The New York Times ran an article on Monday describing an innovative type of training for medical students thinking of specializing in geriatric medicine – spend a week or two in a nursing home. The article profiles how a medical student, Kristin Murphy, pictured here, spent two weeks at a nursing home in New York. She was given the mock diagnosis of “mild stroke that affected her right side, difficulty swallowing and chronic lung disease,“ and had to act the part. She said that the experience gave her an even greater desire to practice geriatrics.

The idea is to sensitize the medical students to the experiences of their elderly patients who are sick enough to be in a nursing home, and to make prospective geriatric doctors familiar with the types of places that their sickest patients may find themselves living. The attention that the training program is drawing to need for geriatric doctors is great, but most medical students who will agree to live in a nursing home in the first place are probably already highly sensitive, and the medical students who need sensitization the most probably won’t participate in this program to begin with.

A cardiologist doesn't need to have had a heart attack herself in order to know how to diagnose and treat heart problems. So why should a geriatrician need to know about the quality of life issues that confront residents of nursing homes?

A recent article by Jane Brody on what is special about geriatric doctors sheds some light on this issue. Jane Brody interviewed, R. Sean Morrison M.D., pictured here,
a geriatric specialist at Mount Sinai Medical Center in New York. Jane Brody asked Dr. Morrison how he would approach a new patient who is 85 years of age. Dr. Morrison said he would start with a series of questions: ''Tell me about yourself. What do you like to do? What are the things you would like to do that you cannot do anymore? What is your medical history? What medications do you currently take? What brings you here today?''

If you are elderly, Dr. Morrison explained, “You want a doctor who asks more than just about your medical conditions. . . . The doctor should ask about the effect of medical conditions on quality of life, and then should explore what improvements are possible. ‘The focus of care should be on quality of life. . . .Too often, doctors lose sight of this goal when the focus is on treating specific diseases.'’ Dr. Morrison gives the example of “ if a patient has serious arthritis and hypertension and cannot go to places without a readily accessible bathroom on the first floor because she takes a diuretic for high blood pressure, perhaps the blood pressure medication should be changed. The patient may prefer a different drug that carries a slightly greater risk of stroke if it means a better quality of life.“

So if quality of life is part of what the geriatrician needs to address, they need to educate themselves on the diminishments of quality of life that can come with old age, and nursing homes, unfortunately, will present many instances of diminished quality of life for the medical student to draw on.

The Brody article also has an excellent discussion of what questions you should make sure your parents’ doctor is asking at their doctors' appointment.

To read Jane Brody’s article, click here.

To read about Kristen Murphy's experience in the nursing home, click here.

Kudos again to Kristen Murphy and others for their efforts to walk a mile in another person's shoes.

Felicia Curran
www.ElderAdvocacyLaw.com

Did you ever think that the term "death panel" would be applied to the scenario in which you speak to your doctor about making an advanced directive, stating your wishes in the event that you became comatose, in a vegetative state, or needed to be kept on a ventilator?


That's the term that is being used by the right wing of the Republican Party (including Rush Limbaugh, Glen Beck, and Sarah Palin --who said that Americans would have to "stand in front of Obama's death panel so his bureaucrats can decide, based on a subjective judgment of their level of productivity in society, whether they are worthy of health care") to describe the provision in the healthcare reform bill that would authorize Medicare to reimburse a physician for providing counseling sessions about end-of-life directives.

Do these right wing pundits even know what an advanced directive is? The AARP, not exactly a subversive left wing group, recommends that seniors complete advance directives so that their wishes will be known to their families and doctors in case they are unable to speak for themselves in a medical emergency. Believe me, a crisis situation in an emergency room or hospital is not the time to consider for the first time how you would feel about living on a ventilator for the rest of your life, or how you would feel about being kept alive in a vegetative state for the rest of your life, or how you would feel about any one of a number of calamities that could befall you in the event of a medical emergency. The idea that your physician would be reimbursed by Medicare to discuss the matter with you, at the time of, or in advance of any medical crisis, is a good one, and by no stretch of the imagination can it be compared to a "death squad."

In fact, it was a Republican Senator, Johnny Isakson of Georgia, who originally made the Medicare proposal that is being labelled "death panel", back in 2007 when he co-sponsored a Medicare End-of-Life Planning Act. On August 10th, Senator Isakson told the Washington Post that analogizing physician counseling for advanced directives to "death panels" is "nuts."

To see President Obama address the death panel issue directly, look at this excerpt of his August 11th town hall meeting in Portsmouth New Hampshire -- click below




To read the text of the town hall meeting click here.

To read the AARP article about advanced directives, click here.

To read the Washington Post's interview with Senator Johnny Isakson,click here.

Felicia Curran
www.ElderAdvocacyLaw.com

The San Francisco Chronicle is running a series of articles under the caption "Dead by Mistake" that is an extremely interesting look at the needless deaths and injuries caused by preventable medical errors. Yesterday's article, "Secrecy Shields Medical Mishaps From Public View" discusses how little progress has been made since a 1999 federal study called "To Err Is Human" outlined steps the medical profession can take to cut the number of deaths by medical errors in half. It shows how the secrecy surrounding hospitals, the lack of compulsory reporting of mistakes, and the financial incentives given to hospitals, all combine to perpetuate if not encourage medical errors.

