Let's talk about death, baby

Let's talk about death, baby.

"After all, what’s a life, anyway? We’re born, we live a little while, we die."

Let's talk about you and me.
Let's talk about all the good things and the bad things that may be.
Let's talk abooooouut death.
Let's talk about death.

Tune stuck in your head yet?

Sorry, mine too.

On a recent NPR podcast from Planet Money, the reporter said something akin to, "Death is kind of like sex-- not exactly something a teenage daughter wants to talk about, especially sitting on the couch with her parents after dinner on a random Wednesday evening."

So true.

Ever since I heard this amazing report about a whole town that got their death wishes in order, I have been singing this song (yes, in a never-ending loop that you too are singing), hoping that, when the time comes, I'll feel comfortable enough to sit on the couch with my son to discuss sex, and pondering my own personal ambivalence regarding death.

My death, my family members' deaths, my patients' deaths. Heck, even my dog's death. 

This got me thinking. Death is happening all the time (just like sex).
Death is inevitable (sorry, mom and dad, just like sex).
And death is unbelievably hard to talk about (no argument here).

But why? 

My answer is pretty basic-- just like sex (ahem, fellow healthcare providers, another topic for another day), I don't talk about death enough. And I don't really know how to talk about it.

Give me birth control. Ear wax. Diabetes. Flu shots. Eczema. Anal itching. Vaginal discharge. Zits. Anxiety. Toe fungus. I can speak on any of these topics with ease and knowledge. I can educate, reassure, empower.

Death, however, is a different matter entirely.

Truth be told, I'm not particularly good at talking about death. Yup, you heard me correctly, I'm a physician-- a family physician, and I'm bad at death. I'm awkward, ambivalent, and surprisingly nervous. I'm too frequently under-prepared, always wishing I had better words, more polished form, and more grace. I'm also young and blessed by health, which means I can avoid death a little more actively. 

On this particular topic, I cannot help but wonder, shouldn't I be better at this?

Yes, I should.

And yet, perhaps not unlike yours, despite not talking about it much, my life is pretty full of death. Okay, so maybe I get a little more death than the average Joe, but I am certain that if you were to sit down and list your own death encounters in the last year, you would find you have quite a bit of death in your lives too. After all, death is an inevitable part of life.

Here are a few of my death memories that stand out over the last year:

• My previously-healthy father-in-law faced several tremendously close calls with death over the last ten months, including a battle with flesh-eating bacteria (unfortunately, he lost his left leg) and an autoimmune paralysis that left him on life support for many weeks and in the hospital for months. 
• An 85-year-old supremely accomplished patient of mine with horrible arthritis of the spine but a mind as sharp as a tack asked me the other day about how she might gracefully end her own life.
• My husband and I recently finished reading EB White's Charlotte's Web with my 3-year-old son. He loved the book and listened actively and patiently to the story every night over a week's time. I wasn't so sure my little guy understood Charlotte's death until he overwhelmed us both with an intense emotional response about an hour after we read the last chapter (poor, sobbing heart). Ever since then, he mentions death frequently.  And by frequently, I mean daily.
• The daughter and 24-hour caregiver of a very old, very demented man (he is my patient) told me she feels guilty about making the decision to transition him to hospice. She's worried her siblings will look down upon her. And so she won't sign the papers.
• A 69-year-old healthy cyclist made a visit to see me to talk about how to document his final wishes. He told me that none of his adult children wanted to be his surrogate decision-maker. He was wondering if I thought it strange if he chose his girlfriend instead.
• Last year, a friend's dear puppy fell severely ill over a relatively short period of time. My friend and her husband had to make the painful decision to either spend a lot of money and time dragging the pup to specialist vets hours away or euthanize her. Though they felt good about their final decision, it was terribly sad.
• My husband's 92-year-old grandfather had been failing gradually over the last year-- until, that is, he agreed to get hospice care. Since then, he started eating again and even makes it to some family functions. We thought he was dying. Turns out he wasn't-- at least not yet.

