debate. Let’s look at each in turn. An organization makes ethical choices every time it sets policy,

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approves a strategic plan, or makes any of hundreds of management decisions that affect employees, patients, families, privileged physicians, and the wider community. The most obvious way to influence the ethical nature of these decisions is to be at the table where such decisions are made and to raise the ethical questions. We know how long it took for clinical ethics to overcome the worry that ethics committees were the “ethics police.” There is something about the word “ethics” that lends itself to this misunderstanding. Therefore, at the management tables and in the board rooms, a much more effective means of raising these questions is to call out the inevitable conflicts of values that exist any time we have to make trade-offs, whether because resources are limited, because legitimate interests compete, or because vulnerable people may be disproportionately affected. Attentive to disparities in power that ordinarily accompany decisions made in organizations that are necessarily hierarchical, leaders and others must recognize that the best decisions are made by teams of moral equals. Even though we may not always fully address all the values at play, making conflicts visible and addressing them openly will promote better plans, policies and decisions over all. The ethical issues that reside at Glaser’s societal, or outermost, level is perhaps the most difficult. At the same time, if it is true that ethics at the organizational and individual level can only be marginally more ethical than the constraints set at the level of society, it may be the most important level to find a way to affect. When we approach the issues of human trafficking, global warming, or gun violence, for example, which so dramatically undermine human flourishing, it is insufficient to wring our hands and feel bad. There are several actions that concerned health care professionals can take. The first is to name the issues as ethical issues and to conceptualize them as ethical issues in health care. For example, characterizing the effects of gun violence as a public health issue rather than an outcome of a particular political stance on the Second Amendment can set a perspective that is sometimes missing in public conversation. When individuals do this, it changes individual minds; when institutions do it, public conversation can affect the larger debate in society. Professional organizations and health care companies are uniquely situated to contribute to these public conversations. To the degree that such institutions utilize the language of values conflict and trade-offs in their own internal decisions, they will be better situated to identify such tension in the arenas that shape our social environment. Lobbying for fair regulations, the promulgation of consensus statements, and sharing responsibility for the effect of public policies on vulnerable populations are all ways organizations and institutions help form that outermost ring. Individuals can have a voice in organizations and are ethically bound to use that voice. Organizations can have a voice in the making of law and public policy and are ethically bound to use that voice, not only to protect the organization’s interests but also to contribute to a society in which human beings can flourish.

California’s End of Life Option Continued from Page 16 . . . their final goodbyes to their loved ones. Hopefully, the majority of these patients will have chosen to enroll in hospice and ensured their advance care planning documents, including advance directive and Physician Orders for Life-Sustaining Treatment (POLST) form indicate their end-of-life wishes. Some may request their physician or hospice provider to be with them in their last moments while others may choose to be alone. Whatever the patient decides, one hopes that the end is peaceful, comfortable, and how they wished it to be. Dr. Ruchika Mishra is a Bioethicist at Sutter Health’s Program in Medicine and Human Values at California Pacific Medical Center (CPMC), San Francisco. She oversees the standardization of ethics services across Sutter Health Bay Area Hospitals. She completed her Fellowship in Clinical Ethics at CPMC after receiving a PhD in Philosophy, specializing in Medical Ethics, from the University of Leeds, England. She also edits the ‘Ethics Committees and Consultants at Work’ department for the Cambridge Quarterly of Healthcare Ethics.

Somebody’s Somebody Continued from Page 17 . . . stance abuse issues. Our efforts have included trainings with local single residence occupancy (SRO) hotels on-site advocates, DPH, and health clinics serving this patient population. These trainings have helped at-risk community members identify a decision maker who is in line with their own beliefs and needs regarding health care, and, ideally who can act as their health advocate. As part of these efforts, Saint Francis hosted the California Coalition of Compassionate Care’s (CCCC) “Beginning the Conversation: POLST Train-the-Trainer” two-day conference this year. Saint Francis also has partnered with the Chinese Coalition of Compassionate Care (CACCC), Hospice by the Bay, Self-Help for the Elderly-Hospice, and Pathways Hospice to hold two-hour Advance Directive workshops in Cantonese for San Francisco’s Chinese community. Our hope is that we can help our citizens identify decision makers and a support system in advance of an acute illness. Kathleen Jordan, MD, is Chief Medical Officer of Saint Francis Memorial Hospital.

Carol Bayley is the Vice President for Ethics and Justice Education at Dignity Health, a large multi-hospital health system with services in California, Arizona and Nevada. She is responsible for education in applied ethics for physicians, nurses, residents, staffs and ethics committees, and the integration of ethical concerns into business decisions at all levels of the organization. WWW.SFMS.ORG

NOVEMBER 2016 SAN FRANCISCO MEDICINE

Ethics in Medicine

LAST RIGHTS A Personal and Professional Reflection Steve Heilig, MPH California has now legalized “physician-assisted dying,” or PAD—a human right none of us hopes to ever need to

use. And therein lies a story, or at least my version of one. San Francisco in the 1980s was an epicenter of the HIV epidemic, before the virus was even identified and before any real treatment came available. Landing in the city to continue my education and training, I took a job with the SFMS helping coordinate the city’s response, became a trained hospice caregiver, and volunteered as a board member of AIDS organizations. It was a baptism by fire for many. But what I most recall are the people who died premature and often difficult deaths, and of those who took care of them breaking down and weeping even at medical meetings due to the overwhelming suffering all around us. Only later did it become clear how much lasting PTSD lingered in many people living through those years. Even without the possible resurgence of infectious diseases, heart disease and cancer remain our two leading causes of death, but the real underlying diagnosis is birth itself, for nobody gets out of here alive. Becoming all-too-aware of this central fact of life at a relatively early age, I immersed myself in healthcare ethics in general and physician-assisted dying, or PAD, in specific because I’d seen it, firsthand, many times. AIDS patients were passing around the formulas needed to end their own lives when that was coming soon anyway, and were asking for exact dosages of medications. Thus, for me the ethics of the “right to die” became a central concern.

With respect to PAD some signature memories followed.

