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Jokes Patients Tell Their Doctor

These are a few of the commonest jokes I hear regularly.

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Why the wait?

Advance Care Planning: Goals of Care Designations

You only die once. But, if given a second chance, would you have chosen to die differently?

Your medical team needs to understand your wishes and specific preferences for resuscitation and care in the instance of a life-threatening illness or change in your health.

Let us get the conversation about end of life experience started.

EngageWithGrace

Advance care planning is a way to help you think about, talk about and document your wishes for health care.

An Advance Care Directive (or living will) is a legal document that gives your health care team and your loved ones the confidence to speak for you when you can no longer speak for yourself.

Here are the steps in planning for the end of life.

Step 1 – [Think about what’s right for you]
You hold personal beliefs about prolonging life and measuring the value of quantity against quality of life.

Step 2- [Learn about your own health]
What do you understand about your medical diagnosis and prognosis? What can you expect from various medical procedures and treatments? What can they do and what can’t they do?

Step 3 – [Choose someone who will speak for you when you can’t and who will make decisions on your behalf]
That person is known as your agent, proxy, alternate decision maker, or substitute decision maker

Step 4- [Talk about your wishes]
Communicate your wishes and values regarding health care to your family and doctor.

Step 5 – [Record your wishes]
Document your wishes in a personal directive. This directive only comes into effect when you are unable to make decisions (what we refer to, in medical parlance, as a lack capacity).

You can review these steps and reinforce some of the concepts at the following links:

https://theconversationproject.org/ (International)

http://www.advancecareplanning.ca/ (Canada)

Additional resources

Alberta: conversationsmatter.ca
SK: https://www.saskatoonhealthregion.ca/patients/Pages/Advance-Care-Directive.aspx
BC: https://www.youtube.com/watchv=5BD9yJJdhIQ&feature=youtu.be

What is CPR and is it right for me?

Ask yourself the following: What are my hopes for this treatment? What benefits or burdens could I expect?

 

 

CPR tries to restore blood flow temporarily when an individual’s heart or breathing stops. It involves repeatedly pushing down hard and fast on the chest and may include mouth-to-mouth breaths or using a device to push air into the lungs. Electric shocks may also be used to try to correct the rhythm of the heart.

The survival rate of CPR is low. It works best in a young, healthy, person whose heart suddenly stops. Success rates drop to around 10% in people with chronic disease and a mere 6% in older people. Those who do survive CPR usually need advanced life support machines and medicines in a hospital intensive care setting.

CPR does not necessarily improve the illness that caused the heart or breathing to stop, so many people do not return to the life they previously enjoyed. The risks of surviving CPR include physical disability and brain injury. Survivors may not be able to return to their homes or live independently anymore.

To help you understand what medical staff can reasonably provide for you and what your expected outcomes of treatment are, ask your doctor about a medical recommendation based on your medical condition and preferences.


Alberta Province and our clinic

In Alberta, a Goals of Care Designation is a medical order used to communicate the focus of care including the preferred location of that care. This personal directive may change over time as circumstances and health conditions evolve.

The three general categories of care are:
Resuscitative care, Medical care, and Comfort care

Resuscitative care focuses on prolonging life and cure. These measures may not achieve the aim of restoring previous health. Interventions include CPR, ICU, medications and ventilation (a tube down your windpipe when you can’t breathe on your own).

Medical care focuses on prolonging life and curing or controlling disease without resuscitation or ICU. It is the focus in people for whom CPR and a breathing tube won’t work and is unlikely to restore their state of health. This category of intervention may include dialysis, feeding tubes, antibiotics, surgery, and hospital admission.

Comfort care focuses on maximising comfort and relieving symptoms like pain and shortness of breath. No resuscitative treatments are provided. This category is not less care, but the focus shifts to quality of life, and relief of symptoms. These patients are usually treated at home but sometimes hospitalisation is needed for optimal comfort.

There are sub-categories to these goals of care designations. Each patient decides on their wishes regarding chest compressions, intubation, ICU admission, surgery, site transfer, and symptom control.*

The information related to your Goals of Care is carried in a medical passport called a Green Sleeve. The Green Sleeve is a plastic pocket that you carry with you between different care providers and sites. It contains your personal directive, name of an agent, and a medical order completed by your doctor (goals of care). The Green Sleeve should be kept on or near the fridge.

**Doctor’s notes**
R1: Full resuscitation protocol
R2: No chest compressions (restarting of heart when stopped) but can be intubated
R3: ICU but no chest compressions or intubation
M1- Transfer to acute care but no ICU
M2- Care within the patient’s current location (home/long-term care). Transfer to an Acute Care hospital would rarely be considered and would only occur to achieve better symptom control
C1- Transfer to a new health care setting may be undertaken to understand or control symptoms.
C2- Goal of care is directed at preparing for death, which is expected to occur within hours or days. Transfer to a new healthcare setting is not usually undertaken.

Major surgery is not usually undertaken for M2 and C1 designated patients but can be considered, in the event of unexpected illness and injury, for procedures aimed solely at symptom relief.