Each of these encounters presents an opportunity to tackle the topic head on: to discuss how my father-in-law might really want to die, to enrich my son's understanding of life in the context of mortality, to empower my patient to choose dignity for her father, to support the difficult decision that is euthanasia and suicide, to enrich my own skills by simply practicing having the conversation. And I am embarrassed to admit that, in too many of the examples above, I tripped and fell or just ran way.

This is hard stuff.

And so, in an attempt to work on this obvious weakness of mine, I wandered into a reflection on why death is so hard to talk about-- for ordinary humans, doctors, and even super heroes.

Death is morbid. Uh, duh, you might say. That sentence makes no sense; morbid and dead are synonyms. But that's not really true. In fact, according to the esteemed dictionary of Google, morbid actually means "characterized by or appealing to an abnormal and unhealthy interest in disturbing and unpleasant subjects." Is death actually morbid, then? Maybe only if you believe it's inevitably disturbing and unpleasant. I can think of plenty of ways to die that would be disturbing and unpleasant; drowning, for example, one of my least favorite ways to imagine my own death. Burning to death another one that comes to mind. Recent media coverage about botched lethal injections definitely seem disturbing and unpleasant. That being said, the act of dying need NOT be disturbing, particularly if the dying person is comfortable and surrounded by people he/she loves, having felt like life has been sufficiently fulfilling and that its end comes with dignity bathed in love.

Death is uncomfortable. Or is it? How many of you have actually watched a person die, and I don't mean on TV or in the movies. I mean, sat there at there and watched someone take his/her very last breaths, his/her heart beat its very last beats? I have-- at least a handful of times-- and I am here to tell you that death CAN be uncomfortable-- the most uncomfortable death I have seen was a young man dying of liver failure as a result of his alcoholism. He died extremely uncomfortably. And the memory of his gruesome death is seared into my consciousness forever. It didn't need to be that way-- we all knew he was dying-- but the system let him down, didn't prepare him to be comfortable with his own death, tended his symptoms without confronting his mortality.  I have been in beautiful, quiet, peaceful, comfortable deaths, deaths in which someone literally looked like he/she moved from a place of sleep, to a place of final rest. And breathed a sigh of relief. Death nurtured life.

Death is scary. Definitely scary. No doubt about it. I know I am not the only person on the planet who (morbidly) imagines my life ending amidst the screams of a crashing airplane, or trapped underneath a body of water, or in a beeping-tube-filled ICU hospital bed.

Death is definite. Perhaps this is where death and sex do converge. Sorry, parents, every single one of your sweet children will eventually die (and close to that same number will eventually have sex).  Henry David Thoreau wrote "Death has beauty when seen as a law. Not as an accident. It as as common as life".  Perhaps it's the certainty that it will happen to each of us that makes it the most overwhelming. Inevitability is not always a man's best friend. Particularly in the 21st Century when we feel inclined to employ amazing amounts of technology to keep people alive during their last weeks on Earth. We cannot, however, ever win. Death always wins. And that perhaps is the only truth in all of this.

Doctors are hypocritical too. Please don't misinterpret my words. I am no model. I am no expert. I, too, am scared shitless of my own death-- and don't even get me started thinking about my mom's or my son's death. I won't sleep tonight.  It is NOT easy to talk about death-- even when my graceful and brilliant 85-year-old patient, trained psyschologist says matter of factly to me, "How can I die gracefully." I, too, squirm. I hem. I haw. I WANT to be able to have as much grace and perspective as my patient, to guide her majestically into the netherworld. I think I'm generally pretty suave in uncomfortable situations-- I thrive on difficult conversations and want to be good at this. But, to be perfectly honest, I'm not. As many of my colleagues are not. For lack of training. For lack of cultural exposure. For lack of tools.

And so, I bumble along, doing my best to do my best in that moment with that patient-- be it in my office or at the bedside in the hospital.

And despite death's definiteness, we systematically avoid it, even as we sit before the oncologist facing our own mortality, even as our own parents face serious and grave illness. We act as though we will escape, we fail to fill out a living will or an advanced directive or a medical power of attorney.

