Introduction

Dr. Bob: And welcome to The Dr. Bob Show. Thank you so very much for taking your time to watch the Dr. Bob Show to learn a little bit more about being healthier and being happier. That's what we will try to do for you in the next 30 minutes. We're going to be talking a lot on this show on one of the most important issues in medicine and it does involve you and it involves your loved one. Have you ever been in a waiting room in intensive care and somebody wasn't doing too well in the hospital. Maybe there were life supports and you didn't know if you should continue that. You didn't know what to do. Should you not be on a respirator? Do you know that there are some directives that we can have where everybody knows your desires as a patient and everybody should have those. By the end of this show, you'll know what type of living will or health power of attorneys you should have. So, you'll want to stay tuned.

Dr. Bob: I'm Dr. Robert Overholt and I'll be your host for the next 30 minutes on The Dr. Bob Show. Later on we'll be talking about kidney stones. You know, one in 10 men and one in 20 women will have kidney stones. Why do we have them and what can we do and what's new out there for you? We'll be talking about atherosclerosis. What a big word. You know, the chances are really good that you've got it and it could be involving your brain or your kidneys or your extremities or even your abdomen as well as your heart. Later on, we'll be talking about those itchy eyes. What do you do for eyes that itch? Is it allergy or is it infection? We'll be learning the difference and we'll tell you what you can do about those so you'll want to stay tuned

Dr. Bob: We're going to be talking about the difficult times in your life and your loved ones when maybe somebody is near death in ICU and you need to know what directives to have. How should people treat you? Should they allow you to die gracefully? Who makes that decision, you or the doctor? Most of the time the law requires that the patient be involved with that or his loved ones be involved with that. I have two outstanding guests. One is a physician. One is a trained theologian. Dr. Richard Dew, primary care physician, family practice, hospitalist, has spent his last several years just working in the hospital. He deals with this problem all the time and sees what a mess sometimes you and I as individuals do in not preparing for that time. Dr. David Bluford is a theologian. He trained in Southern Seminary in Louisville and he deals with this problem in counseling people in the hospital all the time. And David Bluford and Richard Dew, thank you so much for coming to The Dr. Bob Show.

Richard, how long have you been a hospitalist?

Dr. Dew: I've been a hospitalist for nine years.

Dr. Bob: Do you see a lot of problems as a hospitalist about living wills and advanced directives?

Dr. Dew: We see this almost daily since most of our practice deals with older patients, mainly in, from 70-90.

Dr. Bob: Do people not have their proper things in order?

Dr. Dew: The vast majority don't.

Dr. Bob: And, when we're talking about the things that people need to have, we're talking about advanced directives. That just means ahead of time we need to direct. Is that correct?

Dr. Dew: Right.

Dr. Bob: And, what kind of advanced directives are there?.

Dr. Dew: You need to have two basic ones. One is a living will that says what I want done with me if I get in certain situations and secondly, durable power of attorney for medical care where you designate who will make those decisions for you if you're not able to make them yourself.

Dr. Bob: Let's talk about a living will. Now, you know, a lot of times when I think of a living will, I think about, am I going to donate my organs? Am I going to give a kidney, or an eye, or something. A living will really is what? What is it telling your doctor, the hospital and his loved ones?

Dr. Dew: Well, part of it has to do with organ donation but more importantly, there are about three things that ought to always be addressed in a living will. One is, do I want CPR done? Do I want them to resuscitate me if my heart quits beating? If I can't breathe on my on, do I want to be on a respirator? And, if I can't swallow enough to nourish myself, do I want a feeding tube put in? These are the three major things that need to be addressed. Some of them are so vague you have no idea what they want. But they usually say if the situation is hopeless, don't do heroic measures. Now, what's hopeless and what's heroic?

Dr. Bob: Yeah and that's very difficult because we're getting so good in medicine we can keep people alive for a long period of time. Now, let's talk about CPR first and that's when somebody actually may have died right there and you can bring them back. What should a patient be thinking of? Doesn't everybody want to come back to life? Is there ever a time when you don't want CPR? What are some examples?

