DOLPHY AND THE NEED FOR DIALYSIS

English: Dolphy, Filipino actor

English: Dolphy, Filipino actor (Photo credit: Wikipedia)

“Most nephrologists would agree that patients who are likely to have an unacceptable quality of life should not be subjected to the discomfort of dialysis. Sparing such patients the inconvenience and discomfort of hospital attendances, surgical access procedures, and dialysis treatments is a major benefit.”

– Indranil Dasgupta and Hugh C. Rayner

  Consultant Nephrologist, Renal Unit, Birmingham Heartlands Hospital, United Kingdom

A living legend needs our prayers.  Comedy King Dolphy, whose comedic talent has brought laughter and cheer to multiple generations of radio, TV, and movie followers, was recently admitted to the Intensive Care Unit and is said to be suffering from Toxic Metabolic Encephalopathy.  The illness requires regular dialysis treatment, because his kidneys can no longer do the job of removing toxic wastes from the body.  This has affected his brain function, thus the medical term “encephalopathy”, which generally refers to an illness that affects brain.  As a hospice and palliative care practitioner, I decided to look into the benefits and risks of dialysis treatment on our 83-year-old comedy king.

According to studies,  patients on dialysis are subject to much more intensive medical care in the last month of life than are patients dying of cancer or heart failure.  Data reveal that 30% of dialysis patients receive intensive procedures, a rate that is three times higher than that of cancer patients. Also, only 20% of kidney-failure patients are referred to hospice, compared with 40% of the patients dying of heart failure and 55% of cancer patients.  Among patients 75 and older, the five-year survival rate for patients on dialysis is 15%.

This brings us to some  important questions.  Is it sometimes better to provide supportive and palliative care without dialysis to an elderly patient with renal failure?  Can dialysis be safely delayed when the benefits remain uncertain at best?  What does conservative management entail, and how should it be given?

According to experts, a patient over 75 who has heart disease, diabetes, liver failure, severe chronic obstructive pulmonary disease (COPD), or other significant chronic illnesses will have little to gain from dialysis.  A more conservative approach with the consent of the patients and relatives may be better.  What could be more cost-effective is to treat anemia and ensure acid-base and fluid stability.  Health care workers who are well-versed in hospice and palliative care should also be on hand.

However, it must be stressed that data can only serve as a guide.  The best medical decisions rest on a collaborated effort between doctors, nurses, caregivers, social workers, the patient’s family, and the patient himself.  Our prayers for Dolphy would also be invaluable, not just to prolong his life indefinitely, but to pray that he is at peace with himself and with his Creator.

CERVICAL CANCER

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May is Cervical Cancer Awareness Month.  What must one know about this disease?

C – The affected organ in cervical cancer is the cervix.  This is not located in the cervical area of the spine (the neck area), but the lower third portion of the uterus that opens into the vagina. The narrow opening referred to as the cervical os closes to help keep the fetus in the uterus until birth.

E – Epithelium.  This is the thin layer of cells on the surface of the cervix.  The changes in these cells are monitored when one undergoes a Pap smear.  It is important to detect early changes to the cervical cells which may lead to cancer, so a Pap smear is a very important diagnostic tool.

R – Rich less affected.  Most people who die of the disease come from the lower income classes.  This is because those from affluent societies have better access to screening tests.

V – Virus.  The causative agent of cervical cancer, called the Human Papillomavirus (HPV), is one of the most common sexually transmitted viruses in the world.

I – Intercourse.  During unprotected intercourse, the virus may be transmitted.  Thus, sexual promiscuity is a risk factor for the development of cervical cancer.

C – Common.  Cervical cancer is second most common cancer in women.  It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year.  Approximately 80% of cervical cancers occur in developing countries.

A – Acetic acid.  Visual inspection of the cervix with acetic acid allows doctors to directly see lesions and other changes in the cervix.  The health practitioner simply swabs acetic acid, the active ingredient in vinegar, on the cervix and looks for areas that change color.  This is a very important procedure for screening among those who have limited access to a Pap smear.

