On Letting Go--Thoughts From An Anesthesiologist On Death

Today we are going to bring up a subject that might make some people uncomfortable.  This is not the intent.  The motivation is to bring to you the benefit of my over twenty-years experience in the Operating Room, and to help you make the most of your quality of life when it comes to end-of-life care.



Three Hots And A Cot

This is an old saying among those who work in the hospital, where on the coldest of nights, people who have no place else to go, will come to the emergency room complaining of chest pain. They understand the protocol to rule out a myocardial infarction (heart attack) requires three blood tests taken eight hours apart.  This why food and shelter is given to them for one day, and it is free of charge, as there are few resources typically available for people who use this as a last resource.

People are clever.

So are those who work in the hospital for figuring out a quick saying that captures the situation succinctly, and allows more energy to be focused on other priorities besides the current situation. You can't win. The patient has won by faking a heart attack on a cold winter's night when there is no shelter. And you go through the steps and do what has to be done, but you don't worry or lose any sleep over it, does this make sense?

This patient needs a six pack and a fishing pole.  -- James Jakowatz, MD, Surgical Oncology

To me, this quote from my teacher sums up all of end of life care for the patient's highest good:  there is a point where further intervention will decrease the quality of life for what little time the patient has left--everything must be done to ensure the patient's comfort and to meet the patient's goals of care.

I want you to think about that as we go through the next few scenarios...

Disease Has Its Own Course Over Time

Recently I did major cancer with reconstructive surgery on a patient who was 'lost to follow up'. After the initial abnormal finding on the mammogram and instruction to have a follow-up radiology exam 'just to make sure'--the patient didn't do anything except go from one second opinion to the next, trying to decide what to do.

Cancer growth is described as a 'doubling time'--one abnormal cell takes a certain amount of time to divide into two cells. By the time where it can be detected, it has been present for what could have been a length of time!

Disease is not going to slow down its progression once it gets detected; rather, it is going to pick up steam and accelerate itself in your body whether you choose to act upon the test results or not.

This is difficult and painful for me to say to you.

I know you would like to have time for the emotions to settle after receiving a devastating diagnosis, before you resolve to act. Anyone would like to have unlimited time to search for the best course of action which is right for them...I know this all too well.  I've done it myself, and fortunately I got lucky. But I was playing with fire, with my own life, and I was gambling with very high stakes with my delay.

This is where the love and support of family and friends, and if you are alone then the social worker or chaplain--to help you sort things out once the cards have been dealt.

What could have been a twenty-minute operation with nipple sparing turned into a seven-hour ordeal, with much greater risk of anesthesia and surgery, as well as extensive restructuring of the body appearance because of this delay.

If money is a concern talk to a social worker. Most of my patients these days are funded by the county or the state or Medicare...there are options you might not know exist...

Dedicating This To Mommy and Daddy

My father challenged the system in which I work.  He had a total fear of the ICU. When I worked at the VA, on ICU, and wasn't allowed to leave the floor, sometimes he would bring me Taco Bell...it took a lot of courage for him to walk the length of the ward to the break room to visit with me. He stared straight ahead, and avoided looking at the rooms on either side of him that were his worst nightmare.

I suppose this only further strengthened his resolve to have 'no heroics' when his pulmonary fibrosis was diagnosed.

Have you ever seen 'air hunger'? Father died of it. After a while even the oxygen doesn't work any more. At the end he was so exhausted he did not have the energy to brush his teeth. Mom had to do it for him.

When I got the call, that he 'wasn't looking so good' and it was time to come to his bedside, the hospice nurse from Kaiser was at my parent's home. To my eyes, I saw her giving him an overdose, and withholding definitive care (intubation of the windpipe, like I do every day).   I accused her of all of these things!

My brother--in-law and mom yelled back, and said, 'HE WANTS IT THIS WAY!'

And he died.  It took hours. I had to tell mom to give him permission to go. And once the chaplain anointed him with oil, I saw a vision, my clearest and first one of the pearly gates. I saw him cross over...(there is a blog post describing it in detail, around June of 2009 he passed...not sure when I blogged it).

Father said NO! To long-term care in a facility on a ventilator. Father said NO! to being embalmed. Father said I ACCEPT DEATH after a lot of work with his chaplain and hospice team (they call it Palliative Care with his medical system)...

I learned to respect Daddy for the lesson he taught me--on how to 'let go'.

Mom, on the other hand, said, 'I WANT TO LIVE FOR MY FAMILY'. In 1999, December 31, mom had renal failure.  She could have died in four days had she rejected dialysis.

She took the dialysis.  Then she said, 'NO!' to the support group of dialysis patients. But after a while, she and father decided to go.

Then she said, 'NO!' to the extensive medical testing you need to do to be on the transplant list. She was terrified of having to do the spirometry test.  But after a while, she and father decided to complete that last test and be placed on the transplant list.  She waited with excitement for the day her new kidney would come!  (she didn't want ours, because as she said, 'you girls will need them.')

After time, she said, 'God? I accept this life of dialysis in my heart. I won't fight it any more.'

Two months later she got the call! 'Charlie' the new kidney was hers! She had energy, and a new life! Except for a bunch of pills she had to take, she could travel and enjoy her grandchildren again!

