Encouraging Patients to Complete Advance Directives

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Every adult in the U.S. knows what happens on April 15. But do you know the significance of the following day? April 16 is National Healthcare Decisions Day. It is a day designated to highlight the importance of people filling out their own Advance Directive (AD), no matter how young and healthy they are. The theme for 2016 is “It Always Seems Too Early. Until It’s Too Late.” The idea is to let people know that something catastrophic can happen to anyone at any time. That is why filling out an AD is important for everyone.

Physicians understand the importance of ADs. But our profession has not been that successful in getting our patients to make their wishes known and fill out these forms. The time available during appointments is limited and usually filled with other pressing issues. Talking about end-of-life wishes can be uncomfortable for patient and clinician alike. But it is an important issue to address periodically with every adult patient, as important as reviewing standard medical screening tests, updating vaccinations, and talking about healthy lifestyle.

Here are several ideas to make the discussion of Advance Directives a bit easier:

  • Have a supply of Advance Directives available in your exam room. Being able to hand your patient the form will make it more likely the patient will fill it out.
  • Make use of April 16 as National Healthcare Decisions Day as a way to introduce the subject.
  • Make sure you and everyone in your family has filled out an AD. Being able to tell patients you yourself have filled out your own AD, as has your spouse and adult children, can help make the issue less daunting. It can reassure patients that you are not bringing it up because you are worried about their health, but because you are as concerned about them as you are about your own family.
  • Identify one or more people on your staff who can be educated on how to talk with patients about the importance of ADs, and build time in to office work flow for them to talk with patients about this issue. The responsibility does not need to rest exclusively on the PCP.

We will never get 100% of our patients to fill out ADs, just like we will never get all our patients fully compliant with all their needed health screenings. But by working to normalize this sensitive subject, we can get more of our patients to make known their wishes for end-of-life care. Even though April 16 is now in the past for this year, the importance of getting our patients to fill out their ADs is a year-round challenge.

Let the Sun Shine In

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Well, cosmologically speaking, we are still in the Dawn of the Age of Aquarius – (being an “age” is about 2,160 years).  Sun’s out, guns out.  Perhaps it should be more aptly be named the Age of Cancer.

The CDC Skin Cancer Trends state that from 2002 to 2011 skin cancer among men increased by 1.5% per year and 1.1% per year among women.  Mortality from melanoma increased by 0.7% in men ( data not available for women).

In 2010, according to the CDC Sun-Protective Behavior Rates, 70% of adults said they usually or always practice on of the three sun protective behaviors (sunscreen, sun-protective clothing, or seek shade).  Women outperform men and those 25 years or older outperform those 18-25 years old.  Only about 13% and 7% of teen girls and boys, respectively use an effective sunscreen when they were outside for more than an hour on a sunny day in 2013.  About 1/3 of teens aged 14-17 had a sunburn in the past year.

When UV rays reach the inner layer of skin more melanin is produced that moves to the outer layers and becomes visible as a tan – this indicates injury to the skin, not health.

Risk factors associated with the development of skin cancer include

  • A lighter natural skin color
  • Family or personal history of skin cancer
  • Exposure to the sun through work or play
  • A history of sunburns, ESPECIALLY EARLY IN LIFE
  • A history of indoor tanning
  • Skin that burns, freckles, reddens easily or becomes painful in the sun
  • Blue or green eyes
  • Blond or red hair
  • Certain types and a large number of moles

The six skin types, based on how they tan / burn:

  1. Always burns, never tans, sensitive to UV exposure
  2. Burns easily, tans minimally
  • Burns moderately, tans gradually to a light brown
  1. Burns minimally, always tans well to a moderately brown
  2. Rarely burns, tans profusely to dark
  3. Never burns, deeply pigmented, least sensitive

Types I and II are at the highest risk.  I put myself at a IV.5.

The CDC seeks to dispel the myth that a “Base Tan” is a good thing in the Burning Truth initiative. It also states that tanning beds injure thousands of people each badly enough to go to a hospital and creates risk for aging of the skin and melanoma.

To reduce the risk of skin cancer:

  • Stay in the shade – not to be confused with throwing shade
  • Wear clothing that covers the arms and legs
  • Wear a hat!
  • Wear sunglasses – hipster and safe
  • Use sunscreen of at least SPF 15 with both UVA and UVB protection– that graduation speech
  • Avoid indoor tanning

In 2012, the FDA established regulations for the labeling of sunscreens – as described by FDA scientist Raynold Tan (no kidding!!).

