Monday, December 15, 2014

Health Canada warns surgery using a morcellator could spread undetected cancer

They do 100,000 of these in the US each year.
Why, if your womb is filled with tumours, would they not simply remove it? Using this machine, spreads the cancerous cells all around the abdomen.

In hindsight, this is likely what I had back in 1994 or so. I had laproscopic, minimally invasive surgery, and was fine in a few days, but I did not have tumours or fibroids.
  • Laparoscopic hysterectomy. In this procedure, the physician will use specialized tools which are inserted through fingernail-size incisions in the abdomen. This approach may result in a much faster recovery, typically with much less pain than a traditional hysterectomy. Laparoscopic hysterectomy may also result in less scarring inside the abdomen and pelvis. Advanced laparoscopic skills are required to perform a laparoscopic hysterectomy and all of our team members are trained and experienced in this procedure. Laparoscopic hysterectomy can be performed in conjunction with other pelvic floor surgeries for uterine prolapse and incontinence, such as a laparoscopic sacrocolpopexies or rectopexies for faster recuperation. Another benefit of a laparoscopic hysterectomy is that it allows your surgeon to evaluate your abdomen for scar tissue from previous surgeries, determine if there are physiological reasons for chronic pelvic pain and determine if you have any ovarian cysts that need to be drained, all of which can may prevent a second procedure in the future.

WWW.CBC.CA
Not long ago, only surgeons and their patients would have heard of a morcellator. But now lawyers have become involved

Why do 70% of patients with chronic disease die in hospital?


It could be the best place for them.
It could be that caregivers cannot cope elsewhere.

According to Statistics Canada (2011)

  • hospital deaths account for 64.7% of patients
  • In Ontario 59.3% died in hospitals. 
A 2005 Ontario study of 214 home care recipients and their caregivers

  • showed 63% of patients and 88% of caregivers preferred a home death. 
  • 32% of patients and 23% of caregivers reported no preference for place of death.
We have a new study out by Health Quality Ontario. It tells us that only 30% of people with chronic diseases die receiving hospice or palliative care. They fearmonger, citing a desperate need for hospice beds. I totally disagree. Many of my clients are as determined to die at home as they can and eschew a hospice bed. Many of my clients are receiving care, it simply isn't labelled 'hospice' or palliati

ve care. Many go off on meds, and refuse treatment, despite angry family members.
This study showed that palliative care beds in hospitals cost between $630 and $770 per day.
Acute care beds cost more than $1,100 per day. We should blame doctors when patients with chronic diseases end up in acute care beds. Something has gone wrong there.

Almost all of my clients are getting excellent care at home, even if it isn't enough professional care.  For many of my clients, they do the work with their Charge Nurse to determine their needs, assess symptom management, devising a care plan. The province bemoans the fact that we only have 271 hospice beds in Ontario, yet Ontarians are unprepared to pay for more. We must make better use of home care staff to make strategies that work.

Determinants of Place of Death

  • EOL care in the place of residence 
  • time between referral to EOL care services and death 
  • type of underlying disease 
  • frequency of hospitalizations during the last year of life 
  • presence of an informal caregiver 
  • patient or family preference for place of death 
  • existence of advance directives 
  • nursing home and hospital bed availability 
  • the patient’s physical and psychological needs in the place of residence during the EOL period

Not all of my clients have been told, honestly, by their physicians about their life expectancy. 

This is why many end up in an ER, in a period when they are unable to access their Primary Healthcare Team. Where does it go wrong? when families reach a crisis and they find, in the dead of night, that unmanaged pain is an issues, or a new symptom appears, something happens for which they are unprepared. This means they then end up in hospital. That's the sum total of it all.

Many of my clients have excellent pain control. 

They have a pain kit in the home, ready just in case. Their Charge Nurse has explained what they can expect. She outlines the options for them: staying at home, or going to hospital, and/or finding a hospice room. She helps them with a Do Not Resuscitate order, if that is the family's wishes. She responds to the family, not just the patient, and ensures that the caregiver can manage the situation. There is nothing wrong with dying in a hospital, if that is the right placement. All factors must be taken into account. Many know what to expect in terms of their disease trajectory.