She took care of Anthony for two years while I worked part-time.  He was born three years after the transplant.

But the anti-rejection medicines gave mom both diabetes and bladder cancer. It was ADVANCED!  She needed life-saving surgery.

During each step of the way, in private, I asked her, 'Mom? Do you really want to go through with this? Is this what YOU want? And not what you think the family expects of you?  You let me know, and no matter what, I will explain it to my sisters gently if you just want to stop like dad did.'

She valued my openness and concern. And she told me where all the 'funeral packet' is and how she's planned everything. But for now, she wanted to live, and that was her goal.

It was a very long, drawn out time for her in recovery. But now she is content, and alive, two years later.

So whether it is a YES or a NO, you have the right to decide what is right for YOU, every step of the way, when devastating illness makes itself present in your life...

Dad as a little boy

Here Is The Skinny

From where I work in the O.R., I see a LOT. And there are some things that exist that I call 'mortal wounds'...

• that LAST thing that goes wrong in a patient who has multiple serious medical problems of all organ systems--who was living independently until this seemingly minor 'thing' happens.
• end stage cancer to the point of intestinal blockage in multiple locations with ascites
• tumors everywhere and weight loss to the point of being 'cachectic' (wasting)
• going for anesthesia for something minor when there is sleep apnea and morbid obesity
• any anesthesia when there is pulmonary hypertension
• very extensive surgery in someone who is not in the best of health

The patients basically 'want their old life back' and seek surgical intervention as a drastic means to 'obtain it'...

They and their families are not thinking it through.

There are surgeons who will operate on anyone who has a pulse.  Whether it is to do an exciting case, or to 'help', or to make money, there is a lot of pressure not to cancel their case...

In essence, if I have a 'BAD FEELING' about the risk of a poor outcome (death, stroke, etc) but no test results or evidence to 'back it up', I can't cancel the case...but if you look very closely at my face and my eyes, you will see my concern there.

In very brief explanation, for the reasons above, I submit:

• there are too many 'miles on the car' to withstand the anesthesia, surgery, hospitalization and recovery.  There is little or no 'physiologic reserve' to help you get through all what it ahead.
• It's a choice of dying with tubes and bags on the stomach or just without--it won't extend life.
• The doubling time has increased the tumor load on the body to where the tumor is taking more of the nutrition than you. At this point we are just 'feeding the cancer' and tube feeding is withheld...
• airway management in anesthesia is a serious risk we don't talk about. If you open your mouth and no one can see your uvula (that thing that dangles down in the back) you better be having your surgery at an experienced center who handles the difficult airway. No one might tell you that you had a significant desaturation after anesthesia was induced and the airway was controlled with the breathing tube because it was difficult to put in place.
• the risks of poor outcome with anesthesia and pulmonary hypertension are about fifty percent where with other diseases it is less than one percent.
• surgery is like running a marathon--the longer it is, the harder it is on your system.

Have The Talk

There are three talks you need to have about the end of life before you EVER mention it with your doctor...


With yourself
What do YOU want? Do you want to be kept alive? Or allowed a Natural Death? Do you want hospice? Who would you pick to make your medical decisions for you if you can't? How far do you want to extend yourself in treating your ailment? And what 'decision points' will be signs for you that perhaps it is time to change up the plan, and perhaps, suit your goals further, in another direction?  (By the way, I strongly suggest doing what works for you in MANY areas of healing, not just one...)


With your family
I have made it know that if I am in a persistent vegetative state I am OKAY with it. I only want my loved ones to be able to see and touch me as they need to, and when God says 'it's time' I am okay to go. In the meantime, I have my Jewish Friends on alert that I want the Torah read to me as much as possible, in Hebrew--because even though I can't understand it, my soul somehow does, and is deeply comforted by hearing it. My stylist Ed is the one who is 'on the hook' for this right now, and has been for over ten years. When Anthony was born, Ed came to the hospital with his little prayer book--and said blessings over the child and me. It meant so very much to us both, that he would do something so kind that no one else would be able to do for us.


With God
This is the most delicate of them all. Because, as we know, we don't have the final say in the outcome. It is important at this point to invite 'Creator' (I call it 'God' out of habit) to help direct your choices for The Highest Good.  Case in point, a woman I recently met at a mediumship had a husband die young. He was very sick, and he wanted to suicide. She was very disturbed. She loved him and didn't want him to suffer, but the ways he had in mind were messy and graphic and more than she could accept at the time. A mutual friend found a group, 'EXIT' in their native Switzerland. It helps people in his situation suicide. So he drank something, and she listened to his heart, and fifteen minutes later it stopped and he was dead.  she STILL bears the emotional scars from witnessing his suicide, and he left her with three kids to raise all alone...and this was over TEN years ago! So his 'FREEDOM' cost her more SUFFERING... so when it comes to the 'big picture' (read 'karma balances' overall--do you want to owe any in the hereafter?) make sure you get Creator in your court when you can.

There are a lot of blessings at the end of life. Some people spend their energy and purpose in easing the Transition of those who need it the most.  It is inspiring to us all.


