Monday, November 25, 2019

Thank You God for Creation

Silver fern koru

This week the focus is on spiritual health.

Several years ago I accepted a call to serve in  a parish in New Zealand. I love the prayer book used in that part of the world, and some of my fondest memories are from our family's time in that country.

As we approach Thanksgiving week, I share with you a beautiful prayer  that offers thanksgiving for creation (for churchy types it is a form of the Prayers of the People) that is part of the Eucharistic (Communion) service in New Zealand:

Caring God,
we thank you for your gifts in creation:
for our world,
the heavens tell of your glory;
for our land, its beauty and its resources,
for the rich heritage we enjoy.
We pray:
for those who make decisions about the resources of the earth,
that we may use your gifts responsibly;
for those who work on the land and sea, in city and in industry,
that all may enjoy the fruits of their labours
and marvel at your creation;
for artists, scientists and visionaries,
that through their work we may see creation afresh.
We thank you for giving us life;
for all who enrich our experience.
We pray:
for all who are deprived of fulness of life,
for prisoners, refugees, and those who are sick;
for those in politics, medical science, social and relief work,
and for your Church,
for all who seek to bring life to others. We thank you that you have called us to celebrate your creation.
Give us reverence for life in your world.
We thank you for your redeeming love;
may your word and sacrament
strengthen us to love as you love us.
God, Creator, bring us new life.
Jesus, Redeemer, renew us.

Holy Spirit, strengthen and guide us.
God of peace,
let us your people know,
that at the heart of turbulence
there is an inner calm that comes
from faith in you.
Keep us from being content with things as they are,
that from this central peace
there may come a creative compassion,
a thirst for justice,
and a willingness to give of ourselves
in the spirit of Christ.
Happy Thanksgivings friends!

Sunday, November 17, 2019

Medical capacity--what's that?!?

 Image result for dialysis

This week the focus is on physical and mental health.

A 78 year old woman with end stage renal disease is seen in the emergency department after calling 911 due to abdominal pain. She is confused (thinks the year is 1974 and that she is in a medical center in another state) and admits she has missed several dialysis appointments. She refuses a nephrology consult and proposed dialysis, and states she is going to leave against medical advice with plans to take the bus to go home and die because she’s sick of living with kidney disease. Temperatures are below 25 degrees F outside. No family are listed as emergency contacts. A psychiatry consult is placed to determine capacity.

Having a loved one whose ability to make decisions is in question can be very difficult. It may happen suddenly due to a temporary medical condition, such as having low blood levels of sodium or a urinary tract infection. Or maybe that person doesn’t want to start life-prolonging medical treatments, and loved ones disagree with this decision. Or maybe the person is suffering from an acute episode of a mental  health disorder and is refusing treatment for another medical issue due to psychotic beliefs.

Part of working in consult and liaison psychiatry involves responding to consult requests to determine capacity in the hospital setting, such as the one described in the opening vignette. I find that people (patients, families, and even other physicians) are often confused about capacity.

So first some definitions. First, it’s common for people to not understand the difference between capacity and competence. Capacity is a person’s ability to understand the nature and effect of their actions (more on that later in this post). Physicians can determine capacity. Conversely, competency is a legal finding. Competency is determined by the courts and involves determinations about a person’s ability to make decisions about their personal safety, provide for their necessities, and/or to make decisions about their financial affairs. If a person is found incompetent, a conservator or guardian is appointed by the courts. (States differ in the terms they use as well as the specific meanings and consequences and subdivisions of these terms).

So what does a capacity assessment involve? There are four general areas. First is a patient’s ability to understand  the treatment and the proposed options for care. Questions in this area would include ones about the person’s understanding about their condition and what the treatment options are. It’s important to assess if the person knows what the risks and benefits are, and what will happen if nothing is done.

The second area of a capacity evaluation involves questions about how the information applies to the person’s own situation. Questions might include what the person really believes about their medical condition, why the doctor recommended that particular treatment, and which treatment the person thinks is best for them and why.

The third area to assess is the person’s reasoning ability with the information given and how they support it with the facts and statements about their own values. The physician may ask about what factors are most important in making the treatment decision, how the person is balancing the pluses and minuses of particular treatments, and if they trust their doctor.

Lastly, the patient must be able to communicate and express their choice.

(There are formal assessment tools available—one is the Aid To Capacity Evaluation or ACE).

So returning to the opening vignette, what would you do if you were the consulting psychiatrist? 

While it is certainly a person’s right to decide to make the decision to stop life prologning treatment such as dialysis, I would argue that this patient did not have capacity to make that decision at that time. She was confused due to electrolyte imbalances brought on by missing dialysis. While she could understand her treatment options and communicate her choice, her altered mental status likely affected her ability to fully understand her particular situation as well as her ability to apply her values and the given facts in making her decision. Furthermore, to allow the patient to leave against medical advice with severely altered mental status in freezing conditions would have likely led to her death due to hypothermia as it was doubtful she could make her way home safely given her condition at the time. Keeping the patient in the hospital against her will until her mental status cleared would allow her to then make the choice about continued dialysis with a clear head (and full capacity).

What would you have done?

(The AAFP article “Can the Patient Decide? Evaluating Patient Capacity in Practice" was used as a resource in preparing this post).

Sunday, November 10, 2019

Veteran's Day and PTSD

This week the focus is on mental health.

Happy Veteran’s Day and thank you to all who are now  serving or have ever served our country. I’m remembering my father who was  Commander in  the US Navy and worked in Intelligence. He’s in the above photo at the top left (the bald guy). 

In my current work I have the honor of working with veterans. In Cincinnati I worked at the VA in psychiatry as an outpatient psychiatry resident, and in Reno I cover inpatient service for vets hospitalized for mental health reasons.