What I find often happens is that the family panics, and, with no other options, they must go into the ER to find treatments for symptoms, such as oxygen or a morphine pump (CADD) or morphine patch, when the patient is no longer able to take pills. This takes education, research, family counselling by the Charge Nurse, and families could even use a health coach or advocate.

My late mother's case demonstrates quite well where things go wrong and why so many die in an ER. My brother, the caregiver that night, panicked as they didn't have an idea of what to do for mom, and he took her into the ER. She spent hours there, and then they sent her home. She arrived home in the wee hours and died at 9:00 in the morning.

What do we need to do for families?

  • Education for all stakeholders
    Stakeholders in healthcare
  • Better trained professionals who are HONEST with families
  • make the individual stakeholders work better with the resources on hand.
  • Palliative Nurse Practitioners who will make house calls (since doctors don't seem able)
  • Better tax relief and financial support for those who choose to be caregivers
  • Trained doulas, or death coaches, who will be advocates for families if nurses are unavailable
  • Consistent funding for hospice volunteer programs and day hospice groups
  • Better, more honest discussions as end-of-life approaches
What I don't think we need are people like those in the media who fearmonger about Baby Boomers and needing beds. Since 63% of patients want a home death, ensure that the above needs are met. We are living longer and better. These doom and gloom predictions simply fearmonger.

hqontario.ca
End-of-Life Health Care in Ontario

"In July 2013, the Evidence Development and Standards (EDS) branch of Health Quality Ontario (HQO) began work on developing an evidentiary framework for end of life care. The focus was on adults with advanced disease who are not expected to recover from their condition. "

About Health Quality Ontario

Health Quality Ontario is an arms-length agency of the Ontario government. It is a partner and leader in transforming Ontario’s health care system so that it can deliver a better experience of care, better outcomes for Ontarians, and better value for money.
Shirlee Sharkey, co-chair of HQO’s end-of-life expert panel, said these issues are becoming starker as baby boomers get older. By 2036, the number of Ontarians over 65 is expect to double to 4 million, representing roughly one quarter of the population, according to the attorney general.

Thursday, December 4, 2014

BOOK REVIEW: Dementia Beyond Disease

By Dr. G. Allen Power
Dementia Care has changed and is evolving. Unfortunately, we still follow the medical model, treating symptoms, rather than modifying our approach as those with dementia symptoms' abilities change. This author has proposed some thoughtful changed to the ways we manage the care of patients with these symptoms.

This is an excellent book. Groundbreaking ideas.

His previous book, Dementia Beyond Drugspaved the way for an enlightened way to manage treatment and care plans. Unfortunately, physicians tend to be slow to change. Drug-based interventions are failing, as family members refuse to institutionalize a loved one with dementia symptoms, and drug them into submission. Family member must be proactive, accompany loved ones, take notes, and visit long-term care (LTC) homes regularly on an irregular basis. Doctors who work for LTC are more concerned with efficiency, rather than individualized care plans, in my experiences. Widely accepted practices are being questioned by caregivers, family members, institutions (even the for-profits), and administrators. It is uneven, at best, however.

Non-pharmacological interventions

Our deficit based view of dementia has come to characterize people in terms of what they cannot do. Strategies fail to take into account their strengths, rather than harping on and bemoaning their weaknesses. This is a lesson I learned working with special needs students. Power cites a 'living death' for those in LTC, about 30 - 35% with dementia diagnoses receive antipsychotics. Devonand, et al, 2012, says drugs like risperidone are contraindicated. In fact, in my research this is something my late father was given, despite references to it having side effects for those with dementia. In my experience, nurses would phone the doctors, as for a drug, and it would be prescribed. Case closed.

Power sees a new approach to treatment plans that see the patient as one with changing abilities, rather than a fatal disease. The biomedical view has blinded us to the joys of caring for those with dementia. The Changing Melody Conference, in Toronto is a shining beacon. It resulted in A Changing Melody Toolkit, through University of Waterloo's MAREP.

Well-being

There are seven domains of well-being cited by Power: identity, growth, autonomy, security, connectedness, meaning, and joy. What many housing conditions lack is a sense of personal worth, a sense of agency, social confidence, or hope. At least, these are the ones that make the news.

