I can’t believe it’s been so long since my last posting. Perhaps it’s laziness, maybe busy-ness, and most certainly tiredness. I find myself with little time to do much else than school, work and chores. I will be glad when this part of my life is over, and I can move on to something new, or at least different.
You see, I’m in school. An odd thing for a 58 year-old to be doing, but I confess, I’m odd in many ways. I began this adventure several years ago, taking one course at a time, just testing the waters to see what going back to school might feel like. Early on, it was okay. Now, in what I seriously hope is my final semester, the thought that comes to my mind most often is, “What was I thinking?”
When school is done, I’m getting myself a new knee, a graduation present of sorts. I’ll use my rehabilitation time to study for the certification exam that must follow.
But, all this is beginning to sound like whining (and I hate whining) so, let’s move on.
What’s good about this time in my life? Well, I’m actually learning a great deal. Some of it feels very “last minute” but nonetheless, the learning is both welcomed and important. I’m also stretching myself. This is my last semester “under the wing” as they say, with a preceptor responsible for the final decisions about managing the patient’s care. That said, I’m sticking my neck out a bit (as one should), saying what I think, naming the treatment I’d advise. I’m willing to be wrong in both my diagnosis and my treatment decisions, since I know there is someone there to catch my mistakes and guide me back to better thinking. That’s what preceptors do.
I’ve been a preceptor myself on occasion. In reflection, I wonder how I did when I was on the “think through the problem; protect from error” side of the equation. My students would have been RNs mostly, people already accustomed to thinking and doing. I hope I gave them the wisdom they needed in the moment, the evidence to examine on their own and the latitude to “get it wrong” when there would be no harm. We do learn best by our mistakes. The preceptor’s role is to keep those mistakes within the confines of protecting the patient while still teaching the learner.
This final clinical semester should be done in May. I will celebrate when it is. I will celebrate more when I know I have passed my certification exam, and then with my FNP in hand, as I go out into practice I will likely return to the question of today, “What was I thinking?”
Tuesday, March 1, 2011
Wednesday, August 11, 2010
Time Passages. . .
How do you measure the concept of time? Most of us here, in the U.S.A. would say, “Silly question. We use years, months, weeks, days, hours, minutes and seconds. How else would you measure time?”
Think about it. Yes, those are common measures of time. But, don’t we also measure time in the distance between events, regardless of the exact duration? I know that I do.
Like this blog. How long has it been since I blogged here? I could look at the date/time stamp on my last entry and know precisely but in my head, it’s more like hmmmm. . . “Not since summer began, and wow, summer’s nearly gone!” That’s my measure of time, the swift passing of the season.
How long has it been since I’ve seen my best friend? Again, I pause. “Not since that conference in Raleigh which was a year ago last fall. It’s been a long time!” It’s not a precise measure. I don’t go to the calendar to measure it accurately but, it does remind me that I anchor important events to each other and track time between them thinking of the distance as “recent” or “a long time ago.”
I also measure my day, especially at work, by the number of meetings it contains. A lot of meetings equals a long day; few meetings results in an easy or quick day. Sometimes, I measure by the number of trips campus-to-campus I need to make in order to accomplish my assigned chores. Odd ways to measure time, but I notice that I do it more often than I look at my watch or track back on the calendar.
So what? It’s important to regard time, and its natural passage, as a construct we all note, but not in the same way. A family of a hospitalized teen may say, “He hasn’t looked this bad since his last hospitalization.” Admission to admission; it is how they mark time.
The problem with marking time – any way you like – is that it can be discouraging to notice that a goal you’ve set or an achievement you’d hoped to attain by now is still not in your grasp. That’s been happening to me a lot lately.
Whether it’s a new weight-loss goal not yet accomplished or a course for school that I still have not put behind me, the disappointment reminds me that I mark time by my intentions too. I’ll throw that party when I’m done with school – thinking I know when that will be. Hmmm. . .time stretches out in front of me and I’m struck by its inevitable fluidity.
I’m wondering, how does this work as I peer into the future? Time flows out in all directions and I try to steer toward certain destinations, landmarks that tell me where I am, how far I’ve come and where I need to go next. It is less about distance than about consequence; less about lasting to the goal than about learning along the way.
So today, musing about what lies ahead, the directions I’ve chosen for myself and committed to, I’m aware of how little control I have over these matter! I can only invest the effort, set out on the journey, trust the process and pay attention to what happens. Will the achievements happen “on time?” Who knows? Perhaps mine is not the ultimate time-keeping method. Perhaps there is a rhythm to it all that I cannot yet hear or feel, a coursing of the waters that moves me at will and permits me only the illusion of being in charge of my life.
Think about it. Yes, those are common measures of time. But, don’t we also measure time in the distance between events, regardless of the exact duration? I know that I do.
Like this blog. How long has it been since I blogged here? I could look at the date/time stamp on my last entry and know precisely but in my head, it’s more like hmmmm. . . “Not since summer began, and wow, summer’s nearly gone!” That’s my measure of time, the swift passing of the season.
How long has it been since I’ve seen my best friend? Again, I pause. “Not since that conference in Raleigh which was a year ago last fall. It’s been a long time!” It’s not a precise measure. I don’t go to the calendar to measure it accurately but, it does remind me that I anchor important events to each other and track time between them thinking of the distance as “recent” or “a long time ago.”
I also measure my day, especially at work, by the number of meetings it contains. A lot of meetings equals a long day; few meetings results in an easy or quick day. Sometimes, I measure by the number of trips campus-to-campus I need to make in order to accomplish my assigned chores. Odd ways to measure time, but I notice that I do it more often than I look at my watch or track back on the calendar.
So what? It’s important to regard time, and its natural passage, as a construct we all note, but not in the same way. A family of a hospitalized teen may say, “He hasn’t looked this bad since his last hospitalization.” Admission to admission; it is how they mark time.
The problem with marking time – any way you like – is that it can be discouraging to notice that a goal you’ve set or an achievement you’d hoped to attain by now is still not in your grasp. That’s been happening to me a lot lately.
Whether it’s a new weight-loss goal not yet accomplished or a course for school that I still have not put behind me, the disappointment reminds me that I mark time by my intentions too. I’ll throw that party when I’m done with school – thinking I know when that will be. Hmmm. . .time stretches out in front of me and I’m struck by its inevitable fluidity.