In 1988, JAMA published an anonymous physician’s story of PAD titled “It’s Over, Debbie.” I was astounded to see what I knew was occurring printed in such an august publication, especially as the AMA had always been opposed to PAD. In retrospect this brief piece was the start of the breaking of a modern taboo. I began to think about how to further more discussion. In 1989, I published a PAD survey of almost seven hundred San

Francisco SFMS physicians. The results indicated a strong majority supported a legal PAD option. At the SFMS board meeting where I announced the results, the first response was “Can we just bury this?” But we published, and landed on the front page of the Chronicle, making national news. This was the first such survey and more followed, with generally consistent results.

In 1990, Dr. Jack Kevorkian publicly hastened the death of a

woman with an early Alzheimer’s diagnosis. Like many, I found Kevorkian ghoulish; but I also thought him courageous in his effort to “put this issue on the front page.” 20

In 1991, Dr. Timothy Quill of New York published his story of

actively hastening a patient’s death in the New England Journal of Medicine; his compassionate story again sparked much debate.

In 1992, California voters rejected a ballot proposition that

would have legalized PAD, 54 to 46 percent. The California Medical Association (CMA) and Catholic Church were the primary opponents. I wrote an op-ed for the CMA’s journal gently suggesting their longtime “just say no” position was no longer representative. Response was large and positive, and mostly kept private.

In 1997, I served as moderator for a California State Assembly hearing on PAD; when the CMA’s representative said that in thirty years he never had a patient ask him about PAD, the chair retorted “Perhaps they are afraid to ask you.”

In 1999, I convened meetings of many ethics committee members to develop clinical guidelines for PAD. Published in the Western Journal of Medicine, they became the subject of a cover story in the New York Times, titled “Guidelines for the Unthinkable.” The practice of PAD was still illegal, but subsequent guidelines for the practice have been consistent with ours. In 2006 and 2008, California attempts to legalize PAD failed; the CMA remained the primary opponent.

In 2013, the SFMS’s latest attempt to convince the CMA to change its PAD policy from “oppose” to “neutral” was rejected without debate at their annual meeting. Our elected delegates worked hard to convince their colleagues that PAD could be an ethical option, or that CMA should at least be neutral on the topic to reflect true medical opinion as revealed in the surveys. But we were voted down without real discussion—almost as if we were indeed proposing something “unthinkable.”

In 2015, a new legislative attempt to legalize PAD in California began. Aware that such a law would still never pass over the continued opposition of the CMA, I talked privately with some CMA leaders, noting CMA policy is supposed to be “evidence-based” and now we had that. Encouraged to try again, I drafted an SFMS letter to the CMA leadership, which read in part:

As you may recall, the SFMS delegation to the CMA has repeatedly brought resolutions to the CMA urging a “neutral” position on this topic, for two primary reasons: (1) Physician Opinion: Extensive survey data now shows that physician opinion on this topic is strongly divided, with even a majority in support of a legal option. The most recent survey, by MedScape in 2014 of over twenty-one thousand physicians, had a 54 percent “yes” response on the question “Should physician-assisted suicide by allowed?”

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

(2) State experience: The “laboratories” of states that have legalized PAD is showing that the feared consequences have not materialized. In fact, as noted in a review in the New England Journal of Medicine, “The legalization of assisted death has been associated with substantial improvements in palliative care in Oregon, in areas including the appropriate training of physicians, the communication of a patient’s wishes regarding life-sustaining treatment, pain management, rates of referral to hospice programs, and the percentage of deaths occurring at home.” We of course understand that this is a very complex and emotional topic, and we certainly support continual improvements in end-of-life care. We would advocate for nothing that we felt would harm patients or medical practice, or that would require violations of medical ethics. However, we feel strongly that the evidence with respect to medical opinion and experience on this topic logically leads to a CMA position of “studied neutrality.”

The CMA, to their credit, this time decided to reexamine longstanding policy. They posted the question online for member input, and garnered almost a hundred comments, with those favoring neutrality in the strong majority. Then the CMA Council on Legislation convened a meeting on the legislation. Testimony was eloquent and heated. When lunchtime came, the committee chair asked for a hand vote; the result also strongly supported neutrality, by at least three to one. I’ll never forget that moment when some appeared shocked, looking around with their hands up, seemingly asking “Oh, you too?” It was as if a “sea change” of opinion had quietly occurred. Thus, the CMA removed its longtime opposition to PAD. The magnitude of this change was quickly apparent. The PAD bill moved forward, and reached Governor Brown’s desk. We knew his fellow Catholics would be weighing in with him in opposition. I called anybody I knew who knew him and asked them to contact him if they felt strongly regarding PAD. Soon his message came; it was clear he had thought deeply about it, and he concluded “I do not know what I would do if I were dying in prolonged and excruciating pain. But I am certain that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.” Response was immediate, with front-page stories around the nation. Physicians and others who had worked on this got in touch, elated. Many said they never believed it would happen in their lifetime (conversely, some medical students just asked “Why was it illegal so long?”). Old allies confessed they cried. And I was not immune to that. Driving over a mountain road the day after the Governor signed the bill, spotting a road-killed animal, I was caught by surprise by emotion welling up in me and had to pull over and let it come out in tears. Memories of many patients, of pets, of seemingly fruitless debates came to me. I realized I too had not truly expected us to prevail. Many had given up. But now over two decades of work had finally paid off. And as California goes, so goes the nation, some say—the AMA, again via prompting from SFMS and now CMA, is reviewing their PAD stance for the first time in generations. The Hippocratic Oath, for all its wisdom, is rarely taken these days, and proscribes both abortion and surgery—and most notably, was written long before medicine could do much to help patients at end of their lives, whereas now lives can be extended far beyond what most might desire in retrospect. When I taught medical and other students on the topic of PAD, I often used this vignette: A physician has two patients, both near death and askWWW.SFMS.ORG