L – Lugol’s iodine.  Although this reagent, together with acetic acid, is less specific than Pap smear in the detection of cervical cancer, it is more sensitive.  This means that more false positive results may come out which can lead to overdiagnosis and overtreatment.  Public health workers, however, believe that the risk for overtreatment is acceptable, considering the greater risk of dying from the disease.

C -Colposcopy.  If the Pap smear result is found to be abnormal, a physician may order this test for better visualization of the cervix.  He or she may also do a biopsy for suspicious lesions.

A – Anemia.   Iron deficiency and tumor bleeding are common causes of anemia in cervical cancer. The presence of anemia is a negative prognostic factor, and its control and treatment improves disease prognosis.

N – Nutrition.  Although some studies on cervical disease and diet suggest that intake of dark green and yellow vegetables, beta-carotene, and vitamins C, D, and E can prevent cervical cancer, these studies are still inconclusive.  The best way to prevent cervical cancer is immunization with human papillomavirus (HPV) vaccine. The bivalent HPV vaccine (Cervarix) prevents the two HPV types, 16 and 18, which cause 70% of cervical cancers.  The quadrivalent HPV vaccine (Gardasil) prevents HPV 16, 18, 6, and 11.  Gardasil prevents genital warts and also protects against cancers of the anus, vagina and vulva.  Both vaccines are administered in 3 doses.

C – Chemotherapy. Chemotherapy is used to reduce tumor growth during the later stages of cervical cancer.  Chemotherapy medicines may be taken by mouth (orally) or injected into a vein (intravenous, or IV).

E – Eva Peron.  The second wife of former Argentina President Juan Peron died of cervical cancer.  Evita, as she is more popularly known, was the first Argentine to undergo chemotherapy for the illness.

R – Radiation therapy.  Radiation treatment is given during the early stages of cervical cancer.  It is given as external beam radiotherapy to the pelvis, or via internal radiation or brachytherapy.

HAPPY NEW YEAR!

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It’s the start of the year.  Here are my wishes for you and your loved ones:

H – Health.  May you have it in you so that you can fulfill your mission and vision for the year.

A – Ability.  May you develop the skill to reach your dreams.

P – Prosperity.  May the Good Lord bless you and shower you financially.

P – Peace. May you nurture your relationship with others and bridge communication gaps with friends and family.

Y – Yearning.  May you never run out of reasons to do what is right and just.

N – Nobility.  May you protect your good name and leave a good legacy.

E – Endurance.  May you have the staying power to endure all the hardships and challenges that come your way.

W – Willingness.  May you have pleasure in following the authority figures in your life who lead you and your organization.

Y – Yes.  May you limit the times when you reject others who want to extend help, and to give help in return.

E – Enthusiasm.  May you always be inspired with divine wisdom and positive thoughts.

A – Altruism.  May you have unselfish concern and compassion for the people you deal with everyday.

R – Reward.  Hope for the best.  Ask and you shall receive.  Seek and you shall find.  Knock and the doors of heaven will be opened up to you.

Happy New Year everyone!

EVIDENCE-BASED DECISION MAKING

The art of medicine consists in amusing the patient while nature cures the disease.

Patient in ECMO

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Voltaire

Much has been said about making decisions and pursuing actions based on sound evidence.  In medicine, doctors are urged to use the best available evidence and not to rely on hearsay or unsubstantiated claims.  Today, with all the technology and equipment available, it has become faster and easier to collate data and execute decisions based on the data gathered.

Evidence-based medicine is a decision-making model that supposedly enables us to make critical decisions. It requires meticulous data gathering and research before making healthcare decisions. Such decisions include clinical decisions about choice of diagnostic tests, treatment, or risk management for individual patients, as well as policy decisions for groups and populations.

However, evidence-based medicine has its limitations.  It may be able to answer queries on probabilities of benefit or harm, but it cannot completely explain details on mechanisms or people’s feelings.   Thus, evidence-based medicine is helpful for deciding whether to carry out certain procedures, but it is not very helpful for finding out how a patient feels today, or why a particular atom or behaves the way it does inside the human body.