Dr. Dew: I think several examples are, if you have a terminal cancer. Do you want people to bang on your chest, shock you to bring you back so you can die from your cancer?

Dr. Bob: And you have been suffering for a long period of time

Dr. Dew: Right.

Dr. Bob: And, some people need to be allowed to die gracefully. It's not a word we like to think about death but people have to think, we're all going to die Which is most important living will or the durable power of attorney?

Dr. Dew: I think a living will is the most important and you need to be sure, not just a piece of paper but to let your entire family know what's on that living will. And, so often you can't address every specific issue so you need someone who knows your philosophy of life, what I would want done in this situation because many times it doesn't fit the letter of what's written down there.

Dr. Bob: And, you know I didn't think of that but if I had a living will that I wrote, I certainly would have to have people that know where it is and how to bring it out and know what my wishes are. Do we normally bring those with us when we go to the hospital for like minor surgery? If I'm going to have you know, ankle surgery or fix my rotator cuff in my shoulder, should we have a living will for those times?

Dr. Dew: You at least need to let people know what's going on. As many times people will bring them in but I advise them, get the information and tell them to take it home as it may get lost while it is in the hospital. But you have a living will whether you know it or not. If you have something to tell us, which direction to go, everything is going to be done. By law we have to do that.

Dr. Bob: Now, David, when somebody comes into the hospital and you go by and you visit as somebody that's a theologian, do you say, I hope you are doing alright here. Do you have a living will? How do you approach, how do you tell people?

Dr. Bluford: Well, generally it comes up in the course of a conversation with the family and/or the patient. But also when they are admitted we're required to ask every person when they come in as an inpatient if they have advanced directives. If they do not have advanced directives, we have the opportunity to provide them educational information about advanced directives. It is also a part of our nursing assessment questionnaire to ask by the nurse whenever they are doing an assessment of that patient, do you have advanced directive?

Dr. Bob: Oh, that's wonderful. Now, is that just in your hospital? Is that in the majority of the hospitals? Does the law say you have to have it?

Dr. Bluford: The law says that every inpatient has to be inquired about if they have advanced directives. It's up to each individual facility exactly how they carry out that procedure.

Dr. Bob: Do people seem confused like, don't bother me with that. My loved ones are sick. Don't talk to me about legal problems. What do you see in the hospital?

Dr. Bluford: A lot of people have concerns about these directives because they don't understand what they're about and so it's not confusion necessarily over them, it's regards to, if I do this, does that mean they're not going to take care of me? And, so, there's a lot of reservations about completing these documents for that very reason.

Dr. Bob: If I have a living will or a power of attorney that's given, can I change my mind at anytime?

Dr. Bluford: Absolutely.

Dr. Bob: So, while I'm in the hospital if I think something's going to happen and I'm not sure, I can change it right then.

Dr. Bluford: Yes. You just. You have to let your doctor know what you want done.

Dr. Bob: Does the hospital help you with the legal parts of this? I take it somebody has to write down, are there fill in the blanks?

Dr. Bluford: The forms that we have in our facility are very complete and all you have to do is fill in certain indicated areas. Of course, name. If you are doing a living will, you indicate as already addressed issue about organ donation, issue about artificial nutrition and hydration. If it's a durable power of attorney, you indicate who you wish to be your attorney in fact, or that agent to represent you and yes, we help. It also requires two witnesses which by a state law cannot be employees of the health care facility nor family members. And so, it has to be somebody not related and then they need to be notarized.

Dr. Bob: If my children are in their 30's, I know they don't have a living will. What if they get in a wreck and it's life threatening and they are teetering on, do I have to make the decision? Does the doctor make… I'm their daddy, do I make the decision or if they had a living will, it would make it easier on everybody.