ing her to help them die. In one room she enters and turns up the morphine drip, saying “I can’t speed your death, but this will treat your suffering”—and the patient dies, sooner than otherwise would have occurred. In the second room, she turns up the morphine, saying “Here, this will end your life.” The exact same action in each room. In the first room her actions have been endorsed by the AMA, United States Supreme Court, and widespread practice. In the second she can be called an unethical killer, eligible for charges of murder. So in the conflicting eyes of the law and of much ethical perspective as well, this is really about intention. The primary dictum of “Do no harm” endures, though—and should include doing no harm via over-treating patients as well. The number of patients who make and carry through with their request for PAD will remain relatively small. It is true that most wishes for PAD can be reduced by better care and communication, but not all. The palliative care movement and all its adjuncts are invaluable. The intent of all of these efforts is better final days. Ironically, one of the reasons I came to support legal PAD was that I came to believe that one effect of granting PAD to a terminally ill patient can be extension of their life. Kevorkian’s first case was a woman terrified of dementia choosing to end her life prematurely—taking a “preemptive strike.” Tragically, that is not so rare. Assuring patients they will have this choice often allows them not to use it. Paradoxical? Yes, but that is confirmed by many experienced clinicians. In some long-forgotten journal of the 1800s, an author likened PAD to “Obstetrics of the Soul.” That striking term refers to a sort of deliverance. That’s a big deal. I feel a sense of responsibility, for helping to enable this new law. We must implement it well, with all of the safeguards against abuse contained in the law - but not too many. It’s a complex balance but I believe that Californians will be up to it. I see the physicians of the SFMS and others who worked on this for years as heroes. Many people worked for this right, and organizations such as Compassion and Choices, the old Hemlock Society, and others played crucial roles. Legislators who took this on were courageous. I have never felt any opponents had evil intent—they truly believed, and many still do, that PAD is not something physicians should do, or that society should sanction. We must respect that, while asking that they respect our views as well. In the time since California’s new law was signed by our Governor, I have been flooded with gratitude to and from so many people, living or gone, and that I was able to play a part in this long, difficult, and now at last, rewarding effort. When, recently, a lifelong friend, nearing his own end via ALS, let me know how thankful he was, and that I might be “not such a bad guy after all,” I knew once more that the effort was wholly worthwhile. And, though I am a fairly tough guy or at least tend to act like one, I’ll admit it: Tears came again. Steve Heilig is Director of Public Health and Education for the SFMS, managing editor of San Francisco Medicine, Co-Editor of The Cambridge Quarterly of Healthcare Ethics, co-founder of the San Francisco Endof-Life Network, a former hospice volunteer and director, and has been an ethics consultant at numerous local hospitals.

NOVEMBER 2016 SAN FRANCISCO MEDICINE

Ethics in Medicine

SO LONG, HIPPOCRATES Medical Students Choose Their Own Oaths Melissa Bailey As they don their white coats for the first time, a new crop of medical students nationwide is taking an oath—but it may not be the one you think. The Hippocratic oath

has been out of fashion for a while. It doesn’t actually say, “do no harm,” but it does pledge allegiance to mythical goddesses, among other things. In its place are modernized oaths, which combine the idea of “do no harm” with vows to remember both the human beings on the other end of the stethoscope and their social and financial well-being when treating them. “We see health as a much broader context than just the physical symptoms and diagnoses,” said Steve Smith, associate dean for student affairs at Dell Medical School at the University of Texas at Austin, one of three new medical schools opened in the U.S. this summer. Dell let its inaugural class select and revise their own oath earlier this month. The students decided to modify parts of a more humanistic oath written in 1964 by Dr. Louis Lasagna, a former dean at Tufts University School of Medicine. “I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being,” the students vowed at their symbolic white coat ceremony. In these ceremonies, now common nationwide, students accept white coats, recite oaths, and commit to practice ethically as they begin their medical education. Oath-taking has become nearly universal at U.S. medical schools, and while oaths of all stripes are often called “Hippocratic,” hardly any schools use the original oath that Hippocrates, the Greek “father of medicine,” is said to have written over two thousand years ago. That oath has several problems, said Smith. For starters, he pointed to the Greek gods: “I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses,” the oath begins. The original oath also asks doctors never to “give a woman a pessary to procure abortion,” and to abstain from euthanasia (“I will neither give a deadly drug to anybody who asked for it”). Lasagna’s oath is the most popular one used by medical schools: thirty-three percent use it, according to a 2009 survey of 135 U.S. and Canadian medical schools. Just eleven percent of the schools use the classical Hippocratic version, researchers found. “I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug,” Lasagna’s oath reads in part. Lasagna’s version also calls on doctors to admit when they don’t know the answer; prevent diseases; and to take responsibility not just for the patient’s health, but for the way an illness affects a person’s “family and economic stability.” Other values influence a school’s oath. Dr. Robert Orr, a professor at Loma Linda, a Seventh-Day Adventist university outside of Los Angeles, surveyed medical schools in the U.S. and Canada in 1993 about this practice. While oath-taking had become wide22

spread, he and coauthors concluded the content of the Hippocratic oath had been watered down over the years. He joined a panel that rewrote the oath in 1995 at Loma Linda’s medical school, which had been using a secular version. The school’s new oath doesn’t swear off abortion or euthanasia, as Hippocrates’s version did. But it brings back one thing Orr noted had gone missing—a pledge to God. “This is not a code of ethics for providers,” Orr told students in a 2012 ceremony before they took the new oath, “but a professional oath sworn to God almighty.” New York Medical College, Tulane, and the University of California, San Francisco, all have students vow not to discriminate against patients based on gender, race, religion, or sexual orientation. Most schools stick with one of three main versions of the oath, often for the sake of tradition—Hippocrates’s, Lasagna’s, and the Declaration of Geneva, said Dr. B. Alex Foster, the coauthor of the oath survey and an assistant professor at University of Texas Health Science Center in San Antonio. But some medical school classes have revised their oaths to reflect their personal values. Medical students at Creighton University, a Jesuit university in Omaha, Nebraska, revised their school’s oath last year to keep up with modern times, adding a pledge not to discriminate against patients based on sexual orientation, according to spokeswoman Cindy Workman. At Harvard Medical School, each class of students now writes its own oaths, one at the white coat ceremony and another at graduation, when they take the oath as a newly minted doctor. The latest version that incoming students at Harvard recited in August reads in parts like a fiery sermon. It calls on doctors-in-training to “wake up to the realities of the world” and “rise up.” “We promise to bear witness to historical injustices that continue to unfold for marginalized communities,” the oath reads, in part. “. . . We must have the courage to act when we witness injustice.” Reprinted from StatNews.org with permission. Thomas Jefferson University medical students take the Hippocratic oath during a white coat ceremony.