I’m wondering, how does this work as I peer into the future? Time flows out in all directions and I try to steer toward certain destinations, landmarks that tell me where I am, how far I’ve come and where I need to go next. It is less about distance than about consequence; less about lasting to the goal than about learning along the way.
So today, musing about what lies ahead, the directions I’ve chosen for myself and committed to, I’m aware of how little control I have over these matter! I can only invest the effort, set out on the journey, trust the process and pay attention to what happens. Will the achievements happen “on time?” Who knows? Perhaps mine is not the ultimate time-keeping method. Perhaps there is a rhythm to it all that I cannot yet hear or feel, a coursing of the waters that moves me at will and permits me only the illusion of being in charge of my life.
Monday, January 18, 2010
Six things I know for sure. . .
I just came home from a family gathering. It was not a fun, pleasant event. It was the memorial service for my brother-in-law and the first step in planning and negotiating about my sister’s future. My sister is disabled, mentally and physically; she has been all her adult life. Her injuries were acquired in her early twenties in a motor vehicle accident. She was married at the time. Most men would have fled. My brother-in-law stayed; for that he is a saint. He cared for her before she was injured, and he cared for her 24/7 after her injuries. Yet, when he died, there was no evidence of that care left.
He died while they were on vacation, in Mexico. He died without a will. He died without constructing a trust for her. He died without adding their only son (also an adult) to their bank account. He died without an executor. He died without leaving any instructions – no back-up plan for a situation he had managed alone for over 45+ years.
My sister was left alone with his body for days. She didn’t know what had happened to him. She didn’t receive her medications (which he always gave her). She didn’t know the chamber-maid who came in and discovered the body (since they should have checked out the previous day). She didn’t know the man from the American Consulate who managed to put her on a plane and send her back to her son in the USA. She didn’t know her house would be turned up-side down by family members trying to figure out what plans might be in place, what bills might be due, what steps to take on her behalf. She didn’t know what to say at his memorial – words are not part of her skill-set any more. She didn’t know we’d end up looking at assisted living facilities until we put her in the car and showed her around. She didn’t even know for sure who we all were who had descended on her home and upset her life and could not bring back her husband.
What this has taught me is: Life is busy for all of us, but we still have responsibilities that do not end at the grave. Each of us needs to own up to those responsibilities once we acknowledge them. These six things we each must attend to if we expect to leave our loved ones adequately supported in our absence.
1. Write a will. It does not matter whether you buy a template and fill it out, go to a lawyer and have it crafted to your specific needs, use a website and construct it on your own, but to die without a will means your state bureaucrats can do with your assets whatever they deem best. When has the state ever chosen what was best for you or your family? Best in the eyes of the state probably means best “for the state.” Surely, no one will fare well if the state directs your estate.
2. Give someone Power of Attorney. Do it now, before you need to. You can change your mind later but if you die without giving that authority to anyone, and your spouse dies with you or your spouse is so incapacitated that s/he can’t make good decisions, everything stops. Bills don’t get paid. You don’t get buried (or cremated, or whatever). Your house may go into foreclosure. You get the picture – a whole lot of nothing gets done. All the things you normally manage don’t get managed. Give someone you trust the authority to manage these things for you – for your family!
3. Tell family what’s what. If you have a mortgage (or two) on the house, someone needs to know that, and when the next payment is due. If you have a car loan or a boat loan, don’t let your son find out about it by meeting the re-po guy in the driveway; be honest, let your kids know now. If you have possessions that belong to someone else, give them back (your neighbor’s lawn mower in the garage; your co-worker’s laptop under the bed) your family shouldn’t have to play guessing games trying to figure out what is yours and what is someone else’s. They’ll have enough grief on their hands!
4. Keep your papers in order. No one should have to go searching through your desk drawers only to discover your current mortgage buried behind the map from your last vacation and the receipts from your fast-food binges. Your widow shouldn’t have to learn what your collection of watches is worth from the local appraiser who might love to swindle her out of that Rollex by telling her it’s a fake. Your kids shouldn’t discover that college is out of the question because all the time they thought you were putting money into their 529-plan, you really weren’t. And your widower shouldn’t have to figure out after your death that you were corresponding (secretly) with your college sweetheart when he finally does read your e-mails. Keep what will be needed. Get rid of what you don’t want to share. Don’t be the reason that anger is piled upon grief.
5. Put your assets into a trust. If your family needs resources (especially if they too are injured, ill, incapacitated, etc.) and you leave your “stuff” without constructing a trust, the “stuff” is of no use to them until probate is over and a lot of legal hurdles are cleared. With a trust, it is clear who you wish to take care of, how you want things managed, and hopefully, who can take charge in your absence.
6. Clean up your mess yourself. If your house is full of clutter, debris, and useless possessions, clean them out now. Leaving your old magazines piled up for friends and family to dispose of or your kitchen so greasy that no one else can healthfully cook or eat a meal there, or your bathroom so filthy that relatives have to scrub the counters before they can occupy or sell the house is in a word, irresponsible.
No, this litany does not represent the omissions of only my brother-in-law. The stories of many friends are woven into these six “musts” that have become a mission for me. I came home from my trip utterly overwhelmed with the work that is left to my nephew and other willing family members. I will not leave my house in such disorder. I can’t; my husband depends on me to put my life in order and together with him, to put our house in order, too. No one deserves to inherit our mess, our debris, our confusion. Our heirs deserve better and we will deliver!
He died while they were on vacation, in Mexico. He died without a will. He died without constructing a trust for her. He died without adding their only son (also an adult) to their bank account. He died without an executor. He died without leaving any instructions – no back-up plan for a situation he had managed alone for over 45+ years.
My sister was left alone with his body for days. She didn’t know what had happened to him. She didn’t receive her medications (which he always gave her). She didn’t know the chamber-maid who came in and discovered the body (since they should have checked out the previous day). She didn’t know the man from the American Consulate who managed to put her on a plane and send her back to her son in the USA. She didn’t know her house would be turned up-side down by family members trying to figure out what plans might be in place, what bills might be due, what steps to take on her behalf. She didn’t know what to say at his memorial – words are not part of her skill-set any more. She didn’t know we’d end up looking at assisted living facilities until we put her in the car and showed her around. She didn’t even know for sure who we all were who had descended on her home and upset her life and could not bring back her husband.