Chances are, when you finish reading this, you'll do none of the above. Fine. Fine with me. But do this one thing-- for yourself. Call or email or take the person out to dinner who you think would be the BEST person in your life to make decisions if and when some complicated time come. It may be your first born or your neighbor, heck, it could even be your mailman. Sit with them, designate them, and give them some background, so if you find yourself unconscious in the hospital or ventilated in the ICU or even just sitting in front of the oncologist with a new diagnosis, you know that person will represent YOUR best wishes, be your advocate.

For death will come to all of us and it sure is nice to have some company on the way out.


Additional references:
http://deathoverdinner.org
http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?hpw&rref=health&_r=0
http://www.agingwithdignity.org/forms/5wishes.pdf
http://capolst.org/
https://www.youtube.com/watch?v=pX1csOAu1IM
http://www.npr.org/programs/death/readings/stories/ebwhite.html

C-sections gone wild?

http://drjennifermercier.com/wordpress/wp-content/uploads/2013/07/babybirthc-section.jpg

Cesarean section refers to delivery of a baby through an abdominal incision. A cesarean section (often called a "c-section") can be a life-saving surgical intervention-- for moms and babies.  Sometimes it is absolutely necessary. In fact, studies in very poor countries show that increased maternal and child mortality directly correlates with poor access to urgent cesarean section.

However, here in the US, we have the very opposite problem:  rising c-section rates are associated with increasing maternal and neonatal mortality. And no one knows just how to stop cutting.

In 1988, US cesarean rates peaked (we thought) at 24.6% of all births. That's 1 in 4 babies! By 1996, largely thanks to public policy work and change in medical culture, the rate had dropped to 19.7%. The US government's  Healthy Families 2010 goal was to get that c-section rate down even further-- to 15.5%.  At the time, this seemed an attainable and health-wise goal. 

Unfortunately, c-section rates started increasing again, and despite policy work, by 2010 we came far short of our goal; the rate was up to 26% and rising. Today, our national cesarean rate is 33.1%. In Sonoma County, our cesarean section rate for hospital births is currently 26.3%, better than the national average, but still pretty darned high.

Did you catch that? Today 1 in 3 women in the US are birthing via c-section. There is a range across states, but it's not terribly wide (Utah has the lowest c-section rate  in the country, at 22%, Kentucky and New Jersey the highest at 38%). Perhaps most telling, our government's 2020 Healthy Families goal of 23.9% seems to be moving in the wrong direction!

The main indications in this country for cesarean section are:
1) Labor isn't progressing (i.e. woman isn't dilating as quickly as we would expect, hope, or imagine)

2) Abnormal fetal heart tracing (i.e. some concern that the baby might be in distress)

3) Fetal malpresentation (this includes breech babies, as well as babies who are occiput posterior in my land sometimes called, "sunny side up")

4) Multiple gestation (twin primary c-section rates have skyrocketed from 53% in 1995 to 75% in 2008, despite the fact that a study published in a super esteemed journal in 2013 reported no improved outcomes in c-section vs. vaginal birth for twins. Huh.)

5) Suspected macrosomia (i.e. big babies)




It's hard to determine exactly what the "correct" c-section rate should be-- WHO (the World Health Organization) has long advocated a maximum c-section rate  of 15%. A 2011 study confirmed that once a cesarean section rates tops somewhere between 10-15%, the benefit for women and babies wanes.
                                                                            ***

Source: Dieva Larissa Tattoo

One thing that most of us can agree on is that 33% is too high--- risks of c-sections including wound infections, blood clots, and other post-operative complications are on the rise. Here are ways that both birth professionals and birthing women should be advocating to change the way decisions are being made regarding c-sections

1) Be more patient: just this year, ACOG (the professional organization representing obstetricians and gynecologists) released recommendations offering women MORE time, and also not labeling a woman as being "in active labor" until she is 6cm dilated. That means a woman can be in labor for over 24 hours before we even start considering that "labor isn't progressing" and that gives women more time to have their own labor curve before we start counting.