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

Ethics in Medicine

END OF LIFE AT LAGUNA HONDA Laguna Honda Hospital and Rehabilitation Center and Zen Hospice Project have partnered since 1988 to provide Laguna Honda patients (called residents) with endof-life care. This includes palliative care services for residents with chronic, progressive conditions who are also receiving disease-focused interventions, as well as traditional hospice care. Volunteer caregivers from Zen Hospice supplement the evidenced-based clinical practices of medical and nursing professionals at Laguna Honda by offering practical, emotional and spiritual support to men and women diagnosed with terminal illnesses such as cancer and AIDS. This innovative collaboration between public and private organizations has enabled thousands of individuals to live out their final months or weeks of life in a serene, peaceful, and healing environment. Laguna Honda opened doors to a new state-of-the-art facility in December 2010. The building layout, anchored by two resident-living towers on sixty-two-acre campus, was heavily influenced by research from the Centers for Health Design, which demonstrated the impact that surrounding environments have on the healing and health of residents. It was also recognized as the first green (LEED Silver) hospital for its sustainable and efficient use of water, energy, and materials. Palliative Care and End-of-Life services are located on the third level of the South Tower and features prominent natural lighting. The unit, referred to as a neighborhood, has four households of fifteen residents. There are both private and semi-private rooms along with shared living room space for visits by family and friends. On each neighborhood are two Jacuzzi tubs available for relaxing baths. Every resident is at the center of an interdisciplinary team of licensed health professionals and caregivers. • Board-certified palliative and end-of-life physicians • 24/7 physician availability • Registered Nurses • Trained and licensed nursing assistants • Palliative and end-of-life trained social workers • Activity Therapists • Clinical Pharmacist • Registered Dietitians • Palliative and end-of-life trained volunteers • Spiritual Care Providers • Bereavement Support Services For additional information or to arrange a tour, please call Admissions and Eligibility, Monday through Friday, 8:00am to 5:00pm at (415) 682-5680. Laguna Honda Hospital and Rehabilitation Center is a member of the San Francisco Health Network, the integrated delivWWW.SFMS.ORG

ery system operated by the San Francisco Department of Public Health. Laguna Honda provides skilled nursing and rehabilitation to 765 seniors and adults with disabilities. Rehabilitation services include physical, occupational, speech and vocational rehabilitation. Each year, up to 240 people complete rehabilitative therapy at Laguna Honda and move to a lower level of care or independent living. Skilled nursing services include the only dedicated facility for HIV/AIDS in the Bay Area, a nationallyrecognized program for people with Alzheimer’s and other dementias, therapeutic services for Traumatic Brain Injuries and the effects of stroke, complex care for people with multiple diagnoses, and pain management and end-of-life care emphasizing comfort and dignity operated in conjunction with the Zen Hospice Project of SF. Rebuilt in 2010, Laguna Honda is California’s first green-certified hospital (LEED Silver), and was designed to take advantage of the healing effects of its beautiful and serene sixty-two acres located in the Forest Hill neighborhood of San Francisco.

For more information about Laguna Honda visit www.lagunahonda.org LOCAL DOCUMENTARY ON END-OF-LIFE ISSUES ON OSCAR SHORTLIST

Extremis, a 23-minute film made by renowned director Dan Krauss, showcases difficult end-of-life conversations by following gravely ill patients and their families in the intensive care unit of Highland Hospital in Oakland, CA. It has just been short-listed as a contender for an Academy Award for best short documentary. This powerful film allows us into the often hidden world of acute medical care where patients, their families and physicians confront the most difficult decisions in life. Dr. Jessica Zitter, featured in the film, remarks, “everyone in this room is going to die someday. It’s good to have a say in how.” Kraus says “I hope audiences will take courage from the incredible dignity and compassion that the film’s subjects displayed amidst the most challenging circumstances”. The film was supported by SFMS member and hospitalist physician Shoshana Ungerlieder, MD. It is available on Netflix. NOVEMBER 2016 SAN FRANCISCO MEDICINE

Ethics in Medicine

CALIFORNIA’S OPIOID EPIDEMIC Turning the Tide Sandra R. Hernández, MD, MPH The U.S. surgeon general recently sent me a letter. In fact, Dr. Vivek Murthy sent a letter to every one of the more than nine hundred thousand doctors in the United States, asking us to help end the opioid overdose epidemic that now kills more people each year than traffic accidents. His call for us to commit to “turn the tide” on the epidemic hit home for me, both as a physician and as Chief Executive Officer of the California Health Care Foundation, where we are supporting a multipronged effort to fight opioid addiction in our state. “We arrived at this place on a path paved with good intentions,” writes Dr. Murthy. I can attest to this. For decades, we clinicians took classes informing us about the need to regularly assess patients for pain and imploring us not to undertreat pain. Today we know much about the biologic processes that cause pain. We also know a great deal about the neurobiology of addiction and the impact of high-dose, long-term opioid use on the brain’s ability to manage stress, pain, and daily functions. We want to help patients suffering from chronic pain. But while the promise of long-term benefit from these opioids rarely materialized, addiction and other opioid-related problems often did. And now we’ve experienced a wake-up call. Each year more than forty-five hundred Californians die from opioid overdoses. The opioid epidemic is a complex public health challenge requiring a multifaceted response. The problem starts with overprescribing, so educating providers and changing prescribing practices is central to the solution. We need to address pain management in a safer and more holistic way. We need to ensure naloxone, a life-saving overdose antidote, is more widely available. And we need to help people addicted to opioids gain access to proven, safe medication-assisted treatment that—along with psychosocial interventions—can help them beat addiction. There is reason for optimism. This year we surveyed dozens of California health plans and published a paper detailing systematic health plan approaches to addressing the epidemic. Three plans in the state have reduced overall opioid prescribing twenty to fifty percent among providers in their networks and brought down the use of high-dose, high-risk opioids by ten to fifty percent in three years. While the medical establishment can and should change, others affected by the crisis are also critical to eradicating this epidemic. California Healthcare Foundation (CHCF) is supporting seventeen local opioid safety coalitions covering twentyfour counties. These coalitions bring together people from health care, addiction treatment, law enforcement, local government, public health, consumer groups, and families to develop lasting local solutions. Clinic workers present safer prescribing guidelines at Rotary Club meetings; action teams create flyers to inform patients about pain management alternatives; fam24