Dr. Bluford: Right. I think a living will. One, yes. They would have to… You would have to make the decision for them. If they had not designated someone else, you certainly go to the next of kin. But, it's much better if they let people know ahead of time and let the whole family know. That's, I think that's, if anything comes out of this, is have a living will, have an advanced directive and be sure everybody knows about it. The worse situation we get into is when we have a family come in and three of the children understand that you've said, I wanted to die, and then someone from out of state comes in and says, oh, no, I don't, don't you do that to daddy.

Dr. Bob: Yeah and I guess there's different family members that would think different ways. What's most important - a living will or power of attorney?

Dr. Bluford: Actually, power of attorney is one of the more important ones because…..

Dr. Bob: And that's what we are going to be talking about. We're going to be talking a little bit more about the power of attorney concerning your health but first, let's talk to a patient that had these very problems and see how they handled it.

A Patient's Experience with Patient Rights

Bob Mason: I brought my parents to Oak Ridge from Boston in 1988. My dad was about 77 and my Mother 82 and their health, health was starting to fail a little bit. When they came to this area, I sat them down and they agreed with that now is a good time when they had their full faculties to work with a lawyer and a physician and come up with a good program for the future where there wouldn't be any difficulties and we would be able to at some point and time if they needed care, we would be able to get it for them.

The living will then became a very useful tool several years later when my mother developed Alzheimer's disease and it progressed extremely rapidly to where she could not consciously make good decisions and really had a difficult time starting in about 1995 where I had the power of attorney and living will, it was really able to make a difference in how to treat them, the level of care I was able to get for them and the facilities I was able to put them in and I had to put both of them in to keep them comfortable in a good quality of life.

To make that decision to put them both in a long-term care facility was a hard one but the paper work was all there and the doctors were all current with their status so it was very easy where we had the living will and the power of attorney in being so it made the process extremely easy.

Dr. Bob: We're talking about the patient's right to decide. Advanced directives and we're talking about two things. A living will and a power of attorney. I've got so many things I want. The first thing, these are legal documents sort of and I would worry about the expense of having to get an attorney to do that. What is, is there another way to do it? Does it have to be expensive?

Dr. Dew: No. It doesn't have to cost anything. Other than maybe a notary fee. You can get it from your local hospital. Most primary care offices will have copies of typical forms of both of these that you can get and all you have to do is fill it out, have two people witness it and have it notarized and it's perfectly legal.

Dr. Bob: Now, are there levels of my direction to somebody? Is there something that says well, you can do everything but this or you can, what are some of the levels that people have the…?

Dr. Dew: There can be levels there. At our hospital we have four different levels of advanced directives and sometimes we have to fit the living will into what, how that form reads. Ugh, this is in the front of every chart so if you have a sudden attack and the emergency room doctor has to come, he has to know what he is supposed to do when he gets there and the four levels of care. One says you do everything possible to get this patient back..

The second one says, do everything possible. However, they have chronic lung disease, they don't want to be on a ventilator. So, don't put them on a ventilator. The third level says that they are on a monitor and they may have a heart rhythm problem. Give them medications to correct the rhythm but don't shock them, don't do CPR, don't put them on a respirator. And the fourth level says do what you can but don't do any of those things above and primarily keep me comfortable.

Dr. Bob: The word DNR. What does that mean?

Dr. Dew: It means do not resuscitate.

Dr. Bob: And that means what? Do not resuscitate because I have seen that on a lot of charts, DNR. Who gives that directive and what does it mean?

Dr. Dew: Well, it comes from your living well or the person who has the durable power of attorney for medical care. And DNR means do not resuscitate which means that basically we don't do anything if your heart quits beating or if you quit breathing.

In many cases, this is exactly what the patient wants. However, the family understands DNR can mean, don't treat and it doesn't mean we don't treat. If they get an infection, then we treat the infection. And, if they are in pain, we give them pain medicine. In fact, I try to emphasize to the nurses that people who have DNR orders, may require more attention than the people who don't have DNR orders.

Dr. Bob: Let me walk into something else. Let's talk about some chronic illnesses. Let's talk about Alzheimer's. It's sort of getting to be a dreaded thing in our society there are newer medications that are helping people but if somebody has Alzheimer's, how do you handle that? They are demented. They really can't really write down…so, what do you hope would happen with somebody that has Alzheimer's?