The suicide statistics for veterans are deeply troubling. While studies over the past years have differed somewhat in what was reported, since 2008 there have been at least 6000 veterans every year who have taken their own life. That means that on average over 16 veterans, people who loyally served our country, take their life every day. (See for the full report).

In my own work I’ve seen PTSD as a contributor to the suicidal thoughts and other mental health difficulties that vets and many other people who have been through traumatic events experience. So on this Veteran’s day, in addition to giving thanks for service and sacrifice, here is a checklist of 20 problems that people can have in response to stressful experiences (from Cognitive Processing Therapy for PTSD by Resick et al). As you look over the list think about how often you have been experienced the following in the past month:
  1. Repeated, disturbing and unwanted memories of the stressful experience
  2. Repeated, disturbing dreams of the stressful experience.
  3. Suddenly feeling or acting as if the stressful experience were actually happening again.
  4. Feeling very upset when something reminded you of the stressful experience.
  5. Having strong physical reactions when something remined you of the stressful experience.
  6. Avoiding memories, thoughts, or feelings related to the stressful experience.
  7. Avoiding external reminders of the stressful experience.
  8. Trouble remembering important parts of the stressful experience.
  9. Having strong negative beliefs about yourself, other people, or the world.
  10. Blaming yourself or someone else for the stressful experience or what happened after it.
  11. Having strong negative feelings such as fear, horror, anger, guilt or shame.
  12. Loss of interest in activities that you used to enjoy.
  13. Feeling distant or cut off from other people.
  14. Trouble experiencing positive feelings.
  15. Irritable behavior, angry outbursts, or acting aggressively.
  16. Taking too many risks or doing things that could cause you harm.
  17. Being “superalert” or watchful or on guard.
  18. Feeling jumpy or easily startled.
  19. Having difficulty concentrating.
  20. Trouble falling or staying asleep.

If you have lived through a stressful experience and found yourself answering yes to the above questions, you may be living with PTSD. There are good options available for treatment, and I’d encourage you to reach out to a mental health professional or ask your primary care doctor for a referral to someone who can help. That trauma doesn't need to overshadow your life or continue to have a negative impact. 

If you are experiencing suicidal thoughts or urges,  call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). There is also a Crisis Text Line: Text HOME to 741741. For crisis support in Spanish, call 1-888-628-9454.

Sunday, November 3, 2019

Healthy Sleep

Image result for sleeping dog

    This week's focus is on  physical (and mental) health. 

    I’m writing this post while working an overnight shift on inpatient psychiatry. Sleep (or lack there of) is on my mind.

    One of the most frequent complaints I hear in my outpatient practice is that people have a hard time sleeping. It’s also a common late-night call from nurses concerned about their patient’s inability to sleep. Good sleep is important for everyone, and it’s especially important for optimizing both our physical AND mental health. So what can we do to sleep better?

    Good sleep hygiene is the first step. What is sleep hygiene? It’s those practices that can help us to sleep well. The National Sleep Foundation lists eight practices that can help us achieve good quality sleep—I’ve added some additional information from my rotations with a sleep specialist. There is much more information on all of these 8 areas, but here is a brief summary:

    1. Be in your bed and sleep the right amount—not too little and not too much (reminds me of Goldilocks and the Three Bears). Beds should only be used for sleep and sex—nothing else. Setting regular bedtimes and regular times to get up can also help.

    2. Limit day time naps to no more than 30 minutes. 

    3. Avoid caffeine and nicotine close to bedtime, and use alcohol only in moderation. While alcohol can make you fall asleep faster, it interferes with your sleep later in the night. 

    4. Exercise every day—even as little as 10 minutes of aerobic exercise helps. However, some people have a hard time sleeping if they have a strenuous work out close to bed time so if you fall into that category it is best to exercise earlier in the day. 

    5. Avoid foods that give you heartburn/indigestion before sleep. For me drinking a sparkling water right before bed results in waking up with painful heartburn a few hours later. Other people are bothered by spicy foods.  You probably know your own offenders so it’s best to avoid them.

    6. Make sure you get some sunlight every day, and keep your room dark at night. This can strengthen your sleep wake cycle which can improve the overall quality.

    7.      Establish a calming bedtime routine. A bath, lavender or other calming scents in an infuser, reading or whatever works for you. Make your own rutine and que your body into knowing it is time to turn off the day and restore itself.

    8.      Set up a sleep environment that’s pleasant for you. Comfortable bedding, cool temperatures, limited lighting (including screens—you can even set your iPhone to dim to a “Night Shift” setting which changes the screen to warmer color to help you sleep better), noise machines, anything that works for you. I have black out curtains in my new home and my sleep has improved dramatically.

    But what happens if you try all of the above and still have difficulty? I recently attended a lecture on CBT-I. I’d never even heard of it. It’s a type of cognitive behavioral therapy specifically for people with insomnia and it reportedly works extremely well and fairly quickly. I’d love to hear from anyone who’s had success with it because the data presented with the lecture was encouraging.

    Another option is to try melatonin which is sold over the counter. Melatonin is the hormone that our pineal glands produce that regulates our sleep wake cycle. It can help reset the body’s clock (such as when you are working night shifts or traveling across time zones). For some people it can also improve sleep. For a natural remedy that has few side effects trying approx. 3mg-6mg can be very helpful for some people. There is even a new time-release form available by prescription called Rozerem. (Stay tuned for a future post on melatonin as it is one of my most commonly prescribed medications).

    And, if sleep is still elusive it is time to see your doctor. There could be an underlying medical problem interfering with your sleep, or other issues such as an undiagnosed depressive or anxiety disorder. Prescription medications could also be indicated, although in my practice they are never the starting point.

    Now time for some ZZZZZZs.