Many patients have multiple diagnoses and problems. Diagnosis alone is a poor predictor of treatment outcome. Personality characteristics and social circumstances influence therapeutic response.  While evidence is important, we must remember  that we treat human beings with emotions, fears, and anxieties.  There are also other factors to consider such as finances and social support systems.  All these come into play when making treatment plans, and clinical experience plays a big role in holistic healing. If medical management were solely based on statistically measurable standards of evidence, then our training programs will no longer need experienced physicians.  Just give every student access to the Cochrane library and they will be able to treat a disease.

The personal qualities of the physician have an important bearing on patient satisfaction.  Sophisticated clinical expertise with regard to an individual patient needs to be balanced with evidence. It is my belief that too much emphasis on a narrow range of acceptable evidence oversimplifies the complex nature of clinical care.  Medical care must not come to a point where a patient would rather log on to a computer and follow the process flow.  After all, medicine was, is, and will always be a relationship business.

 

WHY BE HONEST?

It’s hard to be honest.  In politics, business, and in everyday life, we are always challenged to tell it as it is.  The medical profession is no different.  Sometimes we are tempted to lie to avoid conflict.  We hide the truth to avoid complications.  Or, even worse, we lie because we have our own selfish interests in mind.

However, we can derive a lot of benefits from honesty.  Here is why we should be HONEST:

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H – Helps lift a person up.  A word of encouragement from a trustworthy person enables someone to rise from adversity and face his fears.

O – Observation is aided – When you are honest, you enable someone temporarily blinded by emotion or circumstance to see the situation clearly.  After that, he or she can now find solutions to the problem.

N – Nurtures.  Honesty nurtures relationships and makes the bond stronger.

E – Edifies.  An honest person encourages others morally, spiritually, and intellectually to be the best person they can be.

S – Sustains.  Honesty sustains confidence in the other person.  It nourishes the soul and uplifts the spirit, knowing that someone can truly be trusted and relied upon.

T – Triumphs.  A person who has low morale tends to see the world as negative.  But when he or she sees an honest deed, it enhances the belief that good always triumphs over evil in the end.  This person then sees the environment and the people around in a different light.

In short, honesty HELPS us OBSERVE the world around us and makes us see a NURTURING and EDIFYING universe, SUSTAINING us until we reach our moment of TRIUMPH.

That’s the truth.

HOW TO DEVELOP YOUR SKILL

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“Once you can do something no one else can do, you can pretty well name your price.”

–  Richard Templar

There are now 7 billion people on earth.  They will all need food.  They will need jobs or a source of livelihood.  They will be competing with you and me.  Should we be alarmed?  While I believe that the earth has enough natural resources to serve its inhabitants, for the ambitious and success-driven, there is the insatiable drive to be a cut above the rest.  But it comes with a lot of effort.

Fortunately, there is a simple strategy to develop SKILL.  I formulated this mnemonic for you to remember.

S – Starting Place.  Know what your current abilities are.  Do you have analytical and reasoning skill?  Are you comfortable with numbers?  Do you have a natural inclination to build things from scratch?  Are you detail-oriented?  Are you always the life of the party?  Does everyone want to confide to you?  In my opinion, the best way to know the skill set you can develop is by listening to other people’s compliments – especially those compliments coming from people who do not expect to gain anything from you for saying it.   For example, if a known critic suddenly notices how good a writer you are, that may be your cue to develop your craft.

K – Know your ultimate purpose for developing the skill.   This will serve as your guide post.  Is your purpose to spread the word on the benefits of reading?  Do you want people to adapt physical fitness as a way of life?  Do you want people to enhance other people’s relationship with their Creator?  The ultimate purpose is always for the benefit of others, not just for yourself. Once you identify this purpose, write it out, and have it in your wallet, in your room, or in any place where you will be reminded of it.