2) Reconsider what abnormal fetal tracing is: this is super tricky, as the fetal tracing is what literally tells us "how the baby is doing"-- studies show that continuous monitoring has no better outcomes than intermittent monitoring (i.e. having that thing strapped on all the time while you are in labor vs. for 60 seconds every 15-30 minute) and yet, even in places that "say" they believe in intermittent monitoring, most laboring women are strapped up for large chunks of their labor

3) Make sure we are offering versions for women: a version is a procedure in which a physician literally pushes on a woman's belly in order to turn that baby from bum down to head down. It's usually done around 36 weeks, and though it isn't comfortable, success rates range from 1 in 3 to 1 in 2. That means a good number of women could be saved a section. There is also some interesting data on "moxubustion", an acupuncture/traditional Chinese medicine technique shown to help turn babies around. We should be doing everything we can do to get babies head down, including letting mom's rest!

4) Offer vaginal birth trial for women who have multiple gestation with Twin A in cephalic presentation (that's "baby closest to the vagina being head down", in doctor speak). It's unconscionable that 75% of those women are getting cut without being offered the possibility of a vaginal birth.

5) Be careful about the ultrasounds we order to evaluate neonatal weights. Remember, ultrasound in the end of pregnancy is pretty horrible at predicting weight-- plus or minus 2 pounds. Which basically means you could be having an 8 pound baby OR a 10 pound baby OR a 6 pound baby, on the same ultrasound report. We should be judicious about deciding we need to "check" on a baby's size unless we have some other really good indicators (like, for example, the woman has had two 11-pounders in the past). Sometimes it's tempting, but we shouldn't be tempted without good reason.

6) Lastly, we NEED to stop the FIRST c-section because we know that once a woman had a c-section her risk of having another one goes up. . .This is because an unhelpful combination of fear, hospital policies, and convenience.

Remember, doctors and families, talk about this stuff. It's important.

Also remember that c-section is an important and valuable tool in certain circumstances. Make sure you have a trusting relationship with your healthcare provider so that those decisions that are so important are done in the most shared-decision model way you can imagine.



Additional resources
http://www.ncbi.nlm.nih.gov/pubmed/24720614
http://www.huffingtonpost.com/2013/10/02/twin-birth-c-section_n_4030971.html
https://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Prevention_of_Early-Onset_Group_B_Streptococcal_Disease_in_Newborns

Bad news

You know that feeling when your doctor says something like, "Please sit down, I have some bad news we need to discuss."

You know how your vision gets a little fuzzy, your ears feel this strange pressure with a humming vibrato in the background, your knees get shaky, and you want to vomit?

I know you know it.

You were already feeling pretty anxious driving in for the appointment. The waiting room didn't help. You jumped to the worse possible conclusion. It's bad, really bad. 

Receiving bad news is tremendously difficult. It's impossible to listen, even harder to understand.

Well, I have something to tell you.

It's no fun for the doctor either.

Granted, the implications are less personal, less life-altering. But needless to say,  I, your doctor, lay in bed awake last night at 3am thinking about you. Wondering how best to present the information in such a way that is listenable without being watered-down, in a manner that offers support and reassurance without being overly optimistic, in words that are honest without being hurtful.

Respectfully.

Understandably. 

Carefully.

Truthfully.

I hate being the bearer of bad news.

And I really want to get it right. But I don't always.

I don't want to tell you that your pregnancy isn't viable.
That you have diabetes.
That you need an operation.
I definitely don't want to be the one to tell you there might be something wrong with your beautiful baby.
That it may be serious. 
I hate telling you you have cancer.
Or that the cancer has spread.
Or come back.
I would rather not tell you that your heart isn't pumping like it should be.
That your toe needs to be amputated.
That your mind is going.

I tell you all this not because I want your sympathy-- after all, you are the one receiving the news. It's your body, your health, your illness. The journey will be yours to bear.

I just want you to know-- um, well-- I just want you to know that I care.

The Meaning of Ear Wax

Poor earwax.

Yes, this came out of my 3-year-old's ear.

He is forever being talked about, dug out, probed at, messed with, dripped on, picked at and judged.

We think he's dirty, crusty, gross.

We want him out.

Out of our own ears. Our partner's ears. Our kids' ears.

He is not a hero.
 
In fact, though we all have some amount of earwax, studies show that around 5% of adults, 10% of children, up to 57% of older patients in nursing homes, and 36% of patients with mental retardation complain of earwax problems. Of those, about 4% consult a primary care physician for help with dealing with their ear wax-- and that translates to millions and millions of visits to the doctor every year.

