Search for tag: "decisions"

Announcer: Covering all aspects of women's health. This is the Seven Domains of Women's Health with Dr. Kirtly Jones on the Scope.

Interviewer: Dr. Jones. This wasn't me. This was a woman who actually said this. And when she said it, it seems so kind of crazy that I'm like "Could that really be?" And so I thought I'd come to you. But this woman said women should not make decisions during PMS. And science has actually shown, she said, that you can do a brain scan and see chemical changes in the brain. So you shouldn't accept a proposal, you shouldn't buy a car, you shouldn't make any big decisions during. Is that true?

Dr. Jones: Well, I've heard that guys after their sports teams win shouldn't make a big decision either. So let's have a discussion about recognizing your brain's state and when you should make emotional decisions or a financial one.

First of all, many women actually who have periods don't have PMS. We do know that the brain is different the first half of the menstrual cycle when you're making an egg to the second half of the menstrual cycle when you've hatched the egg and you're making a lot of hormones call progesterone. And progesterone falling, meaning as you get closer to your period, four, five days can affect some people's brains in a negative way. And you can study mice and rats and do some studies with them.

Now I think the more important question isn't whether or not women shouldn't make decisions. Meaning only menopausal women should be elected to office and only menopausal women should run businesses. Perhaps no men should run any of these because we know that men's testosterone levels go up and down. So men who go to a sports event and their team wins, their testosterone takes a big bump and that can lead to increased gambling, increased risk taking, and increased hostility. And the guys who lose, their testosterone makes a big drop.

So I think more importantly than talking about women and PMS is talking about emotional intelligence. And I want to introduce the RULER Project, R-U-L-E-R. The Yale Center for Emotional Intelligence has encouraged us with a program that's brought into the schools for children, but we're all children when we're emotional.

So let's talk about making decisions when you're sleepless, when you're hungry. I should never make food decisions when I'm hungry. And in fact, there's a term in my family called "hangry." Which is the way you feel when you're hungry and it's not a good thing. I never went to clinic without the right amount of caffeine and food in my tummy because I didn't want to my irritable.

But I am emotionally intelligent, at least I think I am. Because I recognize, understand, can label my emotion, can express it appropriately and regulate it. So that's the RULER. When you're making decisions about getting married or buying a car or whatever, our lives are not smooth.

We have different amounts of food in our tummy, alcohol in our brain, sleep under our belt. We have had relationships with our kids that might have affected the way our moods are. It's not that we shouldn't make any decisions, we should just be thoughtful and mindful about the way our brains are working.

Interviewer: And take into account how those situations might be affecting our thinking.

Dr. Jones: Right. So yes, women might have PMS. Not all women do, but some women do. But men have road rage whether they recognize it or not. So I think all of us have our brains in different emotional states. So let's go over the RULER again.

One is recognize. When you're feeling something irritable, snarky, sad, anxious, happy, one should be able to recognize the emotions in yourself and others. You should understand that's the U that causes and the consequences of these emotions. So I understand if I'm PMSy and I get irritable because the dishes haven't been done, that it's about the dishes but my coping mechanism isn't so great and it's time for me to sit in the bathtub for a while.

Interviewer: Or I as a man, say I'm in a high-stake situation and have just won a victory whether it's in the office room or a sporting event, that maybe the decisions I make after that might be tending towards gambling and risk taking and I should consider that.

Dr. Jones: Exactly. Exactly. It's helpful if you can label the emotion in yourself and others. So being able to recognize an emotional state and label it, gives you a word around which you can start to decide whether this is an emotional state that is safe for making a car decision.

You should be able to E, express your emotion appropriately. So when you're having this emotion, it's helping to let others know how you're feeling. "I'm feeling irritable because you have not done the dishes again. Now I know it's before my period and I get a little crankier, but you should still do the dishes." Well, not exactly like that but sort of like that.

So E is express your emotions and R is regulate it. So that's the important thing. When I know that I'm PMSy, thank God I'm not anymore. So I can rule the world because my hormones are the same everyday unless I haven't eaten and then I get hangry. So regulating your emotions now that you know what it is.

You can express it, you can give a name to it. You can say, "You know what? Before I make this emotion about having this discussion, before I make this statement about the dishes, I'm going to go walk outside for a little bit and look at my favorite stars. And then I'll come back."

So whether you make decisions, whether you're sleepless, hungry, had a fight, whether your moods are up and down because of your own mood state, or because of your hormones, you should RULER and measure your emotions so that you could have a more effective dialogue with yourself and with others.

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Dr. Jones: When women have had breast cancer surgery, the major surgery such as a mastectomy, they are often looking forward to living their lives and getting their body back. What are the new steps and what are the things that we have here at the Huntsman that will really help them make this difficult decision? How do we make the decision, and who is the team involved?

We are in the office of Dr. Agarwal here at the Huntsman Hospital with a beautiful view out the back door of people living their lives. I want to talk about how women who have had mastectomies make the decision to live their lives going forward as they make the transition from a cancer victim to a cancer survivor. We're talking about breast reconstruction here with Dr. Agarwal, plastic surgeon and reconstructive surgeon here at the Huntsman Hospital.