I – Identify you goals to attain your purpose.  Your purpose will not be achieved immediately.  So you must break it down to more realistic and time-bound goals.  For example, if you are a first year student today, your goal is to simply become a second year student.  Don’t worry about your thesis in fourth year, or your board exam after graduation.  Just focus on getting a good grade on your upcoming exam next week.   Just do your best on the project you are currently working on.  Take your goals one step at a time.  You’ll have enough time to create a strategy to achieve future goals.

L – Let’s go and act!  Carry out those goals today.  A goal without action means nothing.  Once you have a goal outlined, make an action plan to achieve it.  Is your goal to develop memorization skills?  There are so many books and tutorials available on the internet.  Once you have the material in hand, follow its recommendations.  Grind it out. Practice the skill.  And don’t stop until you have reason to believe that you have acquired the skill.  What’s the best way to determine whether you have become proficient with a skill?  Teach it to others!  When they become skilled as well, it’s a very good sign.

L – Lionize!  The term lionize means to treat as a celebrity.  When you perfect a skill, you become a celebrity in your own right.  So as a celebrity, celebrate!  Give a toast to your skill.  Relish it.  Have time to enjoy the fruits of your labor.  All work and no play makes Jack a dull boy.  Make sure to take some time off  from time to time.  And to maximize your accomplishments, don’t forget to celebrate with others.  This will provide you with renewed desire to do more, to do better, and to develop more skills in the future.

In this age of globalization, a unique skill is priceless.  We are all unique in our own way.  Let that uniqueness inspire you towards unprecedented success.

STEVE JOBS AND ALTERNATIVE MEDICINE

the human atmosphere

The Human "Aura"

“I didn’t want my body to be opened…I didn’t want to be violated in that way.”

–  Steve Jobs on his decision to pursue alternative treatment

I just read an article which claims that Steve Jobs regretted his decision to undergo alternative medicine treatment for his pancreatic neuroendocrine tumor, which resulted in his death a few weeks ago.  According to Walter Isaacson, who has written a biography on Steve Jobs, by the time the former Apple CEO made a decision to discontinue alternative treatments, the tumor in his pancreas had already spread to surrounding areas.  Thus, from a supposedly good prognosis, his condition deteriorated and proved to be fatal.

The relatively new revolution called Alternative Medicine  has evolved over the past few years.  Just like Steve Jobs, there are individuals who opt to try alternative treatments to cure common and not so common illnesses.  The claim of alternative medicine practitioners is that it is safe and it works. While most people accept that conventional medicine is essential for emergency treatments, some sectors believe mainstream treatment is less effective when it comes to disease prevention, chronic disease management, and even in cancer therapy. These are the realms where alternative medicine is usually practiced, and it has supposedly earned millions of dollars for its business proponents.  In fact, a number of large tertiary hospitals, both public and private, have started to offer alternative medicine services.

So how does alternative medicine claim to differ from allopathic or conventional medicine?

First, alternative medicine practitioners claim that their practice is more holistic, treating patients as a whole individual instead of breaking them down into organ systems.  According to them, too much specialization has crept into allophathic medicine practitioners.

Secondly, alternative medicine says that it is less aggressive in treating disease, which means that it does no rely on a “quick fix” approach.  They claim to rely on more gentle modalities, and allow the body to heal on its own.

Third, some sectors maintain that allopathic medicine is based on too many strict rules.  To some, it seems as if the guidelines of allopathic medicine practitioners cannot be violated or interpreted in any other way, for fear of malpractice suits.

Fourth is the assertion that conventional medicine seemingly views the body as a machine, and most disorders are best treated with drugs. Alternative medicine claims to assert that the body is “a network of channels” involving simple energy transfer mechanisms. Impediments in the flow of energy through these channels lead to ailments, and the goal of the healer is to remove these impediments or “energy flow blockers”.

Lastly, alternative medicine alleges that it is more open to participative and coordinated treatment with patients, while conventional medicine is more paternalistic in approach, with patient opinions not listened to or dismissed as unscientific.