What this has taught me is: Life is busy for all of us, but we still have responsibilities that do not end at the grave. Each of us needs to own up to those responsibilities once we acknowledge them. These six things we each must attend to if we expect to leave our loved ones adequately supported in our absence.
1. Write a will. It does not matter whether you buy a template and fill it out, go to a lawyer and have it crafted to your specific needs, use a website and construct it on your own, but to die without a will means your state bureaucrats can do with your assets whatever they deem best. When has the state ever chosen what was best for you or your family? Best in the eyes of the state probably means best “for the state.” Surely, no one will fare well if the state directs your estate.
2. Give someone Power of Attorney. Do it now, before you need to. You can change your mind later but if you die without giving that authority to anyone, and your spouse dies with you or your spouse is so incapacitated that s/he can’t make good decisions, everything stops. Bills don’t get paid. You don’t get buried (or cremated, or whatever). Your house may go into foreclosure. You get the picture – a whole lot of nothing gets done. All the things you normally manage don’t get managed. Give someone you trust the authority to manage these things for you – for your family!
3. Tell family what’s what. If you have a mortgage (or two) on the house, someone needs to know that, and when the next payment is due. If you have a car loan or a boat loan, don’t let your son find out about it by meeting the re-po guy in the driveway; be honest, let your kids know now. If you have possessions that belong to someone else, give them back (your neighbor’s lawn mower in the garage; your co-worker’s laptop under the bed) your family shouldn’t have to play guessing games trying to figure out what is yours and what is someone else’s. They’ll have enough grief on their hands!
4. Keep your papers in order. No one should have to go searching through your desk drawers only to discover your current mortgage buried behind the map from your last vacation and the receipts from your fast-food binges. Your widow shouldn’t have to learn what your collection of watches is worth from the local appraiser who might love to swindle her out of that Rollex by telling her it’s a fake. Your kids shouldn’t discover that college is out of the question because all the time they thought you were putting money into their 529-plan, you really weren’t. And your widower shouldn’t have to figure out after your death that you were corresponding (secretly) with your college sweetheart when he finally does read your e-mails. Keep what will be needed. Get rid of what you don’t want to share. Don’t be the reason that anger is piled upon grief.
5. Put your assets into a trust. If your family needs resources (especially if they too are injured, ill, incapacitated, etc.) and you leave your “stuff” without constructing a trust, the “stuff” is of no use to them until probate is over and a lot of legal hurdles are cleared. With a trust, it is clear who you wish to take care of, how you want things managed, and hopefully, who can take charge in your absence.
6. Clean up your mess yourself. If your house is full of clutter, debris, and useless possessions, clean them out now. Leaving your old magazines piled up for friends and family to dispose of or your kitchen so greasy that no one else can healthfully cook or eat a meal there, or your bathroom so filthy that relatives have to scrub the counters before they can occupy or sell the house is in a word, irresponsible.
No, this litany does not represent the omissions of only my brother-in-law. The stories of many friends are woven into these six “musts” that have become a mission for me. I came home from my trip utterly overwhelmed with the work that is left to my nephew and other willing family members. I will not leave my house in such disorder. I can’t; my husband depends on me to put my life in order and together with him, to put our house in order, too. No one deserves to inherit our mess, our debris, our confusion. Our heirs deserve better and we will deliver!
Monday, December 28, 2009
On the eve of a new decade. . .
Technically, the year 2010 belongs to the first decade of the 21st century, but we rarely talk about it that way. You remember all the Y2K hoopla we went through when, technically, the new century wouldn’t officially have begun until we FINISHED the 20th century (1901 -2000). Oh well, so much for technicalities.
So, giving in to popular convention, we sit at the dawn of our second decade of the 21st century and what do we know that we didn’t know ten years ago?
That a “failure of imagination” can kill you. That’s what the 9/11 Commission called our failure to foresee and prevent the attacks of September 11, 2001. While we acknowledge that hindsight is 20:20 and that most of us “Monday morning quarterbacks” think we know so much more than those in charge, it is hard to accept that we ought to be learning our next moves on the international chess board from the writers of science fiction and mystery. What is our next failure of imagination – only a look back at what we now call the future will tell.
That healthcare is a right, not merely a privilege. At least that’s what Bernie Sanders, Independent U.S. Senator from Vermont declared earlier this year.1 He goes on to remind us that “At the individual level, the average American spends about $7,900 per year on health care. Despite that huge outlay, a recent study found that medical problems contributed to 62 percent of all bankruptcies in 2007.” So, at the 11th hour, the American congressional leaders gave us a healthcare bill. Now we’ll see how long it takes for ordinary citizens to begin to feel the effects of such righteous medicine.
That we’re all getting older. No big secret here, but what I mean is we’ll all be paying the price for the birth of the Baby Boomers some 60+ years ago. We boomers were born between 1946 and 1964. Based on a July 2008 estimate there are 303,824,640 U.S. citizens and roughly 12.7% of us are 65 and over. The real sad truth is that most Americans live to be at least 75 years of age and some of us (at increasing rates) will become centanarians – about 214,000 by 2010 according to census bureau estimates.2 The trouble is not that we enjoy longevity, it is that the rest of the country will end up footing the bill for our long-term healthcare needs – a very costly enterprise.
Industry experts suggest that “By 2030 those needing LTC will skyrocket to 23+ million Americans, with projected, individual long term care costs reaching $300,000 annually per individual!”3 And we think health care is expensive now! When you consider who is and will be paying for Medicare and Social Security political pundits have warned, “Starting in 2008, 70 million baby boomers will begin retiring, and they will live longer than their parents did. That means that the number of workers paying for each beneficiary will drop to just over two by mid-century.”4 Two-to-one; dreadful odds, especially if you’re under 30.
For myself, I also know that:
- Being called grandmother trumps all the other titles I’ve had.
- I can live comfortably on less than I make.
- I don’t need any more jewelry.
- Life is a mystery – enjoy the ride!