The cult of clock time, and tasks that drives most nursing home operations, is the long-term-care residence which revolves around clock time. A returned to the sanctity of lived time would be beneficial to remove some of the distress we see in long-term care. Sundowners syndrome also would be relaxed.

Sunrise or sunset - what are your rituals?
 Appearance, loss of self, and loss of the ability to recognize others, reflect a common view of people living with Alzheimer's. Sundowning often impacts people with unique and changing biorhythms been forced into an institutional schedule, causing their psyches to rebel. Sunset causes old patterns of activity, such as the end of the day after work, or past leisure activities, and could be thought to be caused by the commotion of people saying goodbye change of shift, for example. I think it is deeper than this, however. Circadian rhythms, and light levels, for example.

The first step in enhancing identity is to reject a narrow, biomedical view of dementia and the stigma and shame that results. We have to have a new normal. Fazio, 2008,  summarizes this in The
Enduring Self. The past must be allowed to influence the present, yet not to define it. One of my pet peeves is failing to ask a person prefers to be addressed in long term care, for example. Some people with dementia who have been called Dr. Davis all their lives, are fazed by perky little personal support workers (PSWs) waltzing into their rooms and calling them 'Dan.'
I was shocked to hear them call my father 'Ray!'

The Power of Language

Rather than calling them a patient, they are residents living with dementia not than suffering from dementia, or worse, a victim of dementia. Behaviour problems, being difficult, being bad, acting out, or wandering. Many terms such as a paranoid delusional are improperly applied based on all or one single observation. As with a diagnosis of cancer, we must refrain from the battle language and the negative stereotypes: 'fighting cancer.' We must use person-centred language in healthcare (for a few more examples).

Connectedness

Example of this concept of connectedness, include letting people decline certain activities in an activities group.  Being connected to someone with dementia is to respect their mistakes, such as refraining from correcting a person who misstates names, and does not remember a date or an event.

Continuity of Care

Continuity of care is important for us. We know how much we depend upon a hairdresser or dentist for our comfort levels. Substitute caregivers in LTC can make a resident insecure, and that we know that security arises from familiarity. Looking at positive care outcomes such as: reduced physical restraint use, urinary catheter use, proper pain management, and pressure ulcers. There is a significant improvement in homes that use dedicated staff assignments at a level 80% or more.

Respect

It is important to make a connection with a loved one in their present reality. Don't ask me, tell me about a name or date. Don't quiz me and test me. That way I don't feel pressured to find the right answer.
One of my pet peeves I spotted when visiting a friend of mine. She was in a private room and she kept the door closed most of the time. Personal support workers would barge in without knocking, and would see the space as being institutional, rather than as belonging to Kay, and it being her actual living room. Too common, also, are loud sources of noise from repair staff, or busy care staff in halls, alarms, announcements, and bells being rung. I think of those days I'd be at work on a PD day and the bells ring every 40 minutes come hell or high water. It's irritating.

Security

Keeping loved ones feeling safe is something that must be done with dignity and respect. This is true for all of our loved ones, young or old, fragile or frail, near or far. Power tells a story about a man forbidden to go out the back door of an institution, all he wanted was to go out and see the flowers in the garden. Once they allowed that, he would safely go out and come back on his own. It's also about respect. I read, with horror, a Tweet that tells adult children to senior-proof their parent's bathrooms.
How undignified is this? A pet peeve of mine, is professionals posting articles on 'How to keep your parent from falling' or, "When to move your parent into LTC." If a loved one with dementia wants to do certain things, facilitate them as much as you can. Sure there are risks, but we are talking about quality of life here.
Another point Power makes – when someone tells you they are afraid of a perceived issue, or person, or place, tell them:

"This sounds really scary. I will keep you safe,"

The Lexicon of medical care

Another issues he touches on is the language we use. We don't use terms like retard or mongolism anymore. We've come to see that such terms are offensive. The DSM fifth edition has proposed dropping the word Dementia from the lexicon, in favour of minor of Major Neurocognitive Disorders. This is an excellent point. The person in not their disease. IT's better to refer to the condition not the illness or the disease, because this way the latter reinforces reductionistic thinking.
Preserving modesty, doing personal care and avoiding potentially disparaging comments, or any comments in public areas, will enhance privacy and dignity.