How do we resolve these differences in mind-set?  The key is to incorporate the best characteristics of alternative and allopathic medicine in order to enhance health care.  The ability to establish scientific evidence is a strength of allopathic medicine, but some of its practitioners truly pale in comparison to alternative medicine proponents in terms of patient interaction – the “art” of medicine, so to speak.  By combining the science and art of medical management, incorporating both ideologies into the education of future physicians, an integrated and complementary approach would benefit everyone.  Alternative treatments must be researched in order to establish their effectivity through evidence-based studies.  In turn, conventional medicine practitioners must see the whole person and be more  open to conversation to establish a more trusting relationship with patients and their families.

HOW TO MANAGE STRESS

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“If you can manage your own life and have complete power over what you wish to achieve, you can actually reduce stress. Separate and focus on your daily goals and set practical expectations for yourself”. – from Beyond the Quote
Stress is  part of our daily lives. Some people believe it is bad for our health.   But the truth of the matter is stress is only bad if it is not managed well.  When stress pushes a person to excel, it can be beneficial.   Recognizing when stress becomes detrimental is therefore of utmost importance.
Unfortunately, most people find it difficult to deal with stress.  People go through so much trouble in trying to relieve stress – to no avail.  From relaxation techniques, to doing some exercises, and sometimes even performing risky activities, most people COVER UP the stress, but it comes back to haunt them.  Fortunately, there are more effective ways to deal with stress.
In my clinical practice, I have come to the conclusion that stress is the main reason for most outpatient consultations.  When people are stressed out or anxious, they begin to think of going to a physician.  As long as they can manage the stress and anxiety on their own, patients will try to postpone a trip to a hospital or clinic.  Is this you?  If your answer is yes, you are not alone.  I guess it is more stressful for you to pay for professional fees.  So let me save you anxiety.  I will attempt to make you handle stress on your own – that is until you can no longer bear it.

Lack of time is a major cause of stress for everyone. To find balance between your family, career, and your personal needs, the first tip I have is this:  SLEEP AND REST WELL.  A tired person becomes sluggish and is unable to perform tasks.  He or she is also unable to plan activities well.  If you want to have quality time for work and play, never sacrifice your time to rest and sleep to perform more tasks.

Setting achievable goals is also essential.  MAKE SURE YOUR TARGETS ARE REALISTIC.  Break it down to smaller goals, and reward yourself a little for every accomplishment.

Know what your priorities are.  This will keep your schedule less hectic.  LIST DOWN YOUR MOST IMPORTANT TASKS.  My wife is very good at this.  I admire her resolve to accomplish things everyday.  Once her tasks are done, she feels relaxed knowing that she has crossed out tasks from her list.

HAVE TIME FOR YOURSELF.  Everyone needs a few moments alone. If you can’t get away from it all, why not go to the restroom?  Wash your face, groom yourself, and put on some perfume.  If  you can do this while humming a tune, that would be so much better.  In the afternoon, if it would be possible, why not spend part of your lunch hour just sitting in a quiet corner with eyes closed for 15 minutes? Better if you could take a short nap!

Never forget EXERCISE.  Do it for 30 minutes at least 3 or 4 times per week.  No excuses.  Brisk walking is enough.  Or take the stairs.  If you can incorporate stretching and weight-bearing exercises to your routine, then so much the better.  Studies have proven that the earliest manifestation of aging is muscle atrophy due to inactivity.  Sarcopenia, or muscle degeneration, plays a major role in functional impairment.  So if you want to age gracefully, exercise today.

Finally, there are only 2 ways to deal with  stress head on.  Either you decrease your load (less activity and responsibility), or increase your ability (by continuous learning).  If you cannot do one, then do the other.  Which is more feasible for you?  Only you can answer that.  But if I were you, I’d choose the latter.  Life is too short to spend just idling away without being productive.

ARTIFICIAL NUTRITION AND HYDRATION AT THE END OF LIFE

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It is not necessary to feed a person when it no longer results in a better quality of life.  Surprised?  Yes, most people are.  The notion of withholding food runs contrary to our beliefs regarding care.  Just look at today’s babies.  When they cry, what do parents do to stop them?  If the diaper is dry, the next step is most likely to insert a feeding bottle into the mouth.  For adults, a get-together is not complete without food.  When we travel to faraway places, we often give food as “pasalubong” to our loved ones when we arrive back home.  No wonder why an advice of withholding feeding is often met with much contradiction from the family.  We equate food with good health, satisfactory care, and loving gestures.  So when we stop feeding, it is as if we no longer care.