What is ear wax?
Our ear canal is a literal cul-de-sac.  On the normal highways, byways, and side streets of our skin (think face, arms, legs, even between your toes), the stratum corneum-- the outermost layer of our skin, composed mostly of flat dead cells filled with keratin-- slough off with physical erosion.

In other words, we run around, we shower, and we shed.

But the unfortunate reality about life in a cul-de-sac is that the dead cells have nowhere to go. No job to serve and not much to do but to just hang out.

Enter Captain Cerumen (aka earwax), that very villain you have been acculturated to abhor!

He is a hero!  (Well, sometimes).

This unlikely hero is specially designed to help us shed our ear canal's stratum corneum. He is a mixture of oily fats (like cholesterol), proteins, glandular secretions from hair cells and other types of technical "gunk".

There are two main types of ear wax: wet and dry. Wet wax, which is brown and sticky, has a higher concentration of fat and pigment. Dry wax, more grey-tan and brittle, has less fat. There are ethnic differences too: wet wax tends to be most frequent in Whites and African Americans, dry  in Asians and Native Americans. Kiddos tend to have wetter wax (easier to break up than adults)-- thank goodness for those of us trying to get that wax out!

In addition to helping abrade the canal, Captain Cerumen cleans and lubricates the ear canal. Some scientists have theorized that wax is actually antibacterial, though studies have shown lots of different types of bacteria growing in wax, so how effective it is in protecting us against bacterial and viral illness is controversial.


Earwax isn't inherently problematic
If earwax does it's various jobs, it isn't actually problematic. After all, we all have some! It's when earwax gets impacted (in other words, stuck deep inside the ear canal) that people complain of problems: itchiness, pain, hearing loss, ringing, dizziness.

How does earwax get impacted?
As in many things in life, genes play a big role; our behaviors can exacerbate the issue. The same can be said for dental cavities, weight, and even perfect skin. Some of us happen to be lucky to have big open ear canals and soft wet wax, just like some of us were born with teeth of steel, skinniness we couldn't fatten up if we wanted to, and smooth, unblemished faces.

You have poor grounds for bragging rights just because your ear canals are clean (and your partner's aren't). You are mostly just lucky!

In the case of impacted earwax:

• Some people just have biologically small or twisted ear canals (yes, blame your mother). 
• Some people just have dryer thicker, more keratinous (and less waxy) wax (this time, maybe, blame your father).
• Some people stuff the wax in their with cotton swabs (aka qtips)-- This is why the doctor is always telling you not to put qtips in your ear. Not only because you could bust your eardrum with one (you can, but that's rare), but more because you think you are pulling ear wax out, and mostly you are probably stuffing it in further, particularly if you have that dry thick stuff

People do all kinds of strange things to get rid of their earwax.
 Here are a few of my favorites:

Chinese ear picks: Cute and very commonly used, particularly by Asian mamas to dig their kiddos' earwax out; may be dangerous in the wrong hands, but plenty of (particularly Asian) mamas swear by them (and are pretty skilled at these little buggers). Here's another example.

Ear candling: A little weird, right? This method has lots of believers (something to do with creating negative pressure, vacuum, blah blah blah) without much data, studies show it's as effective as placebo and may be dangerous. Careful!

Q tips: I am the biggest hypocrite doctor on the planet, advising my patients not to use, but oh, qtips feel so good. . .it's hard to resist these useful little guys after a long hot shower

Hydrogen peroxide: This is my hubby's favorite. He loves the bubbling sound in his ear. . .







What actually works?

Doing nothing: Most people don't actually need to do anything to their earwax. Unless it's literally causing you problems (pain, itchiness, hearing problems, etc), leave it alone. Having earwax doesn't mean you are dirty or unhygienic. It's normal and healthy! And check this out: even for those who presented to the doctor with problematic earwax, a study showed complete resolution in 5% of patients and moderate resolution in 25% after a few days of doing absolutely nothing. Take home: if you procrastinate, it may just resolve itself. Our body is powerful!


But. . .for those of you who feel compelled to do something about your earwax, there are few studies actually comparing what works best.