Let's talk a little bit about women who request the bilateral mastectomy. Of course, there are women with BRCA mutations, mutations that increase their risk of cancer. They don't have cancer yet, but both of their breasts are going to be involved so that's pretty easy to understand. How about if a woman has breast cancer on one side and wants the other one done? Does insurance pay for that?

Dr. Agarwal: Not always. We're seeing an increased demand, if you will, in patients who want to have the contralateral breast removed. A lot of times, this is driven by fear of developing cancer in the other breast. Oftentimes, it's driven by the desire to have symmetry and it's not a guarantee that your insurance will pay for this. More and more, we're seeing that insurance wants to really focus on the breast that has cancer and may not always pay for removal and reconstruction of the other breast.

But any time a patient has these concerns or desires to have both breasts removed, it requires a good discussion with their doctors, their oncologists, their surgeons because while things like symmetry may be improved in some cases, there are also potential consequences to having your other breast removed. You lose sensation of an otherwise normal and healthy breast. Just like with any other surgeries, there is the risk of potential complications by adding more surgery time or more operations.

Dr. Jones: And if women are young enough that they might want to consider having children if they get past their diagnosis and are cured, then they couldn't breastfeed if they have bilateral reconstruction and that has to be discussed. There is so much on the Internet about the pros and cons, but are there other women that someone can talk to? Do you have support groups of women who have made decisions and how they worked through their decisions? How do women go about finding out more information?

Dr. Agarwal: There are definitely support groups here at the Huntsman Cancer Hospital. There are teams of patients who have offered their services to other patients because they've gone through this process in the past and they give the whole picture, the good and the bad of going through this process. Throughout the Salt Lake community, there are organizations that provide a lot of information to patients, including Susan Komen's Foundation. So there are definitely support groups. I think that it is a very personal decision in the end and I think that a frank conversation with your medical team and your family is important when finally making these types of decisions.

Dr. Jones: Let's talk briefly about nipple reconstruction. I've heard that you have an amazing tattoo artist here at the Huntsman who might be able to even tattoo a nipple or are you using other tissues for nipple reconstruction?

Dr. Agarwal: First of all, we do have a great tattoo artist here at the University of Utah and Huntsman Cancer Hospital, but there are different ways of reconstructing a nipple. We can actually use some of a patient's own tissue to create the nipple itself and then tattoo the areola around it. And another option is to purely use tattooing. Some of the tattoo artists can create 3D tattoos of a nipple, which looks amazing. They look like real nipples that have projection even though they're flat on the surface of the skin.

Dr. Jones: That must be very gratifying to have the ability to give a woman that gift, not only as a reconstructive surgeon to give the gift of having symmetry and a self-image that will carry her forward as she works through her recovery but even having the ancillary staff that can help her through that like the tattoos and the counselors and therapists and all of the people, a whole team that can take care of people.

Dr. Agarwal: It's absolutely gratifying to see a patient go through this process and come out feeling whole again and feeling like they can get past or move beyond their initial diagnosis of cancer, and that's really the goal is to help them move forward in life.

updated: June 8, 2021
originally published: October 22, 2015

Interviewer: A new video game that teaches about air pollution in Utah. What does the creator hope to accomplish? We'll talk about that next on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: "Bad Air Day: Play It Like UCAIR" is a brand new web-based game that teaches why Utah's air pollution woes are local and frequently misunderstood, their words not mine. Actually, I want to ask a question about that because I found that misunderstood thing interesting. Kerry Kelly is in the Department of Chemical Engineering at the University of Utah and the game was originally her idea. So first of all, tell me about the game, what is it about? What is the objective?

Kerry: Okay, so you get to be the mayor of Salt Lake City, and you get to decide what kind of policies you're going to make to either help improve air quality or maybe you don't care about air quality and you'll make other decisions.

Interviewer: Sure.

Kerry: So you get to fly a paper airplane around the city, and it is your job to collect votes. If you make decisions that improve air quality, you'll have a nice clear day and you'll fly quickly around the city. If you choose to make air quality poor, you'll see a visible deterioration in air quality and it will also be much more difficult for you to fly around the city. In fact, if you make enough bad choices, you'll have trouble seeing.

Interviewer: Really?

Kerry: Yeah.

Interviewer: Okay. One of the other aspects of it that I thought was interesting is that you have what is called a "Wall of Public Anger".

Kerry: Yes!

Interviewer: How does that play into it?

Kerry: We were trying to figure out how to address the challenges when you're looking at public policies and strategies, and we developed this "Wall of Public Anger" as a way to address that some of these strategies might incite a lot of public anger. For example, if you forbid all driving, we believe that there would likely be a lot of Walls of Public Anger. In the game that means these walls go up and you can see shadows of angry people and you'll have to fly around the Wall of Public Anger if you wish to continue to collect your votes.

Interviewer: And it makes it a lot more difficult. I think that's an interesting juxtaposition that a lot of people don't think about is, sure, you'd have great clean air but you're also making people angry because it's really unrealistic to think everybody is going to stop driving.

Kerry: Exactly.