Aloha and Mahalos,
Namaste,
Peace,

Reiki Doc



P.S. for synchronicity--I've had this post rattling around inside for two days--and my friend and Reiki student also published this--and she is thousands of miles away, and we don't really keep in contact much <3  http://thewaytotheway.com/the-cure-for-death/?utm_source=rss&utm_medium=rss&utm_campaign=the-cure-for-death
(Dis-Ease is energy imbalance, disharmony in the energy body that develops into physical illness if left uncorrected)

On Love And Acceptance

Earth is not an easy 'school for life lessons'. The curriculum will take everything you have. Here are some tales of individuals who are pushed to their limits, and how acceptance and trust in 'what is taking place' is important for our spiritual growth.




Meconium Aspiration:

Two happened recently and our team responded with love and faith and hope for both families.

The first appeared to do okay, although the neurological injuries were profound. It was so severe that the baby could not suck, which is a very primitive (this is the medical term for something 'hard wired' into the species) reflex. The child was sent home on tube feeds with a little g-tube, and there was observation if perhaps the injuries would improve...

In the meantime, a little girl was born with similar circumstances, and coded in the delivery room. There was anoxic brain injury, and she was put on ECMO, which is the 'heart lung machine'. Prognosis was poor. In a matter of days, the family withdrew support, and said goodbye to their beloved angel, and let her go.

What kind of life exists for a family with a child with severe neurological injury?

Will the child ever know you? Or be on a ventilator for the rest of its life?

This is the decision the first family is facing. The brainstem is affected by the low oxygen at birth because the meconium blocked the lungs from functioning.  The medulla and the respiratory drive does not trigger enough for the carbon dioxide levels to be compatible with life. There is low possibility that the kidneys will compensate for the respiratory acidosis (high CO2).

In both cases the medical teams said, 'There is nothing more that we can do for your child.'




Overuse Injury:

A friend of mine, a surgeon, has a son who is so wise he says, 'Mom? Is your job just to make a drawer full of blank checks to pay people to do things for you with us because you are always at work?'

He lives, eats, breathes baseball.

He likes to pitch.

And he throws the ball hard. And fast. The past four years have been one team after another, each one more 'prestigious' than the next.

Until his arm started 'feeling not right' in his shoulder.

One day, he couldn't throw. He couldn't make the ball dribble four feet.

The coaches said he just needs ice and ibuprofen.

His mother, a physician, knew something was wrong.

It wasn't easy to get a sports specialist to see a patient who is twelve. Most draw the limit at the lower edge of adult, at sixteen. One appointment she had made was cancelled.

At Kerlan-Jobe, where all the professional athletes go in Southern California, there was ONE orthopedist who saw patients as young as twelve.

It was an overuse injury.

The boy had shattered the growth plate. And by the films you could see a pattern of many, many episodes of inflammation that had never healed. One arm had a thick space on the growth plate, the other, the non-pitching arm, was thin and normal.

My friend spoke to me with tears in her eyes, from one physician to another, with the pain only a physician mom could have for her child--she missed the diagnosis because it was not her specialty, and she thought something so serious would HURT while it was happening. She didn't know.




Bullying and Fatty Liver:

My nine-year old threatened suicide about one month ago.

He had a plan and the means were available in the house.

The bullying at school over his obesity was so painful he never wanted to go to school again, and in his own words, 'If I get diabetes my life is OVER so I will...' and he told me how he would do something in the middle of the night and I would wake up and find him dead in the morning.

Metabolic disease is a long slow suicide.

I had noticed a pattern in him of being less willing to walk and to play and to be active.

I turned to vegetarian diet, allowing him meat, to make of myself an example to him. I have seen amazing results with the RAW vegan diet.

But the more I pushed, the more he resisted.

I once bought packages of every single kind of nut there is, both raw and roasted, because nuts are healthy for people with insulin resistance.

Peanut? no--I don't like it.
Cashew?  no--I don't like it.
Macadamia nut?   no--I don't like it.
Hazelnut?   no--I don't like it.
Sunflower seed?    no--I don't like it.

Almonds? roasted, raw....I only like ones that are covered in dark chocolate.

Pine nuts?    no--I don't like it.
Walnuts?     no--I don't like it.
Pecans?       no --I don't like it.

All he wanted was chocolate and coke and lots of meat. Some fruit, but not much. Eggs and toast every day. And cheesecake. Orange juice, lots and lots of it between the various households--co-parenting, grandparents, cousins, sitters...there was emotional eating and no portion control.

I got medical help. Counseling. And a dietician.

At the dietician he shut down completely. He felt he was going to starve, he felt nothing would work, he didn't even want to try...

And I realized when someone doesn't want to participate in their own health, even if mom is a doctor, there is nothing more that you can do for them.

So although at nine, his BMI is obese, there is high cholesterol and fatty liver (which can lead to cirrhosis), he is not motivated to change.

And the future is diabetes, neuropathy, cataract, amputation, cardiac disease, and sleep apnea...with high risk of hypertension and renal impairment as well.

I didn't need a doctor to say 'there is nothing more that we can do' because I AM a doctor and I HAVE tried everything!

In my mother's heart, I grieved his loss, and my having to watch the painful results of his life choices.

I realized then and there that much as you like them and love them and want them to stay with you forever, those children of yours are on borrowed time, and belong to GOD and no one else.

The same is true for pets, family, parents, and friends.