1. Sanders, B. (2009). Health care is a right, not a privilege. The Huffington Post (December 28, 2009) accessed from http://www.huffingtonpost.com/rep-bernie-sanders/health-care-is-a-right-no_b_212770.html
2. Projected Number of Centenarians in the United States bySex, Race, and Hispanic Origin: 2000 to 2050. Current Population Reports, P25-1130, U.S. Government Printing Office, Washington, DC. Accessed from http://askville.amazon.com/centenarians-United-States-men-women/AnswerViewer.do?requestId=5959708
3. Long Term Care Insurance (2008). Long term Care Insurance National Advisory Center accessed from http://www.longtermcareinsurance.org/
4. Cannon, M.F., (2005). Medicare vs. social security: who’s on first? Nationalreview.com (April 14. 2005) accessed from http://www.cato.org/pub_display.php?pub_id=5357
Tuesday, August 25, 2009
Open letter to Charles Babington...
This is an open letter to Charles Babington, writer for the Associated Press, whose article in the Minneapolis Star Tribune on August 3rd made me wonder if he was interested in shedding light on the health care debate or merely adding to the heat. He asks that we check the facts, and then goes on to offer us his five insights on “the facts” as he sees them.
I offer a personal and a professional perspective as a nurse with 34+ years experience in the American health care system. I see our elected officials struggling to manage the macro-economics of health care yet failing to recognize, let alone understand, the micro-economics that confront each of us as citizens and consumers every day. I confess that my opinions are shaped by what I’ve seen over the years and read in documents like the Rand White Paper (1), Living Well at the End of Life, which lays out the costs of disproportionately using our resources to stave off death.
My bias is that our health care system is mostly an “illness care” system, prepared to tackle our health problems only after they have become huge obstacles in our lives. There is little about it that offers us wisdom on preserving health, managing minor illnesses well or making thoughtful decisions about the quality and length of our lives. The data, in some cases, are out there (smoking contributes to cancer and heart disease; exercise prevents many chronic illnesses) but our health care system is poorly set up to move the public health of our nation toward genuinely healthy decisions. Intervention comes a day late and a dollar short for most of our citizens. The rest of us just shake our heads and tolerate it. Oh, and by the way, we pay for it, too.
Mr. Babington hits on some important issues and offers us good arguments but no direction. Here are the five facts he points us toward:
1.THE FACTS: The House bill would require Medicare to pay for advance directive consultations with health care professionals. But it would not require anyone to use the benefit.
I agree with Mr. Babington, advance directives are intended to lay out a patient’s wishes for life-extending measures. Generally, these documents are constructed in consultation with health professionals, not government agents. Will Americans pursue with more vigor the construction of their own advance directives simply because a law permits payment for the consultation? Few people bother to write out their wishes now. Worse, even fewer emergency departments and first responders have access to these documents when important and immediate intervention decisions arise.
Jones (2 ) indicates that by 2007, only 41% of Americans had created living wills. However, for the advance directive to be an effective tool, far more of us need to subscribe to the premise that we want and need such a tool to live our lives thoughtfully and ethically, especially at the end of life.
Will paying for consultation lead people to take advantage of the opportunity to make their wishes known? I have my doubts. Perhaps instead, the law should require (at least for members of any “public plan”) that we must write out an advance directive. For me, I’ve done that, but in addition, I intend to have Do Not Resuscitate tattooed over my sternum, where hopefully, anyone attempting to save my life with CPR should find it.
2.THE FACTS: The proposed bills would not undo the Hyde Amendment, which bars paying for abortions through Medicaid, the government insurance program for the poor. But a health care overhaul could create a government-run insurance program, or insurance "exchanges," that would not involve Medicaid and whose abortion guidelines are not yet clear.
Since we don’t have any final language, I’d hate to see us dismiss the first serious U.S. health care reform in my adult lifetime on language we haven’t even read yet.
I’m a person of contradictions and paradoxes. I’m Catholic, so you know that my bias about abortion leans seriously against it. I’m also pro-choice, so while I admit I couldn’t choose to have an abortion, I am grateful that my government no longer criminalizes a woman’s choice to consider it. That said, if what we’re interested in is lowering the COST of healthcare, we have to think about the amount of futile care that goes on at the two ends of life – near birth and near death.
Our arguments about abortion get so loud that we forget to even discuss the topics that we should, like America’s infant mortality rates. If we want to talk about the wellbeing of babies, that’s the place to start. We forget all about PREVENTION and the modest expenditures required to bring most children into the world safely. Krisberg (3), writing for The Nation’s Health, alerts us to data “released in October 2008…the Centers for Disease Control and Prevention’s National Center for Health Statistics ranks the United States 29th globally in infant mortality in 2004.” It is a sad commentary on where our values lie.
In America, we rely on neonatal intensive care units (NICUs) to preserve the children who, with a little prenatal care, might have stayed safely in the womb until full term.
Lantos (4) reminds us, “Neonatal intensive care is one of the triumphs of modern medicine. Babies who inevitably would have died a few decades ago routinely survive today. But the success of NICUs should not lead us to see them as the only solution to infant mortality or as an adequate moral response to our children's health needs. We should constantly remind ourselves that the need for so much intensive care for so many babies is a sign of political, medical, and moral failure in developing ways to address the problems that sustain an epidemic of prematurity.”
That’s where our attention must be focused, on that epidemic of prematurity. Yet we insist on getting hung up on the abortion issue, and miss all the opportunities prevention could offer.
Then, when we do care for a child in NICU what criteria are we using for the treatment we insist on doing? It is usually not statistics (which can be grim). Hack (5) and colleagues remind us that the mild and moderate handicaps associated with preterm and low-birth-weight babies include asthma, attention-deficit disorder, visual problems, cerebral palsy, and the need for special education. These outcomes can drain a family financially, physically, emotionally, and spiritually. Clinicians, families and most in our society share a built-in bias to treat newborns aggressively.
But, we also owe it to these parents to help them become well informed of the potentially long-term struggles in raising a child with special needs. Health care providers should not tell them what to do, but counsel them fully so they are not surprised or saddened by the outcomes of their decisions.
3.THE FACTS: The proposed legislation would not require people to drop their doctor or insurer. But some tax provisions, depending on how they are written, might make it cheaper for some employers to pay a fee to end their health coverage. Their workers presumably would move to a public insurance plan that might not include their current doctors.
Wow – news alert, you may have to change providers! Every time your employer picks a new insurer you run that risk. If you lose your job you may lose your provider. And, if you have to change cities to get another job, you’ll probably have to find a new provider, too. This isn’t news. Primary care provider (the person you see for year-to-year preventive care) numbers are dwindling at break-neck pace, and they’re aging too. So, honestly, if you live a good long life, you’ll have to find a new provider from time to time.