Manual removal (i.e. scoop it out): Manual removal refers to literally having someone dig out your ear wax. It should be distinguished from home tools like q-tips and Chinese ear picks; safe manual removal should be done by someone who can visualize your eardrum (i.e. not yourself) and who actually knows what he/she is doing so as not to cause more problems. It also requires a "cooperative patient" (i.e. not a tantruming, squirming, screaming child). I do this with some frequency in my office (especially if I am trying to evaluate a child for an ear infection and cannot see his/her eardrum);  my son's pediatrician has done it for my son (for the same reasons), and otolaryngologists (ears nose and throat docs) are definitely qualified to do this, particularly for someone with a complex ear history. No one know if this is a better way than the others listed below, but it's quick, safe if done by someone who knows their anatomy, and usually not terribly uncomfortable. Also, it avoids the use of moisture, which may be associated with increase risk of infection in certain cases.

Ceruminolytics (i.e. soften it/break it up): "Cerumen", as you know, means wax, and "Lytic" means literally "break up". These cerumnolytics include all those products you see in the "ear section" at the drug store, including Debrox, Cerumal, and Earax, as well as home remedies like hydrogen peroxide, mineral oils and olive oils. Most ceruminolytics are thought to help make wax softer and, well, more waxy than it may be naturally.

There are three types: oil-based, water-based, and non-oil non-water based. There are a few small studies comparing different types, and most studies are pretty equivocal (in other words, they are all the same). Buy the cheaper one. Or the one you like the most. I have found that individuals (including myself) have super strong opinions about what actually works. Probably whichever type you use, the longer you use it (i.e. for several days in a row) is the most important factor in how successful you are.

Just a note: my favorite ceruminolytic is olive oil. It's cheap, easy, you already have some at home (or you better, because it's one of the best oils to be cooking with), it's has minimal side effects, and it works pretty well. Try it! Just a few drops (with a dropper or a small syringe) in each ear.

Irrigation (i.e. spray it out): Irrigation, also, should be done by someone with some experience. Though you can certainly try this at home, the tools we have in the office (fancy water bottles with specially designed tips) are probably more effective and safer. There are a variety of products on the market designed to limit trauma to the ear and maximize effectiveness. My medical assistant is a super professional with the ear irrigator and can clear almost anyone with enough time to hang in there with her. (I've been trying to get my husband to see her for years). It's considered effective and safe, though anyone with a known ruptured eardrum should stay away. One study found it worked alone 70% of the time. Irrigation should NOT be done in someone with ear tubes or with a questionable ruptured ear drum. It has been associated with a low risk of infection of the ear canal.

Ceruminolytics + irrigation: If irrigation works about 70% of the time, then irrigation after a course of ceruminolytics is thought to increase the probability of success to about 97%. Putting in some lytic about 15-30 minutes before irrigation has been shown to be more successful than doing it immediately and not any better than in the days leading up. So, I might suggest that at the start of your visit, ask the medical assistant to instill a ceruminolytic of your choosing. You can meet with your primary care provider for 15-20 minutes, and then finish up with an irrigation. Walk out of the office feeling like a new guy/gal. Voila!

                      
                                                       ***

In truth, people have an unbelievable attachment to their earwax. Or perhaps the proper term is detachment. They grant earwax a ton of negative attention and more meaning than it merits without appreciating it for its inherent utility. And everyone always want to talk about it (comes up in my office at least 3 or 4 times a day)!

Most of you should just LOVE your earwax-- after all, it serves a good purpose. Plus, there is no real point in having spick and span ear canals. Earwaxlessness=overrated.

Those of you with issues, though, consider something cheap and easy (e.g. olive oil) or go see your primary care provider and ask for a washout. The visit may also be a good opportunity to talk about your weight, your mood, or your blood pressure. While that ceruminolytic is soaking in. . .



Additional References:
http://www.aafp.org/afp/2007/0515/p1523.html

http://qjmed.oxfordjournals.org/content/97/8/477.long
http://udel.edu/~mcdonald/mythearwax.html
http://www.webmd.com/cold-and-flu/ear-infection/news/20080829/earwax-too-much-of-a-good-thing
http://www.ncbi.nlm.nih.gov/pubmed/14979962