My client' wife told me today she hasn't painted since she got 'stupid.' It suggested to her that she is not stupid. Her brain in changing the way it thinks and it is thinking differently. People with dementia symptoms think, just in a different way that others. We have to suspend judgement and change the way we think about them and their abilities. We have to accept that their lives have value, their thoughts have value, and while we may not understand them, this is simply the way they are now.
  • Sometimes it helps to simply ask someone 'WHY?' 
  • Sometimes we must move beyond logic into the symbolism of their words.
  • Sometimes we must move beyond labels, hallucinations and delusions, and live in their world. 
  • Sometimes their changing perceptions may be like that phantom pain people with amputations experience. It hurts to not know.

Privacy

Another area which could be improved is to remove double room situations, whereby people must share a bathroom. This limits privacy and gives them lack of security. We know from sleep studies that sharing a room can be detrimental to the mental and emotional well-being of a resident.

Dependence and waiting eventually become synonymous the dilemmas of dependency, as posed by Lustbader in Counting on Kindness. Sitting, waiting for help and care, is emotionally degrading.
Our medicalised view of the person causes us to see an expression of anger or sorrow is the emotional lability of a damaged brain, especially in nursing homes. We have an expectation that all must be tranquil, and we confuse the absence of emotional upset with well-being.

What would be beneficial for long-term-care care operators is to sit in a wheelchair and examine what it's like to move around the home.
Involving all stakeholders in negotiating risk involves several steps.
  1. discussion 
  2. exploration of values 
  3. conditions of empowerment 
  4. continue another empowerment 
  5. club decision 
  6. monitoring results 
  7. keeping stakeholders abreast of the process.
This will be the same as action research in education. Try it, test it, improve it!

Rituals

This is an important aspect of care. We've always had important rituals around bed time, bath time, morning routines, evening routines. It's important to honour this part of our lives. This holds true for ceremonies, and special calendar days. In my experience, many LTC do much around these days like Mother's Day and other holidays. It is important to remember this at home, as well.

Now that we are living longer, and have better quality lives, we must remember to enjoy our leisure years. Here are questions caregivers can pose:

  1. What do you enjoy?
  2. What about that do you enjoy?
  3. Recently, what has brought enjoyment and happiness to your life?
  4. What is stopping you from enjoying any of these activities?
  5. How can we modify this for you?
  6. Is there something else you've wanted to do?
One thing Power suggests is the importance of volunteering. Many seniors around my area do so. It is possible that, with support, someone may be aided in volunteering in many places.
There are many ways to help make connections in their world: gardening, pets, being with people, young and old. There is a privilege and profound experience, a reward in caring for a loved one with dementia symptoms. Their lives can be meaningful, even if we cannot value achievement my monetary rewards, checking off tasks from a bucket list. We must build our lives around the number of times each day we laugh, or give thanks for the day we've had.
"Opening our eyes to the potential for growth begins by rejecting the view of dementia as one of pure decline."
We must enhance the daily joys we experience. Find simple pleasures in achievable or manageable goals. Faith spirituality, essence, this makes a human being. 

Other great resources

Holistic approaches are increasing in the better LTC and home care plans. Caregivers need much support. Here is an excellent webinar:

 The Experience of Spousal Caregivers of People with Early-Onset Dementia.

The solutions, treatment strategies and approaches Dr. Power offers can be utilized in any living environment.
Dr. Power's previous book Dementia Beyond Drugs
www.IN2L.com creates video care plans. resources to bring a sense of identity into a care plan.

Flu season arrives in Ottawa: 5 confirmed cases

Flu season arrives in Ottawa with 5 confirmed cases so far

Vaccine may not be as effective fighting H3N2 strain this year, expert says


Ottawa Public Health says there will be more as the virus spreads.
  • Immunizations at Ottawa's 19 community clinics are down from last year
  • about 8,700 people vaccinated in 2014/5 season (compared to about 11,100 people in 2013)
  • Hoping to vaccinate 57 % of adults, the same as 2013/4
  • Ottawa distributed nearly 370,000 doses of flu vaccine to physicians’ offices, than 170 pharmacies, hospitals and long-term care facilities.
  • In 2013/4 100+ people were hospitalized with lab-diagnosed cases of the flu
  • 15 people died from it, with the most deaths among seniors.