Everyone in your life is there on 'borrowed time' and for one reason or another they can be gone or everything can be changed in an instant.

And that's the way it is.

What more can you do?





Alice In Chains:


My close friend lives in a very remote part of Texas. Spiritually we share a closeness I have not experienced with anyone before. We are like sisters, peas in one pod, mutually supportive and nonjudgmental with each other in every way.

She is dying.

The reason is complex, but the long-story short is end-stage neuromuscular disease with cardiomyopathy and impending pre-renal dysfunction.  The choice of my friend and her husband, who was a dialysis technician, is 'no dialysis'.

She sees Ross. Just like me.

We actually walked her to The Other Side once, and I said a tearful goodbye, without knowing anything about who she was in spirit and how in our past lives we WERE sisters when all three of us were alive in that time.

It tore Ross up. He sat down and cried, and I had no reason why.

So although she had her guides and angels--yes, she sees them, just like I do--tell her after she made Reiki Master in December, that in January, her life plan was the end of her life-contract----we got a little 'bonus time' together.

We made the best use of that time together than any two souls possibly could. Our healing of our spiritual scars and pain leapfrogged over each other, each 'layer' healing with the attention and love of the other, the whole time.

Today she told me she is really tired and she doesn't know how much longer she can go on; I love her so much that even if she were to pass on my birthday, I would be okay and just celebrate it as 'my birthday on Earth and hers in Heaven' from here on out.

We both know our next assignments, and Ross has assured us we will ALWAYS have contact with one another.

This does not take the pain of saying 'goodbye' away, but it does help to know that our relationship will change, and we will continue in a different way, 'next time'.

See you next Thursday, my Beloved sister of my heart....




Jim:

This is an actual transcript regarding someone who is on our Reiki Request list, someone with advanced cancer, and a heroic past in service to our country.

Hola, an update on Jim Conner He is currently unresponsive for unexplainable reasons per the doctors. Please send the Reiki love and healing to him and Annabelle. Namaste Linda

12UnlikeUnlike · 

• Top Comments

  Doctors With Reiki likes this.
• 
• 

  Doctors With Reiki It is our pleasure to serve. 

  Like · Reply · 3 hours ago
• 

  Doctors With Reiki Ross and I took him for a little walk. Ross gave Jim a huge, shiny golden watch Jim put on his left wrist. It is to commend him for his time spent on Earth. Jim could not believe the Glory of Heaven when he saw it. He fell to the ground and wept tears of joy. Blessed Mother knelt down, and encouraged him to get up. He said she was even prettier than me.  His father was there, and said, 'Son? It's time to come home. Are you ready?' Jim was very excited. He will send messages back through me when he is done, if he thinks of them he will let me know, and I will send. It is an honor to have escorted such a fine man Home.

  Like · Reply · 21 hours ago
• 

  Woody-LindaLu Leonard The physical self is lingering His spiritual self is home. Thank you for the escort , his wife is strong today as they wait at bedside. Thank you for your guiding him and Ross escorting

  Unlike · 2 · 3 hours ago

Angelic Reenlistment:

I have a friend, like me, who channels and blogs.

She keeps getting 'reenlisted' after her missions complete.

Just this week she was told she was at the end of her Life Contract.

But she's still here.

And in pain.

Missing the 'ride' Home when you have full memory of life in the Higher Dimensions is agony I can't describe in words.

We have no idea when or how she will 'GO', either in body as Ascension, or through Transition.

Living with this type of 'unknowing' is very stressful. I try to comfort her as much as I can.

We too will have contact after 'what happens'.

But I will miss the stickers and our chats most of all...

The desire to leave the Lower Vibrations is overwhelming for some who have a 'soul signature' that is from the Higher Dimensions.

Because Life is 'change', the 'exit points' too are constantly changing. 

Only thought love and acceptance, both of self and the 'system'--can what remaining time left here on surface Gaia, be meaningful and filled with joy in the face of the end of the Life Contract.

Extensions are permitted, but not for more than six months...and these are given on a case by case basis.

What more can you do?

Somewhere Over The Rainbow  by IZ

http://youtu.be/wZFkXQKCuBc

FYI:  Here's what IZ has to say. This is me, I channeled him.
http://soundofheart.org/galacticfreepress/content/somewhere-over-rainbow



Aloha and Mahalos,
Namaste,
Peace,


Reiki Doc

P.S> you might want to check out my blog on Galactic Free Press, 'Daughter Of Rebekah'--there's some good information on it, and not many posts... xoxoxox

End Of Life Decisions: What You Need To Know

This is me with Nana Angelina.

Things are a little 'sketchy' with insurance and long-term care facilities at the end of life.

I wish to shine Light on the situation to educate you.

In The Old Country:

• the elderly lived at the home of their children.
• people accepted them but neither paid too much or too little attention to them.
• they were part of the family.
• neighbors took care of those without family.
• at some point they would stop eating.
• dehydration set in.
• kidneys failed.
• in four days death was inevitable.
• the body was prepared by the women of the village.
• it lay in state in the living room and guests paid their respects.
• there was a funeral and a get-together afterward.