Dr. Bluford: Well, the intent basically as it says is to do it in advance before you get there and that's what we would like to try to impress people to do that. Once an individual is no longer competent to make a decision for themselves, then actually they cannot complete advanced directives because they have to be a competent individual to sign that themselves.

Dr. Bob: So, everybody that's watching should call their hospital and get a form to fill out for a living will and a durable power of attorney?

Dr. Bob: Just cast it?

Dr. Dew: They should.

Dr. Bob: If they do that, how much easier does it make it on you, the doctor?

Dr. Dew: It makes it easier on me but more importantly, it makes it easier on the family. I don't want my children to have to decide whether to let me died or not and I think if you let your family know ahead of time and you talk with them and you say, this is what I want done in these situations. I find it very difficult to go up to a family and say, "do you want me to let your mother die?"

If I have that advanced directive and say, your mother said that if she was ever in this situation, she didn't want us to do anything to keep her alive, she's in that situation and I think we ought to honor her wishes. This takes the load off the family and puts it on the doctor and the patient where it ought to be.

Dr. Bob: And I really think that too often we require those decisions to be made by the lay public and it's a medical decision but legally we've got to be very careful on that. How about a feeding tube? I had a doctor tell me this. If somebody is about to die, the worse thing you can do is put in a feeding tube because it will keep that person alive, animated, for another year so you'll prolong their misery for another year with a feeding tube. How do you feel about feeding tubes and should that be in a living will?

Dr. Dew: I think it should be in a living will. I faced this situation with my dad who had an accelerated form of Lou Gerigh's disease and he told me adamantly he did not want me to put a feeding tube in him when he couldn't swallow. Ugh, there are situations that are potentially versatile but I would, usually the patient should be alert enough to tell you that. If they're not, again, they need to have said ahead of time what they want done in that situation. Don't unload it on the family. And you can keep people alive. We have people in nursing homes, I work in two nursing homes. We have people in nursing homes who have been kept alive by feeding tubes for literally years and they are just a little ball that we go in and feed two or three times a day because no one will make the decision to stop that.

Dr. Bob: Yeah, and you can understand the dynamics of that being a significant problem.

Dr. Dew: I tell people, it's must easier to decide not to put a feeding tube in or not to put somebody on a respirator than it is to decide to pull the feeding tube out or to discontinue the respirator.

Dr. Bob: Once it's been there.

Dr. Bob: Are there example that we have… I would think if I wrote a living will, I wouldn't know all the circumstances. Is there general language or is it specific language?

Dr. Dew: There is general, the living will document, the general language of that is to include what you do or do not want done if you are in a position by the way the language is used for the state form which is in our document as well, is to address if the physician deems you in a terminal condition. That's when a living will takes effect. And, that's a key issue because you have to be in that terminal condition for a living will to really be a legal document and a person cannot speak for themselves. As it has already been said, if you can speak for yourself, then neither the documents really will address any issue. You still have the final say so. But if you are in a position where you cannot communicate and it's not verbally. It can be a blink of an eye. It can be a squeezing of a hand. However you want to communicate. If you reach beyond that point where you cannot express your wishes, then the documents take effect and that's when a living will needs to address as already said about the terminal state what you want done with the issues of technology. And just because we have technology just like a feeding tube doesn't mean it's the best thing to do for your care.

Dr. Bob: Now, I've got a living will. Should I have a power of attorney and have my brother make decisions if we come up with some circumstances that are not in my living will. Is that what the power of attorney is for.

Dr. Dew: It depends on how much you trust your brother. (laughter)……

Dr. Dew: And that is a key issue, that is a very key issue. Whoever you appoint as an attorney of power, you need to make sure they are willing to carry out your wishes. We have had instances where that attorney, in fact, would not honor the patient's wishes and we were obligated then to follow that directive that that individual left us.

Dr. Bob: Richard Dew, David Bluford, thank you so much for this information. It's something that we all need to know.

