This is the second part of a three-part blog series featuring insight from Genesis Medical Associates primary care physician, Sunjay Mannan M.D., that highlights different pressing topics within preventative healthcare services. In this excerpt, we discuss the benefits of patient care engagement practices, palliative care and POLST forms.
In preventative healthcare, longitudinal patient care engagement is essential to preventing the majority of medical conditions ailing society today. What do we mean by longitudinal? Well, for most healthy patients, it means a once-a-year visit to your primary care physician in order to ensure we catch early onset diseases, or – in the best case scenario – prevent them all together.
“The patient can be very proactive in their own health,” said Dr. Mannan. “If someone has high blood pressure, they can get a blood pressure cuff for their house. When they come into the office with 15 blood pressure readings that show their true values I can adjust their medications off that instead of off 1-2 in the office. This type of engagement can make the care more extensive and individualized ”
Other areas of emphasis include nutrition, exercise and stress reduction strategies. A patient dealing with high blood pressure could speak with a dietician or personal trainer, consider home workout equipment or reduce their work schedule to decrease stress.
However, patient care engagement isn’t a one-sided concept. It falls on the doctor to motivate the patient to play a proactive role in their own health. In this instance, it’s up to the doctor to enable the patient to break down their own barriers.
For instance, let’s say Dr. Mannan pinpoints a specific aspect of a patient’s life that should be improved upon and suggest they change that aspect of their life with a solution. It’s proven that the patient will be more inclined do so if they came to that same realization on their own rather than just following the advice of their doctor.
Doctor: Why do you think you’re stressed?
Patient: I’ve taken on an intensive position at work that is too much for me to handle.
Doctor: What are some steps you can take to relieve that stress?
Patient: I should probably talk to my boss about scaling back my role.
Doctor: Tell me how you can scale back specifically? What would keep you from scaling back?
Doctor: You’ve gained 5lbs and you’re on the border of what we consider obese. Let’s catch this now. What do you feel is causing this?
Patient: I think I’ve been dealing with depression, and I’m overeating. It just makes me feel good.
Doctor: OK, tell me more about what’s going on. Let’s see how we can find a solution.
“For doctors, it comes down to asking open questions and listening,” Dr. Mannan said. “Allowing the patient to talk it out can often lead to them coming to their own conclusion.”
Q: Do you feel that patient care engagement is a concept that some doctors don’t emphasize enough?
Dr. Mannan: I think doctors may underestimate the amount of knowledge that the patient wants regarding their medical condition. It has nothing to do with the doctor caring, but instead the nature of medicine today – whether it’s the length of the appointment or the patient hearing different advice from different doctors. Patients often tell me “I was never explained my medication in that way…. “The doctor never gave me options and allowed me to chose”.
Maybe, they said “You have high blood pressure. This is your medication. Take it.” Or,
“You’re 50 years-old, you need a colonoscopy. Go get it done.”
I think patients want to know more than doctors give them credit for. It’s the providers job to educate the patient so the patient can make an educated decision regarding their health.
Q: What approach do you take in doing so?
Dr. Mannan: If you do it right the first time, it’s a one-time explanation and it builds trust. I have a whiteboard in all of my screening rooms. If we’re treating a kidney stone, I’ll draw the urinary system to explain why they have pain in different areas. If we are talking about fluid collecting in their legs, I’ll draw the veins and the valves that are giving away. I’ll explain on the board why there’s fluid building in your lungs. With those examples, seeing the light bulb turn on with the patient as to why the medication will help dilate the urinary system to help the stone pass, why the compression stockings help the fluid collection, or how a fluid pill can help them breath is all worth taking the extra time.
PALLIATIVE CARE AND ITS BENEFITS
As a family, it’s never easy to accept the natural decline of a family member with a serious illness. At that point, palliative or hospice care can be a resource to the patient and family for care.
There is a common misconception that palliative and hospice care are the same – a place where sick individuals go to spend the final few months, weeks or even days of their life without any kind of medical intervention. In reality there is a difference between the two. Whereas hospice care more fits the above description, palliative care can begin at diagnosis of a severe ailment and still provide the patient medical treatment versus just comfort.