Again, I agree with Mr. Babington when he offers his next set of facts.
4.THE FACTS: Millions of Americans already face rationing, as insurance companies rule on procedures they will cover.
And rationing goes even further into our healthcare choices and decisions:
•When healthcare facilities cut nursing staff, access to needed care goes down accordingly. The length of time from pressing the call bell to receiving a response, that’s an access issue too!
•When cities and towns cut back on first responders and ambulance crews, that’s an access issue as well.
•When drug costs soar out of the reach of common citizens, guess what? That’s an access issue.
Rationing happens! We just don’t want to admit that it does, and always will. Rationing isn’t wrong, but it shouldn’t be thoughtless or haphazard. We all ration, every time we examine our own personal budget. Personal rationing asks, how much will I spend on this or that? Will I make healthy choices for myself, or careless ones, hoping there’s enough money to pay for the damages they will cause?
The issue is WHO should be determining how public rationing occurs? In my opinion, it should be a layered discussion and decision. First, for simple things, the patient, family and provider should handle matters. After that, within a “public option” and for more complex issues, states should have an expert committee made up of healthcare professionals, community members, ethicists and clergy who help determine the tough issues.
There will always be rationing; our technological advances make it so. We’ll always have more tools available than we have time, people or financial resources to use them. And, just because we CAN provide a particular healthcare intervention, does not mean we should!
5.THE FACTS: Obama's pledge does not apply to proposed-spending of about $245 billion over the next decade to increase Medicare fees for doctors. The White House says the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration's policy.
Mr. Babington tells us that the White House and Democratic lawmakers are talking about creating a powerful new board to root out waste in government health programs. He suggests that it's unclear how that would work.
Well, I have some ideas. The new American health care system should:
-- Require advance directives and the conversations they initiate. Write out your health care wishes, update them regularly, let family, friends and your physicians know about them and above all, be informed about what end-of-life care means. Be careful what you ask for!
-- Focus on prevention. Make preventative health care a RIGHT not a privilege so that we begin to level the playing field for all of our citizens. Immunizations cost less than the diseases they prevent; check-ups catch early signs of disease when it is more treatable; information about healthy choices offers us choice about our long-term health care goals.
-- Change providers thoughtfully. Consider a new provider when you’re approaching 65 especially if your physician is too! Consider a new provider when you’re not getting access to information about national guidelines designed to drive best health care practices. Consider a new provider when your provider fails to treat you as a partner in your own care!
-- Ration rationally. Think again about how we use our intensive care units and emergency services (of all sorts) so we’re not spending the bulk of our dollars on the final year of life, but on the early years when a healthy start can make a world of difference.
-- Help the government root out waste! Report fraud and certainly don’t engage in it (like lending your insurance card to an uninsured family member). Don’t steal – no, the towels, pillows, sheets, and extra supplies in your hospital room are NOT YOURS to take with you.
Don’t ignore the signs of illness and neglect to take appropriate action. The life you save may be your own!
References cited:
1. The Rand Health White Paper, WP-137, (2003). Living Well at the End of Life. Accessed August 3, 2009 from: http://www.medicaring.org/whitepaper/
2. Jones, C. (2007). With living wills gaining in popularity, push grows for more extensive directive, Crain's Cleveland Business, August 20, 2007. Accessed August 3, 2009 from: http://www.highbeam.com/doc/1G1-167959744.html
3. Krisberg, K. (2009). U.S. lagging behind many other nations on infant mortality rates: Healthy behavior, healthier babies. The Nation’s Health (February 2009). Accessed August 3, 2009 from: http://www.apha.org/publications/tnh/archives/2009/February09/Nation/BabiesNAT.htm
4. Lantos JD. (2001).Hooked on neonatology. Health Aff (Millwood). 2001;20(5):240.
5. Hack M, Taylor HG, Drotar D, et al. (2005). Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA. 2005;294(3):318-325.
I offer a personal and a professional perspective as a nurse with 34+ years experience in the American health care system. I see our elected officials struggling to manage the macro-economics of health care yet failing to recognize, let alone understand, the micro-economics that confront each of us as citizens and consumers every day. I confess that my opinions are shaped by what I’ve seen over the years and read in documents like the Rand White Paper (1), Living Well at the End of Life, which lays out the costs of disproportionately using our resources to stave off death.
My bias is that our health care system is mostly an “illness care” system, prepared to tackle our health problems only after they have become huge obstacles in our lives. There is little about it that offers us wisdom on preserving health, managing minor illnesses well or making thoughtful decisions about the quality and length of our lives. The data, in some cases, are out there (smoking contributes to cancer and heart disease; exercise prevents many chronic illnesses) but our health care system is poorly set up to move the public health of our nation toward genuinely healthy decisions. Intervention comes a day late and a dollar short for most of our citizens. The rest of us just shake our heads and tolerate it. Oh, and by the way, we pay for it, too.
Mr. Babington hits on some important issues and offers us good arguments but no direction. Here are the five facts he points us toward:
1.THE FACTS: The House bill would require Medicare to pay for advance directive consultations with health care professionals. But it would not require anyone to use the benefit.
I agree with Mr. Babington, advance directives are intended to lay out a patient’s wishes for life-extending measures. Generally, these documents are constructed in consultation with health professionals, not government agents. Will Americans pursue with more vigor the construction of their own advance directives simply because a law permits payment for the consultation? Few people bother to write out their wishes now. Worse, even fewer emergency departments and first responders have access to these documents when important and immediate intervention decisions arise.
Jones (2 ) indicates that by 2007, only 41% of Americans had created living wills. However, for the advance directive to be an effective tool, far more of us need to subscribe to the premise that we want and need such a tool to live our lives thoughtfully and ethically, especially at the end of life.
Will paying for consultation lead people to take advantage of the opportunity to make their wishes known? I have my doubts. Perhaps instead, the law should require (at least for members of any “public plan”) that we must write out an advance directive. For me, I’ve done that, but in addition, I intend to have Do Not Resuscitate tattooed over my sternum, where hopefully, anyone attempting to save my life with CPR should find it.
2.THE FACTS: The proposed bills would not undo the Hyde Amendment, which bars paying for abortions through Medicaid, the government insurance program for the poor. But a health care overhaul could create a government-run insurance program, or insurance "exchanges," that would not involve Medicaid and whose abortion guidelines are not yet clear.