If you don't have a living will. If you don't have your power of attorney, your agent who can make decisions for you, be sure to do that. Call your local hospital. They'll have a piece of paper. All you have to do is fill it out or talk to your primary care physician. He understands those problems. He's been involved with life and death before and he'll be able to help you get that done so that your family and your loved ones won't have to make that decision when the time comes. I hope that each and everyone of you watching takes the time to get your living will and get that power of attorney. You need it. Get it done now. Don't put it off. It's something we all think about but don't want to talk about.

Later on I want you to stay tuned because we're going to be talking about kidney stones or we will be talking about atherosclerosis, what is it? It is very very common. You wouldn't believe it, the word is just big and long and what do we do for itching eyes? So, you'll want to stay tuned.

Dr. Bob: I want to thank Dr. Richard Dew and Dr. David Bluford for a wonderful discussion. If you don't have your living will or power of attorney for health care, be sure that you call your hospital or your primary care physician and get that done.

And now some information I think you, the viewer, will be interested in. I've had some questions on kidney stones.

Letter #1: Dr. Bob, why do people have kidney stones? What can you do for kidney stones? Are they going to be there the rest of my life?

Response #1: Well, kidney stones, let's talk first of all how they are formed. The kidneys form urine, it goes through the ureter to the bladder and then from the bladder it goes through the urethral outside. If there are some calcifications of things causing kidney stones and it traps in the ureter, severe pain and when people have pain, oh, they just can't get still, oh, they are all over the examining table.

The pain usually starts in the back and then goes around the front down into the groin area. Severe pain, one of the most severe pains we have. A couple of things can cause kidney stones. Several things can but the two most common would be uric acid. Now, people with high uric acid sometimes have gouty arthritis. The other one is calcium stones. So, if you do have kidney stones, you know one in ten men are going to have them and one in 20 women will have them. So, it is likely that you may have one. Be sure that you capture that stone so that they can look under the microscope, find out if it is calcium, uric acid, cystine crystals, crystals from infection so that they'll know how to treat it.

Now, the best way to treat when you've got it is to drink lots and lots of water and let it pass. Your doctor will probably give you some pain killers but there are some other things that we can do. There are some devices that can actually send shock waves through the kidney stone and can break that stone. There is also, you can go up with a little basket and grab that stone. Both of those are with general anesthesia. If you've got a kidney stone, you're going to know it. See your doctor. He'll figure out what it is and get the best treatment for you.

Letter #2: Dr. Bob, what is atherosclerosis?

Response #2: We've been talking about that. Atherosclerosis is simply hardening of the arteries and almost everybody has hardening of the arteries. We know that it's caused in part by elevated cholesterol. Some people have an amino-acid called homocystine that's elevated that causes deposition of cholesterol. Now, if you have hardening of the arteries, it can cause narrowing of blood supply to the brain and make it where we get some atrophy or get a stroke in the brain. It can occur in the abdomen where we have what we call mesenteric ischemia. We need blood to the abdomen. If we eat food, we need blood to go there and help digest. If there's hardening of the arteries, atherosclerosis, in that area, then when you eat food, you get abdominal pain and that abdominal pain makes it where you don't want to eat and frequently we lose weight, etc. It can be in the kidneys where it can damage the kidneys or can cause high blood pressure. And it can be on the lower extremities where when we walk, we suddenly get cramps in our legs that's called claudication. All of those are due to hardening of the arteries. What can we do? Know what your cholesterol is and get your cholesterol to normal levels. Your cholesterol should be less than 200 and there are wonderful medicines to bring your cholesterol down. Discuss that with your doctor.

Conclusion:
I don't think we're going to have time for the itchy eyes. It can be allergy or it can be infection. We'll talk about it later on. There are lots of good medicines. That's all the time we have. I hope you've been exercising. Got to exercise 20-30 minutes seven days a week. Start that day off with 8 hours of a good night's sleep and a good breakfast of fruit and fiber. Most of all, what do we like, it's laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com