University of Ottawa experts says the H3N2 flu strain in this year's shot may have mutated since the vaccine was manufactured, meaning the vaccine might not be as effective. There are three strains of the virus in the vaccine.
It is spreading across Canada. Week 47, end of November.

Radiation treatment for prostate cancer




Tuesday, December 2, 2014

Ottawa Hospital nurses making a new kind of house call

Such simple ideas seem too simple. Yet, every time we take our pets to the vet for a serious issue, they call us later.

Imagine how amazing it would be to ask a few questions, and get a few answers without feeling guilty about phoning or making an appointment, or going into the ER!

Studies have shown that about one-quarter of discharged patients suffer some kind of adverse event, such as a drug reaction or infection, soon after leaving hospital.

Ottawa Hospital nurses making a new kind of house call
You could be wrestling with all this stuff.
A simple call could dispel fears

The Ottawa Hospital has launched a pilot project to improve patient care and reduce the number of people who return to hospital soon after an operation. Its low-tech approach? Have nurses call patients once they return home to make sure everything is OK.

On Giving Tuesday: lend a hand

My mail box was full of requests for money on this, Giving Tuesday, but we give our time all the time, as well as our money. I donate monthly to our local Food Bank, through CanadaHelps.org.

My husband dispatches Meals on Wheels at least weekly.

I had the opportunity to volunteer at Dignity House Day Hospice this week. They were short a volunteer. We created some lovely door swags for Christmas.

There was a volunteer Complimentary Therapist, a massage therapist. Lunch was donated by our mother-corp, Community Support Lanark County.


The big news is that Dignity House Day Hospice has been taken in, under the umbrella of Community Support Lanark County. CSLC is a transfer payment agency, but we rely on donations from the community, as well as over a hundred volunteers. We opened Jan. 2011, and have now anticipatied a move. After renting in McMartin House, we will now be able to have our own space at the CHSLC offices. On January 8th, we will be opening in the new location at 40 Sunset in Perth, ON.

Finally, we will be using the kitchen, formerly a cafe, where volunteers prepare lunches,  community dinners and meals for clients and friends.

Sunday, November 30, 2014

Webinar: The Experience of Spousal Caregivers of People with Early-Onset Dementia

These are excellent webinars!


11/6/2014 
Two variants in fronto-temporal dementia:

1) Behavioural FTD variant: belligerent, changes in personality and social conduct. Social, sexual, aggression are possible. It can be embarrassing for caregivers. Disinhibitions can manifest, as well as the literacy issue. There is a lack of inhibition, and clients can steal while out shopping, which results in caregivers having to talk their way out of trouble. Having to manage bodily functions, on the part of the caregiver, such as changing adult incontinence products for a spouse.

2) Language Presentation: Literacy issues; language influency, deterioration of grammar, nonsensical sentences, semantic and logopenic aphasia. It can be both oral and written language, literacy issues. My late father, who had a brain tumour in the language area, had these symptoms. He could no longer draw up nouns, then he lost the ability to read.

The Experience of Spousal Caregivers of People with Early-Onset Dementia

Shnall also covers coping strategies and stages of caregiving. The impact of EOD is terrible on people with young families. In some cases schools refer the family to CAS, without support for the caregiver. People do not question someone who is rude, in power, still driving, demonstrating social disinhibitions. Family physicians fail to diagnose EOD in some cases and blame family dynamics or a spouse for behavioural aggression, yelling, confrontations.

One risk of EOD is unmanaged pain. My father denied his pain all the time. They ask a patient if they are in pain, and they deny and do not understand the concept. Governments may refuse to grant a disability claim, since EOD is not 'fatal.' This provides tax relief.

Extended families are typically unsupportive, as they do not understand, or fear dementia symptoms. Some can be in denial, some fear their own mortality. Caregivers succumb to depression in such cases. Financial obligations can compound the issues, if it is the patient or caregiver must give up earning a living, and the patient requires long-term care.
Adriana Shnall, PhD, RSW

What helps?