Since we don’t have any final language, I’d hate to see us dismiss the first serious U.S. health care reform in my adult lifetime on language we haven’t even read yet.
I’m a person of contradictions and paradoxes. I’m Catholic, so you know that my bias about abortion leans seriously against it. I’m also pro-choice, so while I admit I couldn’t choose to have an abortion, I am grateful that my government no longer criminalizes a woman’s choice to consider it. That said, if what we’re interested in is lowering the COST of healthcare, we have to think about the amount of futile care that goes on at the two ends of life – near birth and near death.
Our arguments about abortion get so loud that we forget to even discuss the topics that we should, like America’s infant mortality rates. If we want to talk about the wellbeing of babies, that’s the place to start. We forget all about PREVENTION and the modest expenditures required to bring most children into the world safely. Krisberg (3), writing for The Nation’s Health, alerts us to data “released in October 2008…the Centers for Disease Control and Prevention’s National Center for Health Statistics ranks the United States 29th globally in infant mortality in 2004.” It is a sad commentary on where our values lie.
In America, we rely on neonatal intensive care units (NICUs) to preserve the children who, with a little prenatal care, might have stayed safely in the womb until full term.
Lantos (4) reminds us, “Neonatal intensive care is one of the triumphs of modern medicine. Babies who inevitably would have died a few decades ago routinely survive today. But the success of NICUs should not lead us to see them as the only solution to infant mortality or as an adequate moral response to our children's health needs. We should constantly remind ourselves that the need for so much intensive care for so many babies is a sign of political, medical, and moral failure in developing ways to address the problems that sustain an epidemic of prematurity.”
That’s where our attention must be focused, on that epidemic of prematurity. Yet we insist on getting hung up on the abortion issue, and miss all the opportunities prevention could offer.
Then, when we do care for a child in NICU what criteria are we using for the treatment we insist on doing? It is usually not statistics (which can be grim). Hack (5) and colleagues remind us that the mild and moderate handicaps associated with preterm and low-birth-weight babies include asthma, attention-deficit disorder, visual problems, cerebral palsy, and the need for special education. These outcomes can drain a family financially, physically, emotionally, and spiritually. Clinicians, families and most in our society share a built-in bias to treat newborns aggressively.
But, we also owe it to these parents to help them become well informed of the potentially long-term struggles in raising a child with special needs. Health care providers should not tell them what to do, but counsel them fully so they are not surprised or saddened by the outcomes of their decisions.
3.THE FACTS: The proposed legislation would not require people to drop their doctor or insurer. But some tax provisions, depending on how they are written, might make it cheaper for some employers to pay a fee to end their health coverage. Their workers presumably would move to a public insurance plan that might not include their current doctors.
Wow – news alert, you may have to change providers! Every time your employer picks a new insurer you run that risk. If you lose your job you may lose your provider. And, if you have to change cities to get another job, you’ll probably have to find a new provider, too. This isn’t news. Primary care provider (the person you see for year-to-year preventive care) numbers are dwindling at break-neck pace, and they’re aging too. So, honestly, if you live a good long life, you’ll have to find a new provider from time to time.
Again, I agree with Mr. Babington when he offers his next set of facts.
4.THE FACTS: Millions of Americans already face rationing, as insurance companies rule on procedures they will cover.
And rationing goes even further into our healthcare choices and decisions:
•When healthcare facilities cut nursing staff, access to needed care goes down accordingly. The length of time from pressing the call bell to receiving a response, that’s an access issue too!
•When cities and towns cut back on first responders and ambulance crews, that’s an access issue as well.
•When drug costs soar out of the reach of common citizens, guess what? That’s an access issue.
Rationing happens! We just don’t want to admit that it does, and always will. Rationing isn’t wrong, but it shouldn’t be thoughtless or haphazard. We all ration, every time we examine our own personal budget. Personal rationing asks, how much will I spend on this or that? Will I make healthy choices for myself, or careless ones, hoping there’s enough money to pay for the damages they will cause?
The issue is WHO should be determining how public rationing occurs? In my opinion, it should be a layered discussion and decision. First, for simple things, the patient, family and provider should handle matters. After that, within a “public option” and for more complex issues, states should have an expert committee made up of healthcare professionals, community members, ethicists and clergy who help determine the tough issues.
There will always be rationing; our technological advances make it so. We’ll always have more tools available than we have time, people or financial resources to use them. And, just because we CAN provide a particular healthcare intervention, does not mean we should!
5.THE FACTS: Obama's pledge does not apply to proposed-spending of about $245 billion over the next decade to increase Medicare fees for doctors. The White House says the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration's policy.
Mr. Babington tells us that the White House and Democratic lawmakers are talking about creating a powerful new board to root out waste in government health programs. He suggests that it's unclear how that would work.
Well, I have some ideas. The new American health care system should:
-- Require advance directives and the conversations they initiate. Write out your health care wishes, update them regularly, let family, friends and your physicians know about them and above all, be informed about what end-of-life care means. Be careful what you ask for!
-- Focus on prevention. Make preventative health care a RIGHT not a privilege so that we begin to level the playing field for all of our citizens. Immunizations cost less than the diseases they prevent; check-ups catch early signs of disease when it is more treatable; information about healthy choices offers us choice about our long-term health care goals.
-- Change providers thoughtfully. Consider a new provider when you’re approaching 65 especially if your physician is too! Consider a new provider when you’re not getting access to information about national guidelines designed to drive best health care practices. Consider a new provider when your provider fails to treat you as a partner in your own care!
-- Ration rationally. Think again about how we use our intensive care units and emergency services (of all sorts) so we’re not spending the bulk of our dollars on the final year of life, but on the early years when a healthy start can make a world of difference.
-- Help the government root out waste! Report fraud and certainly don’t engage in it (like lending your insurance card to an uninsured family member). Don’t steal – no, the towels, pillows, sheets, and extra supplies in your hospital room are NOT YOURS to take with you.
Don’t ignore the signs of illness and neglect to take appropriate action. The life you save may be your own!