Legally, all medical interventions can be refused by patients who still have the capacity to decide.  Artificial feeding is no exception, even if it results in death.  If relief of suffering and improvement of the quality of life can no longer be accomplished by nutritional supplementation and feeding, there is no reason to feed.  In an article published by the Palliative and Supportive Care Journal in 2006, it was also stated that there is no ethical or legal difference between withholding a  feeding tube versus placing the feeding tube and then later removing it.

—Despite increased nutrient delivery, trials show disappointing results in improving clinical outcome for chronically ill patients.  —Improvements in biochemical markers also inconsistently correlate with objective clinical benefits for artificial nutrition and hydration.  Minimal  benefit was also derived from enteral or parenteral nutrition in terminally ill cancer patients, other than for those with obstruction of the stomach or intestine.  Hunger is often not noted and relieved by giving the patient ice chips or small amounts of food and drink.  Dehydration is a normal component of the dying process that does not result in thirst or suffering.  In fact, treating dehydration may actually lead to more pain and difficulty.

There are some cases, however, when artificial feeding and hydration at the end of life may be warranted.  But we must always weigh the advantages and disadvantages of the intervention.  Also important to consider are the wishes of the family and the individualized goal for providing care.  Key principles to consider are autonomy (honoring the patient’s wishes), nonmaleficence (doing no harm), beneficence (doing what is in the patient’s best interest), and capacity (ensuring that the patient and the family understand the information needed to make a decision and provide consent).

It is important to understand that artificial feeding should always be considered relative to patient goals. Physicians and patients, with the patient’s family, must be prepared to discuss the options, bearing in mind the evidence that feeding will do to attain therapeutic goals.  If the viable option is to withhold feeding, don’t despair – it is totally acceptable.    Caring does not stop even if feeding and hydration are withheld.  After all, our ultimate goal is to provide a better quality of life and preserve the human dignity of our loved ones.

ETHICAL ISSUES IN HEALTH CARE

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“The purpose of human life is to serve and show compassion and have the will to help others.” – Albert Schweitzer

I have always wondered why Medical Ethics does not command the attention it deserves.  In medical school, it is relegated to a minor subject in first year, where simply attending is enough to get a passing grade.  While it is important to develop technical proficiency in the healing art, it is now becoming obvious that medical dilemmas mostly stem from ethical issues, not technical issues.  This is because most medical societies have now created guidelines for sound management of disease.  It is clear, however, that most guidelines cannot answer ethical questions.

A health care professional who does not humbly acknowledge the need to place the interest of patients first is not a true health care professional.  Technical competency must therefore be balanced with sound character.  One of the values that must be emphasized is integrity.  From proper disclosure of medical findings to the conscientious assessment of professional fees, a medical professional must be trusted to make decisions based on the patient’s interest, not on the medical professional’s personal agenda.

This is easier said than done when the training of a medical professional focuses too much on science rather than character development.  It is sad that the measurement of ability during board certification examinations is based almost entirely on the ability to manage and treat illness through diagnostic reasoning and drug therapy.  Communication and ethical behavior are rarely evaluated.

Take the issue of end of life resuscitation, for example.  While it is important to empower a patient’s relatives to make decisions in these instances, it is equally vital to provide adequate disclosure for the patient’s loved ones.  Unfortunately, the skill of breaking bad news is not a common topic in medical education.  In fact, I have yet to find it being asked during board examinations.  In a profession where death and disability is equated to treatment failure, breaking bad news is not deemed to be an essential skill.

Ethical issues are increasing in frequency and complexity.  It is high time for hospitals, physicians, nurses, caregivers, and allied medical personnel to give it the attention it deserves.  Otherwise, it would become increasingly difficult to balance the need for improving the quality of care, containing medical costs, and ensuring the survival of healthcare institutions.