  1. Short-term planning
  2. Advocacy
  3. Reframing
  4. Self-care
  5. Spirituality or religion.

Implications for support workers



Thursday, November 20, 2014

Caring for the caregivers

Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomised, controlled trial


Summary

Background

Two-thirds of people with dementia live at home supported mainly by family carers. These carers frequently develop clinical depression or anxiety, which predicts care breakdown. We aimed to assess the clinical effectiveness (long-term reduction of depression and anxiety symptoms in family carers) and cost-effectiveness of a psychological intervention called START (STrAtegies for RelaTives).

Methods

We did a randomised, parallel-group trial with masked outcome assessments in three UK mental-health services and one neurological-outpatient dementia service. We included self-identified family carers of people with dementia who had been referred in the previous year and gave support at least once per week to the person with dementia. We randomly assigned these carers, via an online computer-generated randomisation system from an independent clinical trials unit, to either START, an 8-session, manual-based coping intervention delivered by supervised psychology graduates, or treatment as usual (TAU). The primary long-term outcomes were affective symptoms (Hospital Anxiety and Depression Scale total score [HADS-T]) 2 years after randomisation and cost-effectiveness (health and social care perspectives) over 24 months. Analysis was by intention to treat, excluding carers with data missing at both 12 and 24 months. This trial is registered ISCTRN70017938.

Findings

From November 4, 2009, to June 8, 2011, we recruited 260 carers. 173 carers were randomly assigned to START and 87 to TAU. Of these 260 participants, 209 (80%) were included in the clinical efficacy analysis (140 START, 69 TAU). At 24 months, compared with TAU the START group was significantly better for HADS-T (mean difference −2·58 points, 95% CI −4·26 to −0·90; p=0·003). The intervention is cost effective for both carers and patients (67% probability of cost-effectiveness at the £20 000 per QALY willingness-to-pay threshold, and 70% at the £30 000 threshold).

Tuesday, November 18, 2014

Medicinal marijuana for PTSD study

SMITHS FALLS, ONNov. 19, 2014 /CNW/ - Tweed Marijuana Inc. ("Tweed" or "the Company") is pleased to announce that its wholly owned subsidiary Tweed Inc. has successfully renewed its license to cultivate and sell marijuana under the Marihuana for Medical Purposes Regulations (MMPR).

Despite the fact that the Canadian Medical Association physicians don't tend to like the use of medical marihuana (MM), many people say that they find it works for them. Despite the fact that Health Canada granted permission for Canadians to access marijuana for medical purposes, doctors seem to fear it. They don't know how much, or when or why to prescribe it to patients.

Tweed Inc.
Thankfully, private businesses, like Tweed, have budtenders who are familiar with the variety or strains and how people with various health issues will benefits from specific applications.

They provide MM for chronic pain, muscle spasms, seizures, nausea and loss of appetite. They recommend ingesting it by vaporizing.
"Vaporizing is an effective alternative to smoking which provides the same therapeutic effect without exposure to irritant compounds resulting from the burning of plant matter."

EVIDENCE

McPartland, J. M., & Russo, E. B. (2001). Cannabis and cannabis extracts: greater than the sum of their parts?. Journal of Cannabis Therapeutics, 1(3-4), 103-132.
Vaporizer
Hazekamp, A., Ruhaak, R., Zuurman, L., van Gerven, J., & Verpoorte, R. (2006). Evaluation of a vaporizing device (Volcano®) for the pulmonary administration of tetrahydrocannabinol. Journal of pharmaceutical sciences,95(6), 1308-1317.

Abrams, D. I., Vizoso, H. P., Shade, S. B., Jay, C., Kelly, M. E., & Benowitz, N. L. (2007). 
Vaporization as a smokeless cannabis delivery system: a pilot study. Clinical Pharmacology & Therapeutics, 82(5), 572-578.

Medicinal marijuana grower and UBC hope to test pot as PTSD treatment 

No more do patients have to walk the streets
to find medical marijuana.

WENCY LEUNG

After developing post-traumatic stress disorder during his second deployment in Afghanistan in 2007, Canadian army veteran Fabian Henry tried numerous anti-depressants to quell his suicidal thoughts and violent rages. For three years, he was on as many as nine pills a day. But only one drug worked for him: marijuana.