References cited:
1. The Rand Health White Paper, WP-137, (2003). Living Well at the End of Life. Accessed August 3, 2009 from: http://www.medicaring.org/whitepaper/
2. Jones, C. (2007). With living wills gaining in popularity, push grows for more extensive directive, Crain's Cleveland Business, August 20, 2007. Accessed August 3, 2009 from: http://www.highbeam.com/doc/1G1-167959744.html
3. Krisberg, K. (2009). U.S. lagging behind many other nations on infant mortality rates: Healthy behavior, healthier babies. The Nation’s Health (February 2009). Accessed August 3, 2009 from: http://www.apha.org/publications/tnh/archives/2009/February09/Nation/BabiesNAT.htm
4. Lantos JD. (2001).Hooked on neonatology. Health Aff (Millwood). 2001;20(5):240.
5. Hack M, Taylor HG, Drotar D, et al. (2005). Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA. 2005;294(3):318-325.
School Daze II
School is starting this very week and I feel like a prisoner of my own choices. I’ve chosen to go back to school to pursue this post-master’s FNP certification. I’ve committed my time, my energy, my schedule and risked the significant relationships in my life toward the completion of this graduate work. Yet, right now, I feel as though I may very well have chosen poorly, and that is most discouraging. Some dreadful confusion has led to our not having an instructor in place for one of my courses. The tempus is fugit-ing and so far, all we (students) know is that the school is “working on the problem”.
This seems to be happening everywhere. Just last week I was trying to help another school sort out a similar faculty difficulty. That school was scheduled to bring 8 senior students (BSN program) to my workplace, and they found themselves at the 11th hour without a clinical instructor for the student group. I got pulled into the problem-solving because our Education Specialist was out on medical leave. In the end, the school found someone to teach the clinical section. Who knows what her credentials are, and whether she’s ever seen patients like those we serve every day. She’ll have no rapport with the staff here and no familiarity with the curriculum the students are studying. A lovely way to begin the semester!
In the long-run, this fall’s difficulty will disappear from my memory. I will accomplish my goal and like all unpleasant experiences, this one will dissipate and become a thing of the past. For me, this is merely annoying.
For my fellow students, and especially for those undergraduates who are set to begin their clinical instruction at my hospital next week, I find this situation reprehensible. My colleagues in graduate school are mostly young women (okay, there’s one guy). They either have jobs that function on shift-work or student loans that will bury them for years to come. They have young children and aging parents to care for, and spouses who probably have less tolerance for nursing graduate school than mine (with two PhDs) does.
We (hubby & I) were having a conversation just last evening reminiscing about our fond memories of graduate school. His experiences were in the 1950s and mine in the 1970s, which seems like eons ago. We remember faculty members who liked their work, faculty who liked students and were committed to our success. We remember faculty who mentored us, encouraged us and set each of us (twenty years apart) on paths that would launch us on meaningful careers of life-long learning. What are my school colleagues getting out of their graduate experience? And, perhaps even more importantly, what are today’s undergrads experiencing in their educational programs? Will they even WANT to consider going on for more schooling? If the undergraduate experience is discouraging, why would anyone sign up for more?
This is, I believe, the 21st century challenge in higher education: to recruit, hire, support and retain high-quality teachers. How do you do that, especially with a reward system so skewed, especially in the healthcare fields, toward being out in a practice setting, rather than in higher education? Out in the work-world of healthcare, the practitioner can earn at least half again as much each year as the professor who taught her. Its sad, but true.
That I am in nursing gives me only one perspective and limited insight, but I have to believe that the situation is similar in all the healthcare careers including medicine, the rehabilitation therapies, dentistry and social work, each of which are requiring increasing levels of graduate education for practice. As we continue to require more years of education, we tax the faculty we have and we probably dissuade the practitioner from teaching, given the financial burden he or she has accumulated during the preparatory educational process.
This time around, getting graduate education in the 21st century, I find myself discouraged. If asked by a colleague, “should I go back to graduate school?” my answer might not be the rapid and automatic “yes” that it would have been before my most recent experience. No one is, at this moment, mentoring me as a student. I have to wonder if my younger colleagues, who do not have the nostalgic memories of graduate school of long ago, are even more discouraged than I am.
What should graduate education be?
To my mind it should definitely be:
-- An exciting encounter in which the learner is stretched and challenged by the information, not by the logistics of learning.
-- A reinforcing, supportive place where the learner gains a new vision of his or her own professional possibilities, a time to imagine an ever-opening future.
-- An opportunity to hone those generalizable skills like reading comprehension, analysis, synthesis and problem-solving that will complement anyone’s lifetime of experience.
-- A place where learners meet faculty who are excited and positive about their work, connected to the current trends in their field, happy in the work that they’ve chosen, rewarded for their ability to teach well and impart wisdom as well as facts.
-- An environment where faculty are also supported, encouraged, mentored, enlarged and connected to each other and the practice world into which they are charged to launch the students.
Wishful thinking? Probably.
If only I could see my way clear to be part of the solution, instead of just a prophet in my own land.
This seems to be happening everywhere. Just last week I was trying to help another school sort out a similar faculty difficulty. That school was scheduled to bring 8 senior students (BSN program) to my workplace, and they found themselves at the 11th hour without a clinical instructor for the student group. I got pulled into the problem-solving because our Education Specialist was out on medical leave. In the end, the school found someone to teach the clinical section. Who knows what her credentials are, and whether she’s ever seen patients like those we serve every day. She’ll have no rapport with the staff here and no familiarity with the curriculum the students are studying. A lovely way to begin the semester!
In the long-run, this fall’s difficulty will disappear from my memory. I will accomplish my goal and like all unpleasant experiences, this one will dissipate and become a thing of the past. For me, this is merely annoying.
For my fellow students, and especially for those undergraduates who are set to begin their clinical instruction at my hospital next week, I find this situation reprehensible. My colleagues in graduate school are mostly young women (okay, there’s one guy). They either have jobs that function on shift-work or student loans that will bury them for years to come. They have young children and aging parents to care for, and spouses who probably have less tolerance for nursing graduate school than mine (with two PhDs) does.
We (hubby & I) were having a conversation just last evening reminiscing about our fond memories of graduate school. His experiences were in the 1950s and mine in the 1970s, which seems like eons ago. We remember faculty members who liked their work, faculty who liked students and were committed to our success. We remember faculty who mentored us, encouraged us and set each of us (twenty years apart) on paths that would launch us on meaningful careers of life-long learning. What are my school colleagues getting out of their graduate experience? And, perhaps even more importantly, what are today’s undergrads experiencing in their educational programs? Will they even WANT to consider going on for more schooling? If the undergraduate experience is discouraging, why would anyone sign up for more?