ily members of overdose victims share their stories with city councils, local pharmacies, and neighbors; and emergency room doctors set up clinics so patients can get started on addiction treatment. We are starting to see change. More than one hundred twenty emergency departments (EDs) across Southern California have adopted safer prescribing guidelines (including every single hospital in San Diego and Los Angeles Counties). Some counties with high prescribing rates have cut opioid prescriptions in half. In a Monterey County hospital, all prescriptions for opioids in the ED include an accompanying prescription for naloxone. Plumas county used to have no prescribers of buprenorphine, an effective addiction treatment. Now it has three, and is using telehealth to get patients started on treatment. Since launching the RxSafeMarin coalition in 2014, Marin County has seen overdose deaths go down by half. Because opioid medications can take away suffering, we need to ensure that these medicines are available when people need them, especially in palliative care. But in many cases, there are safer and more effective ways to manage pain and improve function, and we need to make sure these therapies are covered by insurance and are available. Our Pain Care on a New Track: Complementary Therapies in the Safety Net report shows how complementary therapies are integrated into practices. Further, we need to stop criminalizing the disease of addiction. As the surgeon general points out, “opioid addiction is a disease, not a moral failing.” Dr. Murthy’s message to physicians is powerful—and achievable. “Years from now, I want us to look back and know that, in the face of this new epidemic, our profession stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity. These values unite us. They remain our greatest strength.” It is that strength, of many communities united, that we rely on to sustain the work ahead. If you are so moved, join us. Sandra Hernandez, MD, is President and Chief Executive Officer of the California Healthcare Foundation, former Director of the San Francisco Department of Public Health, CEO of the San Francisco Foundation, and a practicing physician at San Francisco General Hospital.

For more on CHCF’s work on this topic, see: http://www.chcf.org/topics/opioid-safety.

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

CLASSIFIED ADS Medical Weight Loss Practice / Retirement Sale. Proven, highly recognized and profitable established weight loss practice in beautiful Marin County. Current multiple 6 figures, room for expansion. Work-life balance, time freedom, financial security, relationshipdriven practice. I am 100% committed in assisting the new owner with all the support necessary to ensure a smooth transition. Please contact me for more information or to schedule a visit. Gail Altschuler, MD, 415-309-6258 or drgail@marinweightloss.com. Practice for Sale - Fertility Clinic, Santa Rosa. Revenue $1.7 million on 32 MD hours/week. 3800 square feet includes an OR, 3 exam rooms, 9 offices/private, 2 storage rooms, embryology lab, and blood/ sperm lab, plus kitchen. Very attractive atrium-style building. Independent appraisal available; photos available. Offered at $815,000. Contact Medical Practices USA for more information. info@medicalpractices.com. 800-576-6935. www.MedicalPracticesUSA.com. Laguna Honda is a state-of-the-art post-acute care hospital in San Francisco. We currently have full time FP or IM benefitted positions open for both weekday, and night and weekend hours, and positions also available for as needed night and weekend. This is a great opportunity to work in a diverse and unique environment. A competitive salary and benefits are offered. If interested please contact Acting Chief Medical Officer, Michael McShane, MD, at michael. mcshane@sfdph.org.

Founded in 1866 to care for one of the first generations of San Franciscans, the Gold Rush Pioneers, today it remains a civic icon representing San Francisco’s tradition of service to the underserved. A top-quality skilled nursing and rehabilitation center with state of the art programs, an integral part of the San Francisco Health Network.

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PAD AND FIDELITY TO THE PATIENT; AS FUTURE CLINICIANS SEE IT Nate Hinerman, PhD Each term in my ethics class I assign a paper that asks students to explore a medical case that involves some intersection of patient autonomy, beneficience, justice, nonfalcience, and fidelity. Most of my students are studying to join a helping profession (medicine, nursing, mental health, etc). The topic of palliative sedation is commonly chosen for exploration, and students often write about the “double effect” dilemma, which occurs in some cases where a particular patient requests medication to relieve pain, with an additional hope that it will also hasten his/her death. A typical analysis of such a case considers how practitioners, especially those in palliative settings, where the need for empathic resonance with patients is central and based on mutual trust, approach interventions which may lead to terminal sedation. Students tend to pit patient autonomy against medical paternalism in their explanations, as they wrestle with terminally-ill patients who are ready to die and who may overreport their experience of pain in the hope this will lead to interventions that give rise to terminal sedation. As students take the role of the caregiver, they often ponder various reasons why caregivers may want to “bow out of such a case,” even if they may be protected under the law. Their conclusions cluster around the importance of maintaining fidelity with the patient, since without that sense of trust, the hope of achieving efficacious outcomes seems unlikely. Now that California has approved PAD, my most recent submissions for this assignment have been a very different lot. Not a single student opted to write on palliative sedation, or to voice concerns about the double effect. When I asked the class about this, their responses indicated that they viewed PAD as largely (although not completely) mitigating of these ethical dilemmas. While not all students said they would participate in PAD, it was noteworthy that the students collectively felt that PAD legislation was the key to maintaining what, in their minds, was the most crucial ethical principle of all in such difficult cases, fidelity. So often, debates about PAD privilege the patient automony argument. I took it to heart that students did not primarily see the matter through this lens, and that their primary concern was to maintain a loyal, collaborative relationship with patients and their families. Nate Hinerman, PhD, is Dean of Undergraduate Programs and Associate Professor of Liberal Studies at Golden Gate University. He counsels hospice patients and directs the San Francisco End-of-Life Network, originally founded at the SFMS (sfeol.org).