The article states that "A national investigation by Hearst Newspapers, including The Chronicle, found that the hospital industry, the federal government and most states have failed to take the effective steps outlined in the report a decade ago. Consequently, over that period, as many as 2 million Americans have died needlessly of preventable medical mistakes." The idea is that hospitals can prevent medical errors by setting up protocols, systems, and procedures that provide safety checks and balances to keep patient's safe, much the way that years ago car manufacturers began to design cars with safety features (such as ignitions that won't start unless the car is in park) that can prevent accidents from happening.

Why wouldn't a hospital want to save lives and prevent accidents by minimizing the number of mistakes they make? According the the Chronicle's report, "Hospitals can actually lose money by providing safer care. For example, when Utah's Intermountain Healthcare hospital chain improved its system for prescribing heart patients the proper medications on discharge, rehospitalizations were reduced by 900 beds a year. As a result, the hospital lost $3.5 million in revenue. 'To my hospital administrators, there was actually a certain amount of whining about this,' said Intermountain executive Dr. Brent James, another "To Err Is Human" co-author."

Medicare has recently taken the approach of denying payment to hospitals for "Never Events" -- viz.,illnesses and injuries patients pick up in the hospital that are entirely preventable if proper procedures are followed. Included in the list of Never Events are pressures ulcers or bed sores, and post-surgical infections. The idea is that if hospitals know they will not be able to bill the patient's Medicare for illnesses caused by the hospital's negligence, the hospital will stop negligent practices that cause injury.

New reporting laws, such as a 2007 California law that require hospitals to report errors to the the California Department of Public Health, and which requires the Department to investigate the error within 48 hours, also can make a difference.


A companion article, Lost, Stolen, or Never Existed profiles patients who have been the victim of medical mistakes. By reading the stories of the victims of medical mistakes you can hopefully learn something that might might protect you or your family next time you are in the hospital.

To read the Chronicle's article, Click here.

The Chronicle has also set up a website that has lots of information on medical errors, www.deadbymistake.com.

Felicia Curran
www.ElderAdvocacyLaw.com

Government-run nursing homes can be held liable for neglect and abuse of their residents under a federal civil rights statute, Section 1983 of Title 42 of the United States Code, under a recent ruling by the 3rd Circuit Court of Appeal. In Grammer v. Hazel the federal appeals court for the Third Circuit (which covers Pennsylvannia, Delaware and New Jersey) held that the Federal Nursing Home Reform Act gives residents of state and county-run facilities the right to bring federal civil rights lawsuits over inadequate care.

In the Grammer v. Mercy case, the lawsuit was brought on behalf of Melviteen Daniels, a deceased resident of the John J. Kane Regional Center at Glen Hazel, in Pittsburgh. At the nursing home, Melviteen is alleged to have acquired pressure ulcers due to neglect; the pressure ulcers became infected, causing her death by septic infection.

Thanks to the lawyers (D. Aaron Rihn and Bob Daley, Robert Peirce & Associates, Pittsburgh, Pennsylvania)who brought the case on behalf of Melviteen's family, for their creative advocacy for their clients.

The ruling is especially significant for nursing home residents who live in states that do not have laws allowing civil lawsuits for elder abuse or neglect, because such residents can rely on the Grammer v. Hazel ruling to bring elder abuse lawsuits, in federal court, or in state court under federal law. To read the 3rd Circuit's decision, click here.

One open question is to what extent this ruling can be made applicable to nursing homes that are not government-operated but which receive government funds, such as Medicare and Medicaid payments (which virtually all nursing homes do). The lawsuit in Grammer was brought against a county-operated nursing home, under Title 42 U.S.C. Section 1983, which authorizes lawsuits against state-entities for violation of federally guaranteed rights. It is an open question whether a nursing home resident can sue a privately-owned nursing home directly under the Federal Nursing Home Reform Act (FNHRA), but one which the law surely lends itself to.

Felicia Curran
www.ElderAdvocacyLaw.com

In an update to a previous entry, the The Los Angeles Times is reporting that the new management of the California is seeking to more than triple the size of their enforcement staff, and to raise licensing fees, in order to get on top of the backlog of patient complaints against nurses, who are otherwise still practicing as the charges go uninvestigated. Congratulations again to the terrific investigative reporters at the Los Angeles Times and Propublica for bringing to light the quagmire of complaints at the BRN.

Whether the Governor and the Legislature will approve this type of staff increase is unknown, but if the cost of the staff increase is paid for by raising the licensing fees paid to the State by registered nurses, perhaps it will fly. Let's hope.

The state agencies that license nursing homes/skilled nursing facilities (the California Department of Public Health) and residential care facilities for the elderly (The Department of Social Services Community Care Licensing) are, in my opinion, even more grossly understaffed and hopelessly behind in responding to complaints on behalf of nursing home residents and the elderly living in care homes and assisted living facilities. And the idea of financing staff increases by raising licesning fees on nursing homes would be a brilliant move. Let's hope that will be next on some investigative reporters' list, because without some kind of crisis, or that type of reporting, it isn't likely to happen on its own.

To read the LA Times story, click here.

Felicia Curran
www.ElderAdvocacyLaw.com