This is, I believe, the 21st century challenge in higher education: to recruit, hire, support and retain high-quality teachers. How do you do that, especially with a reward system so skewed, especially in the healthcare fields, toward being out in a practice setting, rather than in higher education? Out in the work-world of healthcare, the practitioner can earn at least half again as much each year as the professor who taught her. Its sad, but true.
That I am in nursing gives me only one perspective and limited insight, but I have to believe that the situation is similar in all the healthcare careers including medicine, the rehabilitation therapies, dentistry and social work, each of which are requiring increasing levels of graduate education for practice. As we continue to require more years of education, we tax the faculty we have and we probably dissuade the practitioner from teaching, given the financial burden he or she has accumulated during the preparatory educational process.
This time around, getting graduate education in the 21st century, I find myself discouraged. If asked by a colleague, “should I go back to graduate school?” my answer might not be the rapid and automatic “yes” that it would have been before my most recent experience. No one is, at this moment, mentoring me as a student. I have to wonder if my younger colleagues, who do not have the nostalgic memories of graduate school of long ago, are even more discouraged than I am.
What should graduate education be?
To my mind it should definitely be:
-- An exciting encounter in which the learner is stretched and challenged by the information, not by the logistics of learning.
-- A reinforcing, supportive place where the learner gains a new vision of his or her own professional possibilities, a time to imagine an ever-opening future.
-- An opportunity to hone those generalizable skills like reading comprehension, analysis, synthesis and problem-solving that will complement anyone’s lifetime of experience.
-- A place where learners meet faculty who are excited and positive about their work, connected to the current trends in their field, happy in the work that they’ve chosen, rewarded for their ability to teach well and impart wisdom as well as facts.
-- An environment where faculty are also supported, encouraged, mentored, enlarged and connected to each other and the practice world into which they are charged to launch the students.
Wishful thinking? Probably.
If only I could see my way clear to be part of the solution, instead of just a prophet in my own land.
Wednesday, July 22, 2009
Past, Present, Future!
Everyone talks about living in the moment and I do “get” the sentiment of that, being present, acknowledging what is right here, right now, and engaging that set of realities. But I also have to acknowledge why my mind wanders and why I find myself savoring the great moments of the past (and, if I’m truthful, embellishing on them) and projecting myself into some warm, imagined future where all the hassles of today are done and I am free to do all the things I’d rather do.
Foolishness, huh? I agree but it is where I tend to live my life – in the spaces surrounding the now – the past, carefully sorted out to diminish the unpleasant realities, and the future, carefully constructed to allow me to put one foot in front of the other an move forward believing that there is a hopeful finish to it all!
Is that a good way to live? Well, if I have to defend it, I’m going to say, “Hell, yes!” But, if I can step aside from the realization that it is ME I’m talking about, I have to admit that all of this is simply a rationalization, a ruse, to avoid the painfulness of the present I have constructed from myself.
The present (this summer, this time right here and now) is a most unpleasant place. I have been consumed for 10 weeks with one thing, completing the requirements of a 4-hour graduate course that should have been great fun, but wasn’t. Yes, there were moments of great fun (those brief events where living in that moment made the whole semester worthwhile) mainly because there were some delightful successes.
Now these are not the sort of successes most folks could recognize, but for a mid-life adventurer, moving through a world of new information that is confusing, contradicting and often complicating to the learning I’m engaged in, the successes were brief but beneficial. Things like palpating my first prostate gland (no, it wasn’t MY prostate gland, but it was the first one my finger had successfully felt, in a clinical way!). Or actually remembering the five essential health promotion questions to ask during a clinical breast exam (ask the questions when you’re palpating her breasts and she doesn’t have the concentration to lie about whether she wears seat-belts in the car of has guns in her house!).
Hopefully, I will be able to catalogue them among my “great moments of the past” and resurrect them when once again I find my present full of dismal realities. And it is not as though they are few or far between. They merely pale in the reality that the summer has been full of stress, clutter, delayed gratification, disappointments, settling for less, tolerating, putting-up with, doing-over and doing without.
There are two weeks between the end of this semester and the start of the next (yep, two weeks!) and I intend to “savor the moment” on each and every one of those 14 days that separate the summer from the fall in terms of the school calendar. I can’t possibly make up for all the deficits of the last 10 weeks but I can reach deeply into the fleeting pleasures of summer and drink up all I can in this end-of-the-season binge of relief. What will I binge on? Simple things to be sure. . .
- I want to clean my house, and finally put a load of laundry away, rather than just scattering it onto the guest-room bed so I can wear it again the following week.
- I want to invite friends over for a pot-luck and show off that great grill we bought at the end of last year’s season and have only had a few chances to use this year.
- I want to actually visit the gym near my house where I purchased a membership but rarely go because even though it is a 24/7 work-out place, I am only an 18/7 kind of person who needs at least 6 hours for sleeping on a regular basis to avoid automobile accidents. So, my presence ant the gym has been less than consistent to date.
- I want to swing a golf club (duffer that I am) and flail away at that annoying little pink sphere that seems to have a mind of it’s own as soon as it leaves the tee. Not because I’m any good at it or because the tendonitis in my shoulder is helped by the over-use I put it through just to complete nine holes. I do it because for the brief 90 minutes that I’m out there with the bugs and the sunscreen, I feel like a genuine person, with a life and maybe even a lifestyle (God forbid!).
So here I go, plunging into the sacred space between the summer and the fall, the moments I intend to savor over the next two weeks that will permit me to feel human again. And I will remind myself over and over again that there is a purpose for all that I have chosen to put myself through; there is a higher calling, a bright future, a light at the end of the tunnel that (hopefully) isn’t a train! Because fall will be upon me in a heartbeat and there will be new textbooks to buy (and read) new papers to write, new concepts to grasp and new relationships to forge.
But I can do this. I know I can. I have managed my way through so much “stuff” that surely I will have the strength to endure so that I can look back on all of this “schooling” and find amidst it a host of “wonderful memories” to place in my mental scrapbook of great moments of the past. And, remembering them, I will sigh and say, thankfully, “this too, has past!”
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