NOVEMBER 2016 SAN FRANCISCO MEDICINE

Providing Longitudinal Primary Care in Rural Haiti Short-Term Personal Commitment and Long-Term Community Health Gains John Brown, MD

At the start of my medical career, I embraced a dilemma that may providers face: a love of helping patients

in need combined with a desire for proper work-life balance to allow for a long, happy, and productive medical practice. After many opportunities and experiences during my medical school and residency training, I found what I believe to be a wonderful opportunity for service that allows me to maintain my medical practice, family, and community commitments. In the early 1990â&#x20AC;&#x2122;s, the Seattle-King County Disaster Medical Team (SKCDT) developed a partnership with Saint Francis Parish in Derwood, Maryland and the community of Leon, Haiti, to augment a community clinic that functions year round with a staff of nurses, pharmacists and public health workers. The medical team, consisting of physicians, nurse practioners, physician assistants, nurses, laboratorians, paramedics, Emergency Medical Technicians and pharmacists spend one to two weeks every four months providing primary care and public health services to this rural community of some eight thousand people and the surrounding catchment area of twenty-eight thousand. The aims of the program have always been based on a longterm commitment to community health. On an individual basis, patient care is provided at a primary care level with five to six treatment stations, allowing practioners to deal with chronic disease management and acute emergencies such as minor to moderate trauma and episodes of infectious disease. The patients range in age from neonates to the elderly, and medical issues from childbirth to palliative care are tackled by team members ranging in experience from first time global health providers to experienced members with ten or more missions under their belt. The teams are fortunate to be supported by a cadre of strong professional interpreters who have ties with the local community. Physician clinical judgement is supported by strong laboratory services and ultrasound capability. Acute curative â&#x20AC;&#x153;officebasedâ&#x20AC;? procedures are performed, such as incision and drainage of abscesses, simple fracture reductions, and immobilization and wound care. The clinic is a basic facility, with patient examination spaces, a small resuscitation area, a pharmacy and a solar power electric system for basic lighting and ventilation. On a community basis, there is an emphasis on providing a high standard of primary care, comparable to what practioners are used to in the United States, in this more austere environment. The team works together, and shares expertise between providers and the community clinic staff. The overall goals of care are developed in conjunction with the community health committee, and the World Health Organization formulary and local sources for medication and medical supplies are utilized. Short education modules are presented in the evenings after clinic; many based on research done on local health conditions by prior teams. Local medical resources are utilized when avail26

able and appropriate for more complex care, including simple surgeries, HIV patient management, high-risk pregnancy, and certain specialty services such as cataract removal when available. Public health messaging on prenatal care, childhood development, HIV prevention, and basic infectious disease treatment are provided to patients at the time of their visit. Haiti is the poorest country in the Western Hemisphere and has some of the worst health indicators, with short lifespan, high maternal/child mortality, injury disability, infectious disease, and nutrition-related morbidity being the norm. Recent setbacks, such as the 2010 earthquake and a 2016 health care worker strike have diminished gains from investment in health care by multiple non-governmental organizations. We have seen important gains in the management of community health problems with our intervention, such as improving Hemoglobin A1c values, and better tracking and control of hypertension and its complications. Living conditions for team members are reasonable for an austere, rural setting. The team lives in a rectory, with three to four providers sharing large rooms with beds and indoor bath-

SAN FRANCISCO MEDICINE OCTOBER 2016 WWW.SFMS.ORG

rooms with running (cold) water. Food safety is paramount, with team-provided potable water and hot meals prepared by the rectory staff. Teams are composed of varying specialties but always include a team emergency physician and team advanced life support medical supplies. Medical evacuation insurance and a communication plan are provided for team members. The teams pay for their individual participation costs, and may do so by fundraising using the SKCDT Facebook page if desired. In 2017, there will be many opportunities for participation. The team missions have become available to Emergency Medicine Residents through a partnership with the University of California, San Francisco/Zuckerberg San Francisco General Department of Emergency Medicine Residency Program Global Health Interest Group. The dates and location of the missions are listed on the chart below. All teams will travel into Haiti on a Saturday, and return to the U.S. on the following Saturday or Sunday.

Recruiting has opened for all of the teams, and further information can be obtained from Project Director Lori Van Slyke of the Seattle/King County Disaster Team at vanslyke99@hotmail.com.

My experience working on the teams since 2004 has been remarkably positive. I have made many lifelong friends, both among the community of Leon and my fellow team members from all over the United States and Canada. Moreover, I have had a chance to step out of my ordinary practice and continue my lifelong journey of medical learning. The last baby I delivered, the last fracture I reduced using ultrasound, the last cholera patient I treated, and the last hug I received from a grateful family member have all been a part of my Haiti experience. I plan to help this effort and this community for as long as I can. Team

Location

Dates

Leon Team One

Leon

January 28 to February 5, 2017

Leon Team Two

Castillon April

Leon Team Three

Leon Team Four

Leon

Castillon

Leon

Leon Team Five

Leon

Castillon October

Castillon

Abricot October

Abricot

February 4 to February 11, 2017

April 22 to April 30, 2017

June 3 to June 11, 2017

INC.

REGISTRY

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

June 10 to June 18, 2017

October 14 to October 22, 2017 (Tentative)

October 21 to October 29, 2017

October 21 to October 28, 2017

Dr. Brown is an Emergency Physician at Zuckerberg San Francisco General Hospital and the Medical Director of the San Francisco Emergency Medical Services Agency. He is the 2016 winner of the Humanitarian of the Year Award from the California Chapter of the American College of Emergency Physicians. WWW.SFMS.ORG

Tracy Zweig Associates

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com OCTOBER 2016 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS SPMF

Robert Osorio, MD, FACS

One of our goals at Sutter Pacific Medical Foundation (SPMF) is to ensure the highest quality of life possible for patients and their families by helping relieve physical and nonphysical suffering brought on by a patient’s disease. We are always looking for ways to serve our patients better, and to that end Sutter Health recently partnered with OpenIDEO, an open innovation platform, to ask the community to join an end-of-life conversation by visiting a webpage and answering the question, “How might we imagine the end-of-life experience for ourselves and our loved ones?” The intent was to share thoughts, collectively improve ideas, receive feedback and potentially launch fresh ideas. The result of this challenge: contributors from around the globe, including Sutter employees and affiliated physicians, offered more than three hundred ideas. The webpage had thirteen hundred followers and three thousand comments with thoughts coming from ninety countries. The project was supported by Better Health East Bay, a Sutter Health philanthropic foundation; Shoshana Ungerleider, MD, a hospitalist at Sutter Health’s California Pacific Medical Center and a philanthropist; and other community donors. A panel of experts has recently selected ten top ideas that have a strong potential for implementation. One of the top ten ideas selected is a digital concept from Ken Rosenfeld, MD, a palliative care physician at CPMC. The product expands on a poster concept currently in use at other hospitals that allows families to share a patient’s photos, interest and life story with medical staff. The partnership is helping us identify and support compassionate solutions to improve the end of life experience for patients and their loved ones. By helping families and patients express their goals and needs at this time, we hope to increase the quality and effectiveness of our care, said Catherine Seeley, MD, SPMF’s director of palliative care.