 

Medical Cannabis

The number of registered medical marijuana users in Canada has tripled every year since 2014. Compared to the general population, marijuana users score four times worse on a functional assessment (World Health Organization Disability Assessment Schedule).

While a growing number of medical marijuana users self-medicate anxiety and sleep disorders, coping with chronic pain is the most common justification for use.

Unfortunately, cannabinoids are ineffective for most types of pain and marijuana (smoked, oils or edibles) is not an appropriate therapy for anxiety or insomnia. Cannabis oil prescriptions have mushroomed of late, but these preparations have not been shown to be more effective or safer than dried medical marijuana.

Only three conditions have modest evidence to support cannabinoid prescribing. They are:
1. Neuropathic pain (nerve pain, NOT osteoarthritis, NOT back pain, NOT fibromyalgia), or palliative pain (in cancer and end-of-life care);
2. Spasticity in multiple sclerosis or spinal cord injury, and
3. Chemotherapy-induced nausea and vomiting

In our clinic, we DO NOT prescribe medical marijuana (smoked, oils or edibles) as they are inadequately studied. If considering a medical cannabinoid, we prescribe nabilone only under the following circumstances:

1. Failure of ≥3 standard medications for neuropathic pain (or ≥2 for palliative pain);
2. Failure of standard therapies for chemotherapy-induced nausea/vomiting or spasticity in multiple sclerosis (or spinal cord injury).

Medical Cannabinoids Pt Brochure

Neuropathic Pain Pharmacotherapy Treatment

Medical Cannabinoids Summary

 

Are you healthier than Santa Claus?

Santa recently underwent his annual check-up.

His medical report follows:15622518_689548174549764_5949852411560346_n

Since 23 December 2008, Santa Clause has enjoyed Canadian citizenship status, and his official address is: Santa Claus, North Pole, Canada, H0H 0H0.

Santa is aware that a Sleigh Driver’s Medical is an uninsured service.

Santa is his jovial self and has no complaints. He looks remarkably well for his age (1,747 years old).

Although he wears reading glasses for presbyopia, he impressed on his eye exam when renewing his Class 1 (Sleigh) Driver’s Licence. He comfortably read the bottom line on my Snellen Chart (visual acuity measured 20/10; OD=OS=OU). He attributes his extraordinary eyesight to regular outdoor activity and minimal interaction with screens. It is unclear whether Santa owns a cellphone as he did not check his phone once during the entire consultation.

Santa managed to get a flu shot earlier in the year, anticipating close contact with many sniffling, sneezing, crying and coughing kids during the winter. We discussed hand hygiene to reduce his risk of infection. Santa will carry alcohol-based hand rub with him from now on.

On close inspection, Santa’s rosy cheeks are characteristic of papular rosacea. He received a pamphlet on skin care and should use sun protection when travelling in warmer climes. He has a prescription for topical metronidazole cream.

Santa weighs in at 260 pounds (117.93 kg) and measures 5 feet 7 inches (1.702 m), giving him a body mass index of 40.7 kg/m2.

We discussed the need for weight loss and a complete overhaul of his cookies and milk diet. I have referred him to a dietician to assist with a dietary plan. He will attempt to consume 500-1,000 fewer kcal per day but will not be downloading the myFitnessPal app because he does not interact with cell phones much. He has an exercise prescription which recommends at least 150 minutes per week of moderate-intensity exercise and resistance training three times per week. We discussed the available prescription treatments for obesity (liraglutide and orlistat), but Santa wishes to avoid these for the time being and acknowledges that he doesn’t have drug coverage anyway.

Santa’s Automated Office Blood Pressure reading was 132/84 mmHg. He says he has a BP machine at home, but he has been kept busy with the world’s population growth, and hasn’t used it “for a while”. He will start recording his BP and present the data at his next appointment.

Although Santa had his cholesterol checked, we were unable to calculate his predicted 10-year risk of cardiovascular disease because his age falls outside the usual range studied in clinical trials. He will focus on lifestyle, diet and exercise to manage his risk.

Santa has fatty liver disease based on raised liver enzymes and an abdominal ultrasound. His HBA1C level indicates prediabetes. Santa has a prescription for metformin to reduce his risk of future diabetes by 25 to 30%.

Santa continues to suffer from work-related lower back pain. He sees a physiotherapist regularly and there are no red flag signs or symptoms.

Santa has learnt to live with insomnia. His sleeping habits are erratic. He suffers from shift work disorder and frequently endures jet lag. Mrs Claus complains of his snoring. Santa completed a STOP-BANG survey in the waiting room, and I referred him for a sleep study. It is likely that Santa suffers from obstructive sleep apnoea. This diagnosis will not, however, affect his Sleigh Driver’s Licence because Santa flies outside of controlled airspace. Santa reassures me that the reindeer basically “fly the thing themselves.”

Mr Claus says his travel and tetanus vaccines are up to date. He has also received the shingles and pneumococcal vaccine.

I refilled Santa’s prescription for supplemental oxygen during air travel and collected my lump of coal.

Although we discussed the need for regular follow-up, I will probably only see him again next year.