In The Hospital When I Was A Medical Student:

• The disease was considered incurable and end-stage.
• A durable power of attorney (medical decision maker, sometime patient themselves) was consulted about 'ending the suffering'.
• Decision was made to put patient on a morphine drip (comfort measures) and keep patient DNR (do not resuscitate).
• Nurse sets the iv up and keeps dialing it up every two hours.
• About eight hours later, the patient is apneic (stops breathing).
• Family is notified (many times they are not present).
• Body is sent to morgue and death summary note is dictated. All forms are completed.

With My Father Four Years Ago (He was a member of a Big Box Hospital Organization):

• Pulmonary Fibrosis is diagnosed (this is terminal condition, only 'cure' is lung transplant, he is not eligible due to age).
• Patient is 'optimized' with pulmonologist as long as possible, and treated for any infections.
• Disease is 'advanced' and patient is put on 'Palliative Care' (it is not exactly Hospice--aggressive care and hospitalization is still sometimes an option--which is done 'in home'. I read the booklets and found 'Palliative Care' to be a very murky subject which is highly based on the definition of the primary health care provider--which might be different from another provider's interpretation).
• A reader who is a hospice RN defines 'Hospice' as 'withdrawal from aggressive care.
• Cost may enter into this decision-making process, just as with the family they are asked 'do you want to do heroics?', the business entity providing the care must decide the cost-to-benefit ratio of further intervention for the disease.
• To my experience in ICU, there is a point where the outcome is clearly evident to all except perhaps the family, who wish 'to have everything done'. We honor this, although there are times there is a 'slow code' done in name only, as the disease is overwhelming and end-stage. (If a critical care specialist says it is time for DNR, they are basing this judgement on medical knowledge only, and not finances.)
• Once on Palliative Care, a patient is offered experimental drugs (this accelerated his decline).
• Weekly visits by chaplain begin at the home.
• All medicines are sent to the house, including oxygen.
• Weekly nurse visits instead of trips to the doctor start.
• At 'sudden decompensation' on-call hospice nurse comes and remains at bedside giving sublingual doses of concentrated narcotics and drying agents and anti-anxiety meds until patient passes.
• Body is left at home as long as family wishes until one or two days (I forget) then mortuary comes for the body.
• embalming if desired.
• funeral if embalmed, family viewing only if not embalmed.
• burial.

Death In The O.R.:

• Family and patient are informed of the risks before surgery by all members of care team--internist, surgeon, anesthesia, before going to surgery if risk is high.
• Often family and patient 'want their chance' at miracle 'save'.
• Sometimes quality of life is so bad patient has no other option (end-stage disease).
• Patient has 'event' and code blue is run by the O.R. team. 
• Anesthesia is the one who says, 'Start chest compressions' and announces the code. If patient is prone a gurney is brought in and we flip them on their back. A big plastic dressing covers the wound before turning.
• ACLS protocol is followed to the letter, unless Power Of Attorney says, 'no this or no that'.
• The code is called, usually by joint decision by surgeon and anesthesiologist.*
• All lines are left in place and the coroner is called.
• Coroner always asks to speak to me if there was 'anything unusual'.
• Coroner decides whether to come in or not. They usually do. (my heart surgeon pulled out the breathing tube always for the family before the coroner came)
• Surgeon talks to family. I make it a point to be present.
• Body is take to part of hospital where family can view and say first 'goodbyes'.
• Body is taken to morgue and then to the mortuary when they arrive.
• There is a big plastic body bag that zips up. (one Trauma Tech in the ER, when they heard the call about the accident due to arrive, would sometimes put that on the gurney first to save a step. The back-board would roll over it like it would a sheet.)
• All the forms are filled out by the surgeons.
• Anesthesia is expected to go back to work on the next case immediately after all charting is documented. No time is given to process the event. I typically call the hospital chaplain for a brief consolation for about five minutes max, just for my mental health.
• * -- I see the spirit of the patient in the room during the code blue and mentally communicate with it.

With Nana 2013:

• Durable power of attorney is called to a meeting to discuss end of life care with social worker--family is welcome.
• hospice is offered early with promise 'she will have her own nurse!'
• Family declines due to satisfaction with current level of care and 'gut feeling about it'.
• Family learns medicare pays one-hundred percent for hospice, both to hospice organization and facility. (hospice utilization has increased over two hundred percent in last few years in CA).
• By my assessment, what is keeping Nana alive is the LVN who feeds her. She mixes ice cream milk, and nutrition shake together because she knows 'Nana likes sweets'. She is patient and reminds Nana several times each mouthful to swallow in a loud voice.
• What is also keeping Nana alive is the excellent nursing care that keeps her skin healthy--no bedsores.
• Mother does not like the roommate Nana has had for a year. She arranges a room transfer.
• Nurse that feeds Nana does not work on this side of the facility--it's a whole different nursing station.
• Nana 'stops eating' on Friday.
• The physician says, 'Stop feeding her she aspirates'.
• Mother signs a form that says, 'comfort measures but antibiotics and i.v. fluids' on Friday.
• Nana gets i.v. fluids for one day.
• The next day, with me, no fluids are given.
• Nana says she is hungry.
• She can't open her mouth to eat. She milkshake concoction just sits in her mouth. She only swallows once or twice, and takes in about half a small cup.
• She spikes a temperature, gets tachypneic (fast shallow breathing), and starts getting puffy (signs of renal failure)
• Hospice nurse assesses her and says, 'she does not look good'.
• In facility Hospice = one nurse a week with daily visits to 'check progress', facility nurses giving 'comfort medicines--same as dad--' every two hours, weekends get 'on call nurse'.
• In case of 'fast decline', on call nurse comes in but does NOT remain at bedside.
• There is discussion of 'cost sharing' that is $1800 a month to the family. (I call my sister who is in charge of financials)
• After family signs consent to Hospice (no iv fluids or antibiotics--they like them 'dry' for a more comfortable death process) there is a four hour delay until first medication is given.