SFVAMC

C. Diana Nicoll, MD, PhD, MPA

The End of Life Option Act was signed into California law on October 5, 2015, making California the fifth state to legalize physician-assisted death. The law allows California residents, eighteen years or older and with a terminal disease, to request medications to take their own life. The passage of this law has created some confusion over how to respond to Veteran’s requests for physician-assisted death. Health care practitioners who are functioning in their Veterans Affairs (VA) capacity are prohibited from participating in physician-assisted death, even when it is allowed in non-VA facilities by state law. While VA providers may not participate in the process, it remains our obligation to respond to these requests in a non-judgmental and empathic manner that preserves dignity and meets the needs of Veterans who are approaching their end of life. Responding to requests for physicianassisted death should start with listening carefully to the nature and underlying causes of the request, including any aspects of physical, psychological, social, or spiritual suffering that may be leading to the desire to hasten death. We should affirm our commitment to care for the Veteran even when we are unable to participate in the process of physician-assisted death, as we are still able to help to address the suffering of the Veteran and educate the Veteran on other legal alternatives such as withdrawing or withholding life-sustaining treatments. A request for physician-assisted death may be the very first expression of unrelieved suffering by a Veteran to his or her health care provider. This request serves as a flag for VA providers to include other specialists with expertise in symptom management, including hospice and palliative care teams, into the care of the Veteran, as this may aid in addressing the needs of the Veteran.

Kaiser Permanente Maria Ansari, MD

The Kaiser Permanente Northern California Region began offering an End of Life Option Program to its interested members on June 9, 2016, the same day that the California Law became effective. The physicians and care providers who are involved in our program have spent many months developing a humane and compliant service for members and their families to consider. The End of Life Option Act is a state law that allows a terminally ill patient, with decision-making capacity, to request a prescription for a lethal dose of medicine from his or her physician which the patient may use to end life. Many factors have gone into Kaiser Permanente’s program, including creating a Patient Coordinator position to help patients and families navigate the process. A multistep work flow was created to ensure that if a patient chooses the option, he or she has made as informed a decision as possible. The process begins with a Patient Coordinator introduction, then a written request made by the patient, followed by the first spoken request with an attending physician, a mental health consultation (if necessary), a second exam with a consulting physician (a Palliative Care consultation is recommended if not done previously), and a second spoken request with the attending physician. In addition, there is a fifteen-day mandatory waiting period between the first and second spoken request. Once these steps are complete, a physician orders a prescription, the patient takes the drug, and, finally, after the patient has died, there is follow up with the family. At any point during the process, a patient can decide not to participate. We understand the magnitude of the decision a person has to make in order to participate, and so have dedicated resources and expertise to providing the most thoughtful program possible.

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

Saint Francis Robert Harvey, MD, MBA, CPE

Dignity Health Saint Francis Memorial Hospital offers an innovative opportunity through our Timeshare Physician Office. The timeshare allows doctors to maintain or build a private practice, but with less overhead expenses, by leasing the space in weekly time blocks. While standard office and medical supplies are included in the arrangement, the physicians manage their own billing and contracting services. The office is managed by professional Saint Francis staff. This unique business model accommodates physicians’ needs at any career stage. It is a compelling alternative for physicians establishing a new practice, expanding to a second location, looking for a shorter work week, or wanting to minimize overhead. Each timeshare contract can be tailored to meet individual physician needs: hours, charting, medical rep visits, and more. The timeshare is convenient for patients, too. Located across the street from Saint Francis, it is in close proximity to ancillary services like lab and xray. On-site parking also is available. The timeshare already houses an array of specialists with collegial relationships in the office and the hospital, including Dr. Gary Chan, pulmonary; Dr. David Malone, nephrology; Dr. John Mendelson, internal medicine; Dr. John Missirian, orthopedics; Dr. Dennis Shen, gastroenterology; Dr. Richard Sherwood, plastic surgery; Dr. Harlin Watkins, cardiology; and Dr. Jeff Yung, physical medicine and rehabilitation. As part of the timeshare arrangement, these physicians are part of the Saint Francis medical staff, but their practices remain private. In other news, congratulations to Dr. Mel Blaustein, medical director of Psychiatry, who has been honored with the Royer Award for Excellence in Community Psychiatry from UCSF. Dr. Blaustein was recognized for his major contributions over the last 41 years to community psychiatry in the Bay Area. His efforts played an instrumental role in gaining approval for a suicide barrier for the Golden Gate Bridge. WWW.SFMS.ORG

CPMC

UCSF

Barbara A. Koenig, PhD

The bioethics “infrastructure” at UCSF is complex; activities include clinical ethics consultation, education, academic research, and efforts to assure compliance with burgeoning regulations that govern all aspects of health care and scientific inquiry. UCSF activities fall into three categories: compliance, clinical ethics,and academic programing. Theresa O’Lonergan is associate vice chancellor for Ethics and Compliance. Each UC campus includes such a position. She oversees a portfolio of ethics-related activities, including enforcement of conflict-of-interest rules and maintaining research integrity. Christopher Ryan, who leads UCSF’s efforts to assure the protection of human research participants, reports to her. Each hospital affiliated with UCSF is mandated by Joint Commission to have a clinical ethics committee that develops policies and consults on difficult cases. Neurologist S. Andrew Josephson chairs the committee for UCSF Medical Center, which includes the Parnassus, Mount Zion and Mission Bay campuses. Zuckerberg SFGH has its own committee, chaired by Drs. Eric Isaacs and Sharad Jain. Dr. Kathryn Eubank leads clinical ethics at the SFVA. Committees accept consult requests from hospital staff, patients and families. UCSF’s academic work in bioethics includes education and a wide range of research projects, many funded by the NIH. Hospitalist Elizabeth Dzeng is the “ethics steward” for the new School of Medicine curriculum, called “Bridges.” The campus also hosts multiple bioethics research studies, covering topics such as informed consent and clinical trials participation, the impact of novel genomics technology, and methods of community engagement. This year Provost Daniel Lowenstein created “UCSF Bioethics,” a program that will span the four professional schools. One goal is to have bioethics faculty and compliance staff work together when novel research designs demand innovation or when proactive policy making is needed. Over the past year we have worked collaboratively to respond to the End of Life Option Act and to create governance for “big data” projects in Precision Medicine.