“A lot of times there’s a patient who’s sick and the recommendation is that we should get palliative involved,” said Mannan. “But the family members maybe resistant, ‘No, absolutely not. My mom is still fighting.’ They’re just not ready as a family to accept how sick their family member is.”
If explained properly, palliative care can provide both patient and family a means to move forward at this stage.
“The reason we’re going to consult palliative is to provide them more resources,” said Dr. Mannan. “We’re going to keep them comfortable for the rest of their life. We’re not going to do any heroic interventions, but they will still get medication, they can have labs drawn. We will still treat infections.
“In addition, there may be home nursing and care that then becomes available. ”
Q: What are the benefits to the patient/family with regards to hospice or palliative medicine? What are the benefits of these discussions early on?
Dr. Mannan: From the cost side, let’s say an inpatient stay is X amount of dollars a day, which can be thousands every time you’re in the hospital, and the ICU (Intensive Care Unit) is way more than that. If made hospice, the patient will be transitioned to the hospice floor/facility that is tailored to hospice on discharge. These facilities/hospice units will be less expensive rather than pursuing heroic measures that will eventually result in the same outcome. End of life discussions with the patient can avoid the guilt of a family member withdrawing care. Patients are naturally more comfortable having these conversations with doctors they have known for a longer period of time and they trust.
THE IMPORTANCE OF A POLST FORM
Palliative care and hospice are tools help with serious illness and end-of-life care, but what about when the time to pass away actually comes? It’s essential to be prepared. As patients approach the 65-year age mark, establishing a plan becomes increasingly important.
Doctors want to ensure that a patient’s end-of-life wishes are granted, which helps to shape the questions they ask during these conversations.
“The questions pertain to if you were to pass away,” said Dr. Mannan. “If you were to lose a pulse. If your heart stops, do you want a doctor to revive you/bring you back with CPR? If you lose the ability to breathe on your own, do you want a breathing tube placed to help you breathe with a machine?”
Patients don’t understand a lot of times that when you receive CPR, a breathing tube may be placed to protect their airway. Explaining the process can change their choices. These are patient-doctor conversations that need to take place to empower patients to decide on quality or quantity of life.
Typically, these wishes are put into legal writing through a “living will” to ensure the patient’s individual wishes are honored. In the state of Pennsylvania, however, an individual’s living will can be overruled by an immediate family member if that member was made the POA (power of attorney). If the patient grants a spouse, sibling, child or friend their Power of Attorney, that person would have final say in their end-of-life care…. even if it’s against the written will of the patient.
“This is an interesting question,” said Mannan. “Let us say you are married, you tell your spouse you want them to be your Power of Attorney, and state in your living will that you don’t want a breathing tube or CPR. In the event you become incapacitated, they can overrule your
living will if they are the power of attorney. It really blows my mind. These patients often are in the ICU intubated and sedated until the family can come to terms with losing that individual. But it was against that person's wish to be in that state to begin with.”
One way for a patient to communicate and solidify their end-of-life wishes is through a medical POLST (Pennsylvania Orders for Life Sustaining Treatment) form. POLST forms are filled out between the doctor and patient when they have medical decision-making capacity, and is a medical order that must be followed by EMS, nursing homes, and hospitals. Given the nature of these discussion and time needed to fill them out, they are often filled out at the annual exam.
Q: From your experience, is it challenging to discuss end-of-life care with a patient when they may not be completely ready to face that reality?
Dr. Mannan: The conversations themselves do not bother me. The idea of not knowing ones end of life wishes and caring for them in acute situations does. If they can’t make that decision, I still want to have the conversation to the plant to seed for them to begin thinking about it. In that situation, the patient will be full treatment until they decide otherwise.
In the final segment of this series, we’ll discuss the proper way to manage drug regimens and how patients can establish healthy behaviors. For more health-related information, stay up to date with the Genesis Medical Associates blog.