At first try to CONVINCE them.

If that does not work, then try to CONFUSE them.

If that does not work, then CON them.

 (an old Marketing aphorism)

My maid of honor at my first wedding was a Harvard Business School MBA. She said there are classes where they teach you how to manipulate people to do what is desired by management. Both for employees and for customers.

Guess who is running the show in Healthcare?

It ain't Obama!

LOL.

I hope you see the truth in end-of-life care, and make the most of this wonderful gift to each other in the time there is left with your loved one.

Aloha and Mahalos,

Namaste,

Reiki Doc

P.S. if it is any comfort to you, here is a description of what happens in the body as it dies: http://reikidoc.blogspot.com/2012/07/energetic-look-at-death-what-you-need.html

This is Nana Angelina's favorite opera--I grew up listening to opera at her house 

(Pagliacchi is the Italian word for 'clown'. )

Goodbye Uncle Rainy

Legend says at the center of a Celtic Cross time stands still

I walked in to the restaurant, and spied my cousin, who I have not seen since the last funeral. He welcomed me with open arms. Once, he had taken me out line dancing, and we talked about our divorces and swore to keep up. His wasn't the dad that passed. It was our mutual uncle.

His father, came next, and gave me a big hug. The family millionaire, made in real estate investments and flipping houses, this uncle gave the nicest hugs. I have since discovered that behind those hugs are some nasty skeletons in the family closet. But since I have only three Uncles left, and this one never laid a hand on me, I hugged him back and was genuinely glad to see him.

Next came the daughter, the middle child of the deceased Uncle Rainy, let us call her Bree. Childless, she married her childhood sweetheart around the time of Uncle Rainy's accident. Both the bride and the groom had fathers in wheelchairs at the wedding that was over thirty years ago. Uncle Rainy was a quadriplegic. I greeted her husband too. He is one who never looks you in the eye and is in sales.

Around this time I started to notice something odd. All three of the surviving children were not seated together. There were entire sub-family groups at far different tables!

Bree was at the one with my sister, my brother-in-law, and Crazy Uncle Dee. They were close, and were in close contact. We often saw Bree at our family events. Dee had glass after glass of alcohol at the table.

At the next table was Cousin Dick. He too had a drink in hand. I won't go into it, but apparently his name was, ah, rather 'matching' his personality? His children were across the room with their significant others. Their mother was cousin Susie, who has channeled messages to me once or twice in my book. There was a nasty divorce over his hooking up with a mother from his son's roller hockey team.  I met her, and was surprised she calls his kids 'her children' when last I knew, only a few years ago, they were all adults at the time of their bio mom's death. She raised them, single, for like, eight years since the divorce before succumbing to cancer. Her children were devastated by her loss, and have never recovered. They are civil with their dad.

There was a table with the relatives, the sister of the deceased and their family. I hadn't seen them for thirty years. It was nice to see them again.

The one I wanted to see was Annie. Annie is the cousin I was closest to at family gatherings. I had always felt sad for her. Annie had married a black man, and this did not go over well with the family back thirty years ago. She had two children, and there were rumors that the husband was a drug dealer and that she should leave him.

All I know is that Nanu threatened not to go to my wedding if I invited her.

If it wasn't for Facebook, I would not have had contact with her at all. And this has only been in the last three or four months.

When I saw Annie, she was the only one who was crying. She was so depressed. Her best friend sat with her. Both were drinking it up. Annie told me how her friend took her shopping to buy something new for the funeral. Annie had devoted her life to taking care of Uncle Rainy. But only at the end, the last five years. I didn't ask questions. 

She showed me a picture of her dad in the coffin. I was so glad to see him. It had been five years since I last made a trip to the house. 

The story she told would make you cry. 

You know, when people are near death, they are pretty uncomfortable the couple of weeks before. I remember my grandma (dad's mom) calling me in a panic, at all hours of day and night, while I was in medical school, saying, 'I can't breathe!'. I would listen, and ask if she was doing everything her doctors were telling her to do. She would say 'yes' and I would say, well, you are doing everything right then, aren't you? She had terrible congestive heart failure, and there wasn't much left that could be done.

Apparently Uncle Rainy, full of cancer, couldn't feel any pain--'a blessing, his doctor said--from the cancer. But the malignant pleural effusion was what started to make him panic in the end. There was hospice involved, and some miscommunication about the hospital when in panic, Uncle Rainy said he wanted to go to the ER. Cousin Dick ended up taking him, and as the ambulance came, the father whispered into his daughter Annie's ear that he loved her forever, and they both knew it was the last time she would see him again.