Edward Eisler, MD

The World Doctors Orchestra (WDO) performed a special concert in San Francisco this past October. This year the ticket proceeds benefited the George Mark Children’s House in San Leandro. The WDO is a very unique orchestra which was founded in 2007 by Professor Stefan Willich at Charite University in Berlin. Two to three times a year, some 100 physicians from all over the world, exchange their white coats for evening attire and perform a benefit concert for medical aid projects. As an orchestra, they promote the conviction that neither national borders nor political or economic interests, should limit access to basic healthcare. WDO has over 800 physician members from more than 50 countries, and they perform at different venues around the world. Bay Area surgeons are hoping that a specialized camera can help patients survive a deadly form of cancer – melanoma. The goal is to locate leftover cells that could allow the disease to return. To narrow that margin of error, doctors at CPMC will inject patients with radioactive particles that are engineered to attach themselves to lymph nodes where leftover cancer cells could hide. To locate the tiny lymph nodes, doctors plan to use new technology – a camera called Sentinella that can see the radiation footprint attached to the nodes. The effectiveness of the Sentinella camera is now the focus of a clinical trial being run through the CPMC Research Institute. An estimated 15 million Americans experience a severe form of heartburn. CPMC physician, Dr. Kenneth Binmoeller is treating patients with an endoscopic device designed to treat the area where the reflux originates without traditional surgery. His goal now is to lengthen the anti-reflux valve, which is at the junction of the esophagus and the stomach. Clinical trials have shown this technique is more effective than drugs in treating the root cause of severe reflux.

NOVEMBER 2016 SAN FRANCISCO MEDICINE

MEDICAL COMMUNITY NEWS SFHN

Alice Chen, MD, MPH

San Francisco Health Network has a longstanding commitment to providing palliative care services to some of San Francisco’s most vulnerable residents as they face news of a terminal diagnosis, or struggle with physical symptoms or the loss of independence. In response to the AIDS epidemic, palliative care programs were developed to provide interdisciplinary, holistic care across a variety of settings, including in patients’ homes, at Laguna Honda Hospital, and at Zuckerberg San Francisco General. Over the last 30 years, these programs have evolved to meet the changing needs of patients and communities. Laguna Honda Hospital’s well established Palliative Care and End of Life Program, a community partnership with the Zen Hospice Project, is staffed by an interdisciplinary team of caregivers including physicians, nurses, social workers, therapists, pharmacists, registered dieticians and bereavement specialists. While Zuckerberg San Francisco General closed its AIDS ward in the mid-1990s, in 2009 it launched the Supportive & Palliative Care Service, a multidisciplinary team of physicians, nurses, social workers and chaplains who provide hospital-based consultation services for patients and family members. Based on the program’s success, ZSFG began Oncology-Plus, a palliative care program providing symptom management, advance care planning, connection with community resources, and psychosocial and spiritual support for cancer patients. SFHN is also planning to expand community-based palliative care services to other settings and conditions, in part by educating and supporting primary care providers to provide frontline palliative care. No matter what the setting, SFHN’s palliative care patients often experience challenges far beyond their medical diagnoses. Financial and social challenges such as food insecurity, social isolation, and lack of stable housing are common, and cultural factors, immigration or legal status, limited English proficiency, low health literacy and numeracy, and concurrent mental illnesses or substance abuse can pose additional barriers to accessing health care. SFHN’s mission is to address these issues holistically as part of patients’ care.

UPCOMING EVENTS SFMS Annual Career Fair| November 15, 2016 | 5:00 p.m. to 8:00 p.m. | University of California, San Francisco (UCSF) Millberry Conference Center | Join SFMS for our seventh annual Career Fair! This complimentary recruitment event is open to all SFMS residents, fellows, and San Francisco-based physician members of all specialties. Last year, there were twenty-two Bay Area medical groups who exhibited at this event, including UCSF Medical Center, Kaiser Permanente, Stanford Hospital, as well as other local hospitals and community clinics. For further event details or to register, visit www.sfms.org/events.

SFMS Annual Gala | Friday, January 27, 2017 | 6:30 p.m. to 9:00 p.m. | Asian Art Center, San Francisco Join SFMS for our Annual Gala! Come together with many of San Francisco’s most influential stakeholders in the medical community to celebrate SFMS’ one hundred forty-nine years of physician advocacy and camaraderie. Man-Kit Leung, MD will be installed as the SFMS President. Guests will be treated to an exquisite reception with elegant hors d’oeuvres and libations. Ticket information will be available online soon at www.sfms.org and invitations will be mailed in early December. If you have any questions, please contact Posi Lyon at (415) 561-0850 x260. UPCOMING CMA WEBINAR| Nondiscrimination State-

ments: A Detailed Guide to Compliance | November 9, 2016 | 12:15 p.m. to 1:15 p.m. Free for members | www.cmanet.org/ events | The U.S. Department of Health and Human Services Office of Civil Rights recently finalized new nondiscrimination rules intended to advance health equity and reduce health care disparities. The rule, which implements section 1557 of the Affordable Care Act, protects individuals from discrimination in health care on the basis of race, color, national origin, age, disability and sex, including discrimination based on pregnancy, gender identity and sex stereotyping. This webinar will cover whom this rule applies to, give an in-depth overview of the requirements and how physicians can comply, and explain what happens when a covered provider does not comply with the new rule.

SFMS CEO Mary Lou Licwinko and CMA Chief Strategy Officer Jay Hansen tour the site of the new CPMC hospital in San Francisco! 30

SAN FRANCISCO MEDICINE NOVEMBER 2016 WWW.SFMS.ORG

CMA/San Francisco Medical Society sponsored Health Insurance Program

Is your health insurance open enrollment soon? Are your rates going up? Want to shop? Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2017. The open enrollment period for individual and family plans starts on November 1, 2016. Many practices have open enrollment periods for small groups on December 1 or January 1. Did you know that you can get the right insurance though the CMA/San Francisco Medical Society sponsored Health Insurance program with Mercer? If you are covering yourself, or if you’re responsible for providing coverage for your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget. Working with the largest insurers in California, Mercer can help you determine what’s best for you. Call today at 800-842-3761 or visit www.CountyCMAMemberInsurance.com.