  • A labeling maximum SPF value of “50+” Those with an SPF 2-14 can only claim to prevent sunburn not aging or skin cancer
  • “Broad Spectrum” means it protects from both UVA and UVB
  • Those that are both broad spectrum and SPF of 15 or greater can claim a reduced risk of skin cancer and early aging.
  • Two water resistant claim periods of 40 and 80 minutes will be allowed but “waterproof” and “sweat proof” will not.
  • Labelling as “instant protection” and protection for greater than two hours will not be allowed without proof to the FDA – read here reapply every two hours.

Finally, is the “Sun Safety for America’s Youth” toolkit available from the CDC.

Protect yourselves this summer and let love steer the stars.

Wheelchair Pilot Program

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This is just a friendly reminder to our referring providers who need to submit a new request on behalf of a PHC member for wheelchair related items or specialty items, that we have launched a new process to streamline these requests for members within our core counties for Solano, Napa, and Yolo.

Found on our website at www.partnershiphp.org you may download the In-Home Requisition Form and submit the completed form directly to PHC via fax at 707-863-4118, rather than submitting the request to a DME Provider.

Upon receipt Partnership HealthPlan will make arrangements for an in-home assessment to be completed. This process will help reduce the authorization wait time for both members and network providers, and overall improve member satisfaction!  We thank you for your continued support of our members and support of this new process.

Deborah McAllister RN BSN

Director of Utilization Management

MANAGING PAIN AFTER SURGERY – NEW GUIDELINES

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Managing the acute pain that accompanies operative procedures is a challenging and risky process.  Studies suggest that opioid medications started for short term management of pain increase the risk of long-term use by up to 44%1. To provide guidance on a more evidence-based set of pain management strategies post-operatively, the American Pain Society has recently issued an updated guideline. 2  Below are highlights of the 32 recommendations that they have made.

Multimodal therapy should be considered for all patients undergoing surgery. These options should be fully discussed with the patient and their families prior to surgery. These modalities include:

  • Systemic pharmacotherapy including NSAIDS and/or acetaminophen, gabapentin or pregabalin, IV ketamine, or opioids (preferably oral)
  • Local, intra-articular or topical therapies including local anesthetics at incision, or intra-articular anesthetic
  • Regional anesthetic techniques- e.g. regional or paravertebral blocks
  • Neuraxial anesthesia such as epidurals rather than general anesthesia
  • Non-pharmacologic therapies including TENS and cognitive behavioral therapy (CBT)

Use of TENS and cognitive behavioral approaches may decrease the total need for opioid medications, and should be considered unless contraindicated.

If opioids are used, oral dosing is preferable over IV routes. Avoid long-acting opioids. Do not use opioids, long or short-acting, prophylactically pre-operatively. In addition, every patient started on opioid pain management therapy should be given a tapering plan prior to discharge. It is often adequate to discharge the patient on NSAIDs or acetaminophen rather than opioids. If discharged on opioids, tapering off within two weeks is appropriate. This can be done by decreasing the opioid dose by 20-25% of the discharge dose every day or two till off. Patients who were on opioids pre-operatively should be tapered back to the maintenance dose within two weeks.

NSAIDS and/or acetaminophen should be used along with or in place of opioids where possible and dosed therapeutically. Concerns about use of NSAIDs and the risk of non-union of bone or anastomotic leakage is not supported by the literature.

Use of gabapentin and pregabalin should strongly be considered as part of multimodal pain management post-operatively. Both reduce opioid requirements. IV ketamine also has moderate evidence to suggest it is effective and lowers opioid requirement.

For thoracic and abdominal surgery, consider use of epidural anesthesia rather than general anesthesia. Epidurals are associated with improved pain management scores post-operatively and have fewer complications than general anesthesia

 

1 Alam A. et al, “Long-term Analgesic Use after Low Risk Surgery”. Archives of Internal Medicine, 2012, 172(5): 425

2 Chou R. et al “Guidelines on the Management of Post-Operative Pain” Journal of Pain, 2016 17(2): 131

Scott Endsley MD, Associate Medical Director, Quality