(message from) Drug Free Kids Canada

Considering the recent announcement by the federal government to legalize and regulate the sale of cannabis for recreational use, DFK Canada is taking the lead in educating the public about this substance and the risks for teens of early consumption.

News release

The booklet — Cannabis Talk Kit – Know how to Talk With Your Teen — was developed by DFK with the support of the Canadian Centre on Substance Use and Addiction (CCSA) and Health Canada (Talking about drugs).

Parent/physician resources:

Brochure (Download the pdf)

TV messages (YouTube): English and French

Website: https://www.drugfreekidscanada.org/  

Weight Loss

Obesity (BMI > 30 kg/m2) is prevalent in one-in-four adult Canadians and one-in-10 children.

Excessive body weight contributes to hypertension, type 2 diabetes, cardiovascular disease, dyslipidemia, arthritis, cancer, sleep apnoea, chronic pain, depression, and dementia.

The Framingham Study estimated that overweight and obesity account for ~26% of cases of hypertension in men and ~28% in women. A 2009 systematic review found that even for patients with BMI of <35 kg/m2, a weight loss of only 3 kg was associated overall with reduced blood pressure

Although higher BMIs and wider waist circumferences (more than 94 cm, or 37 inches, in men and more than 80 cm, or 31.5 inches, in women) predict obesity risk, the Edmonton Obesity Staging System (EOSS) is a more accurate predictor of long-term mortality.

Obese children are likely to become obese adults and genetics account for over 75% of BMI.

BMI tends to increase during most of adult life, peaking at age 60, as resting metabolic rate declines by approximately 150 kcal/day per decade. The primary focus of obesity management is to prevent further weight gain.

Most weight loss programs fail because the body takes corrective steps to counteract weight loss once it has become accustomed to a certain weight. The body tries to defend its highest weight. For every 10 pounds of weight lost, the resting metabolic rate drops by 3%. During prolonged periods of fasting, the metabolic rate also slows dramatically.

Diet and Exercise

what you should know before you start a weight loss plan

The recommended rate of weight loss is 1-2 lbs per week and the initial goal is to lose 5-10% of body weight. This can be achieved by consuming 500-1,000 fewer kcal per day (myFitnessPal). Reducing calories will lead to similar weight loss at 2 years irrespective of the specific diet chosen. The general principles involve increasing  intake of vegetables, fruits, high-fiber and whole-grain foods while restricting dietary sugar and sugar-sweetened beverages.

Medications

Prescription treatment for obesity in Canada includes 2 drugs, liraglutide (0.6 mg to 3mg/day injection) and orlistat (120 mg three times daily with meals). They are approved for use in patients with an initial BMI >27 kg/m2  in the presence of weight-related comorbidity, and who have failed a previous weight management intervention or who have a BMI of 30 kg/m2 or more.

In a 56-week study using liraglutide, 33.1% of patients had lost more than 10% of their body weight and 63.2% had lost at least 5% of their body weight. During a 4-year study using orlistat, 73% of patients lost ≥ 5% and 41% of patients lost ≥ 10% of their body weight after 1 year. After 4 years, 44.8% and 21% of the patients treated with orlistat lost ≥ 5 and ≥ 10% of body weight respectively.

Both medications cause gastrointestinal side-effects

Bariatric surgery is considered with a BMI ≥ 40 or ≥ 35 kg/m2 in the presence of comorbid conditions. There are various types of surgeries: Roux-en-Y gastric bypass, biliopancreatic diversion, gastric banding or vertical sleeve gastrectomy may be performed.

Important components of weight management include mental health, sleep apnoea treatment, and pain control to encourage physical activity.

Both diet and physical activity are important for long-term weight management.

Do you have Binge Eating Disorder (BED)?

You can take a screening test here: Binge Eating Scale

  • Are there times when you feel that your eating is out of control?
  • Do you have any concerns about your eating behaviour?
  • Do you ever eat in secret because you are embarrassed by how much you are eating?
  • Do you eat sometimes when you are not hungry?

BED is defined as recurrent episodes of binge eating, on average, at least once per week for three months with a sense of lack of control and feelings of distress but there are no inappropriate compensatory behaviours (these are found in bulimia nervosa- Eating Disorder Diagnostic Scale).

Not all emotional eating is abnormal (sugar stimulates the limbic system in the same manner in which cocaine does). About 2.8% of the general population suffers from BED, women are more likely to be affected than men, and there are often coexisting mental health problems.

The treatment of BED starts with behavioural and psychotherapy (Treatment for Binge Eating Disorder)

Lisdexamfetamine dimesylate is the only approved prescription treatment for moderate to severe (3 or more episodes per week) binge eating disorder in Canada. It is started at 30mg per day and increased by 20mg per week to the target of 50-70mg. It is not a good choice for patients with cardiovascular disease (it is a stimulant that will increase blood pressure and heart rate), glaucoma or on antidepressants. Other drugs are used off-label (antidepressants; anticonvulsants; substance abuse treatments i.e., acamprosate, baclofen, naltrexone; atomoxetine; liraglutide; orlistat).