Dyfunctional with a Capital 'D' Uncle Rainy said, in Spirit, when I started to notice the seating arrangements in the room earlier.

He was right. For all of his millions as a 'smart businessman' (after the lawsuit settlement from the accident and 'investments' after), Dick and Bree hadn't wanted to buy him a new suit. He wanted to be buried in a blue suit and a white shirt. Annie had to argue with them that all he had was sweats and tee shirts, but he used to wear suits, wanted to be buried in one, and could afford it. 'But do we have to buy him the pants?' Bree asked. 

He was buried in a grey suit with a blue shirt, Annie said, barely hiding her disappointment. He did get, however, the same type of funeral as his wife, Auntie Ann (no church, just people talking), and 'something for everyone to eat afterwards'.

Annie says she has no place to live. She lived in Uncle Rainy's home with him. There had been so much conflict over the family finances that each has a lawyer, making a total of three over the estate. All he wanted was for peace and to know that Annie would be treated fairly by her siblings. Uncle Rainy had cut them off to make a point to respect her, but the older two said it was Annie 'twisting things around in his mind' and sought legal counsel after the 'gift money' stopped.

Five years ago, I was shocked to see upstairs in that house. Downstairs was where Uncle Rene lived, it was beautiful with everything he could need, and updated. Upstairs was where Dick was. It was filthy and falling apart. He drank, just like his mommy.  And Bree used to be the alternate caregiver, until Annie came on the scene, and then the family grew more strained. All the while there were professional caregivers both day and night to help with his nursing care.

I noticed today Bree, and Dick, and their spouses, looked like cats with a big bowl of cream to enjoy. At the table, Bree was already talking about going shopping at the nearest outlet mall. 

Uncle Rainy wanted me to talk to you about this today. The whole situation that he left behind.

And to leave with these questions:

1. Do you think it will matter who gets the money now that he is passed?
2. Who of the three children is most likely to Ascend? Annie, Bree, or Dick?
3. What is going to happen to the family ties when 'money goes away'?
4. Who listened to their heart and married for love and was ahead of their time?
5. Why were the children not able to rise above their differences, and give their wealthy father the peaceful death he so desired?

These are the kind of thoughts that gets the separation between Duality and the Higher Dimensions clearer when you are an impartial observer.

I love all three of my cousins. I spent time talking with each of them today.

But I also have a bit of advice: watch out for those who spend other people's money and do not earn it themselves.

Namaste,

Reiki Doc

The Role of the Government in Medicine

The Government has far reaching interplay with conventional medicine for the length of my medical career, and beyond. This article is informational, and will review the ten main areas of interactive role the US government has in the Health Care portion of the economy. For example, the supply of graduating physicians is controlled by the government, who places a limit on how many medical schools can exist, and the size of the graduating classes.

I. Funding for Residency and Internships


Upon graduation from medical school a medical student is not able to practice medicine. They must fulfill additional training as internship (first year out), and residency program. Students apply, and are placed at various programs through the match, a very complex process. Some students do not place. They are notified the day prior to announcements on match day and have to scramble to find a place to train.

All of this training is funded by a federal grant to pay the salaries of all these individuals in training. The amount each year is graded according to level of training. There are small pay raises, but the salary is low and the work hours long enough to casually be considered slave labor. In my day, I worked seven days a week, sometimes forty hours straight with no sleep, two to three times a week. One hundred twenty hour workweeks were typical, although eighty was the norm. The eighty hour workweek has been put in place as a direct result of the Libby Zion case in which an over-tired resident gave demerol to a woman who was on an antidepressant that has a fatal reaction when the antidepressant and demerol are mixed.

There are no work hour restrictions on graduates of the training, attending physicians, the working doctors you see every day who have completed the training.

II. DEA and Schedule II and III Medications


All physicians must apply for a federal DEA number from the Drug Enforcement Agency. This bureau assigns a DEA number to each doctor, allowing them to write prescriptions. There are triplicates, special prescription pads for the dispensing of controlled substances such as dilaudid or morphine. Triplicates used to be actual pieces of paper but now they are an entire computerized system that goes straight to the pharmacy. All controlled substances must be accounted for drop per drop in the hospital. I have a balance sheet with all of my anesthesia narcotics and agents that can make someone high. If my records and the balance sheet do not match, I have to write a note in the medical record. A pharmacy that does not correct miscounts will get a twenty-five thousand dollar fine.

III. Medicare


Medicare is the kingpin of all insurance around. Medicare pays competitive rates to just about all specialties besides anesthesia. Anesthesia reimbursement is twenty cents on the dollar that we bill. Despite the high rates members pay into the Medicare system, the doctors are not seeing that much. A long case on a fragile senior that takes much vigilance and is a technical challenge will pay less than a quarter of the value that is being given by my services. A healthy D&C with good insurance will pay two to three times as much, and there is very little risk to the patient from the anesthesia.

Another unusual thing about Medicare is that it stipulates direct payment to the provider. It gets wired into a bank account, but it also has authority to withdraw money without notice to adjust a payment. I still have to pay a seven percent billing fee to my company on all funds given. It just comes out of the other insurance reimbursements. It feels like total Big Brother to me.

However, despite the low reimbursements, Medicare makes up in volume. Hospitals will do everything to get accredited and win a Medicare contract. Unfortunately, Medicare is playing hard to get. For example, a major component in primary care is capitated care. Medicare will pay one lump sum to a provider for all primary health care coverage for a year in advance. It is like a game--if the doctor keeps you healthy, the doctor gets to keep the money. And, to raise the challenge, payment is contingent upon key words in all medical documentation. It is not enough to say, 'massive blood loss'. The physician must write the words, 'symptomatic hemorrhagic anemia'. It is this way for just about every disease state. And there are billing and coding specialists combing through all of the paperwork making sure the physicians are in compliance, in other words, writing those special words to be awarded payment for their services.

And the latest? Any and all medical complications not reimbursed. That can be a lot of care for free. Complications happen--medicine is not perfect, and some patients are more at risk for them, for example, smokers...


IV. JAHCO --Joint Commission


This organization runs the inspection process for all hospitals to be eligible for Medicare contracts. The week that JAHCO comes to the hospital, a transformation takes place. Extra equipment and furniture disappears. It is like a realtor would do staging to sell a house. All the employees are prepared phrases to say in case they are questioned. I hide in the O.R. on a case, but if asked, I will state, 'I will ask my supervisor. I don't know.' In my work, if a case finishes on the hour, the nurse and I alter it by one or two minutes. We call it JAHCO-time, because the inspectors get suspicious if the times are neatly rounded off in the record. Now all anesthesia carts have to lock, no drugs can be left on top of the anesthesia cart. The O.R. is a restricted part of the hospital, and having to go through these steps takes extra time. But some inspector decided unilaterally, 'this would be safe' and now everyone has to do this. It is this way for all parts of the hospital, minutiae in the name of safety, just more regulation to slow you down in your day. Some safety parts are important, but ninety percent do not have the kind of impact on patient care that the inspectors hoped.

Inspectors get rewarded for the changes they bring about. Not if the changes were needed in the first place. Signing charts at medical records is grounds for suspension if you are past a certain time. Delinquent charts after that charge the physician a fee, in hundreds of dollars, just like an overdue library book. It adds up.

V. End of Life Care (TBA)


The are the things Sarah Palin shot down. The implication of government intervention on is far-reaching: the decision as to who lives, and who dies. In the hospital, I have seen countless resources wasted on terminal care, where the family seeks cure when hospice would be more compassionate. The family is just not willing to accept that death is inevitable. I have also seen ICU patients kept alive until a family member could fly in and be present when termination of efforts is done (unplugging from life support). There is room for improvement in this area, but no actual practices have come into the arena. The only difference that the government was proposing to do, is to reimburse the physician for having this conversation with the family. Currently it is not billable. But it is a delicate issue indeed.

VI. HIPAA


Privacy. Now if a staff member goes into the hospital they work, other caregivers have to log into the computer under break the glass security function and state who they are and exactly why they need access to the records.

If you ask me, this is another area of control, where lawyers stand to gain a great deal over infractions.

Now we have a whole layer of administrators on privacy and HIPAA compliance, monitors and officers, in charge of everything. When I was starting out, at the VA, we used social security numbers for identification of patients. That WAS their medical record. We used the first letter of the last name, and the last four of the social security number, to look up patients and to keep notes on who was who. Those days are no more.

VII. HICRA


This is another one of the alphabet soup policies. The Health Care Responsibility Act is a statutory requirement placed on every County. I am not sure what all of these acts and things mean. There are so many of them. There was another one that had letters, and hospitals had to document time of administration of antibiotics prior to incision, or risk a negative measure. It had requirements for patient temperature in recovery room too. That explains all the little blowing blankets in pre-op holding. They are used in surgery and also in PACU too. The average clinician is barely aware of these, and it takes special administrators to decipher them, and give recommendation to caregivers on how to 'toe the line' on the latest things we have to do.

VIII. Work Hour restrictions




Your doctor can work more than twenty-four hours without sleep and still do your surgery, anesthesia, or medical care. There is a disparity between trucking, commercial airlines, and medical care on mandatory rest periods After sixteen hours of work, it is like being legally drunk, as far as impairment measurements are concerned.

Yes, I have worked those hours. I do not enjoy them. And the next day at home, I am a mess. It takes two days to recover from this, but sleep debt adds up. Frequent vacations, about five weeks a year, is helpful in counteracting this.

State of the art organizations have four-hour rest periods built into the call system, with one anesthesiologist assigned to give respite to the Labor Deck anesthesiologist and then the O.R. on call anesthesiologist back to back.



IX. Affordable Care Act


So what? Is this another way to decrease Medicare reimbursement for services? Is it really going to help? Does anyone really know the over one-thousand page law? What will the judges decide? You tell me. As I see it, it is just another step down the slippery slope that leads to less autonomy and less financial reward for my work. Yes, it is good to get the insurance industry in line, and also to give healthcare to others who are in need of it. But who gets the final say? Does medicine have a chance to give input? Or is it unilateral decision-making again?

X. Reiki in the Health Care Industry

Do you want this to happen to energetic medicine and complementary medicine? How to handle it? I don't trust The Establishment on it.  My recommendation is this, invite Higher Powers that Be, for Divine Assistance in the merging of the Healing Arts. And to have the money-changing icky part to stay way out of it.