Interviewer: Or people are going to give up their wood-burning fireplaces.

Kerry: Yes, that's another very hot topic.

Interviewer: I bet it is. What are some of the other hot topics like that?

Kerry: Increased use of mass transit, so how aggressive you are with encouraging that. A shutting down of a variety of permutations of industry, so for example, shutting down the refineries or shutting down all large industry in the valley, so you get to see what that would do to air quality.
I guess one important aspect of the game that I wanted to mention, is that every single strategy that we've proposed in the game we are able to link to a quantifiable change in air quality. We had a lot of strategies that came up in our meetings with the stakeholders, and there are some really interesting strategies, but we weren't able to come up with a quantified change in air quality. So we stuck only with the strategies, I believe there are 20 or 30 of them, and how they will affect our air quality.

Interviewer: And you know exactly how that will affect the air quality, and you can actually watch that in the game so you can experiment and play around with the different choices.

Kerry: Yeah, in fact I think it's kind of fun to select poor air quality choices to see what happens.

Interviewer: Yeah, and how bad it really makes it.

Kerry: And this is from an air quality researcher, so . . .

Interviewer: Exactly. How do you hope that parents will help kids use this game as a learning experience? Because the target is teens, correct?

Kerry: Yes, but we're partnering with Breathe Utah so they have a big educational component to their organization and they're going to be testing this game with a variety of high school and even some middle school students, so we'll see how it plays with each of those two groups. And they're developing some lesson plans that will accompany the game.
One challenge we faced was how much information to put in the game versus how much to just inspire curiosity. I think we went more on the inspiring curiosity and left it up to the teachers and the experts in developing lesson plans, so that they could develop materials that would then tie to state core or whatever they needed it to. We just wanted to make sure that the air quality part of it was correct.

Interviewer: So after some teens, or anybody, plays the game, if they were to walk by you and you were to stop them and say, "Hey, what's your takeaway?", what would you hope their takeaways would be?

Kerry: Well, A, that it's a tough problem, first of all, and that they have a little bit of a feeling for the variety of strategies that we could take, and that it's going to take a combination of strategies to solve this problem, and that there will be some trade-offs. Some of the things we'll have to do will cause us some sacrifices. Whether or not it's paying a few cents a gallon more for gasoline, or not burning wood, we'll all have to make some choices.

Interviewer: Yeah, so kind of educate people on the basics of it, help them understand that there are trade-offs, help them understand that it is a complicated problem.

Kerry: Right, yeah.

Interviewer: So it sounds like there was probably a lot of thought put into this game, a lot of scientific fact, a lot of work and effort from a lot of different people.

Kerry: Exactly, and I wanted to thank the partners we had. In particular, I wanted to thank the students in Engineering Arts and Entertainment. They did the lion's share of the work, they made this all happen. I wanted to thank Breathe Utah. They helped with the educational side of the game, and they're currently out there play-testing the game.
I wanted to thank Utah Education Network, that's who is hosting the game. I wanted to thank the Utah Health Department and the Utah Division of Air Quality. They really helped as we developed strategies and vetted strategies and the Division of Air Quality was invaluable as we were trying to put numbers on each of those strategies we were considering.

Interviewer: In the description of the game it said, "Air pollution woes that are local and frequently misunderstood". Have we covered the misunderstood part of that?

Kerry: Yeah, I think so.

Interviewer: Okay, that's what you referred to there, all right. You can get the game at badairday.org. Kerry Kelly, good luck with your game and thanks for taking time.

Kerry: Oh, thank you very much.

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Dr. Miller: Why you should make your health care wishes known, and why everyone should have an advanced directive. We're going to talk about that next on The Scope Radio. This is Tom Miller.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: I'm here with Dr. Nate Wanner. He's an associate professor of medicine and internist, and a hospitalist, and the Medical Director of the Palliative Care Service. Nate, what is an advanced directive and why should everyone have one?

Dr. Wanner: An advanced directive is usually a written set of instructions that basically communicates to people what kinds of care a person would want in the event that they became unable to make those decisions for themselves in the future.

Dr. Miller: So you're sort of trying to look ahead to an unpredictable future when you know how you want to be treated.

Dr. Wanner: That's right. And we all know that we're going to die sometime, and a large percentage of people who are very ill lose the ability to make decisions well for themselves. And so this is more than a theoretical concern.

Dr. Miller: But you have a long history taking care of hospital patients, how many of the patients that come in are aware of advanced directives when they hit the door? I mean, how many do you think really understand that, and fill them out?

Dr. Wanner: Less than half of patients have advanced directives. And even those who have them are a fairly small percentage who really understand what they mean very well. And a lot of times people make an incorrect assumption that their advanced directive will answer any questions that the doctors have about their care. In reality, a lot of advanced directives are not very helpful in addressing certain specific medical situations.

Dr. Miller: What are the most common things that a patient would direct a physician to do or not to do in an advanced directive?

Dr. Wanner: One common scenario would be if a patient had a terminal illness, and was not able to have any treatments that could prolong life significantly, whether they would want certain treatments that are more burdensome to be done.

Dr. Miller: These are events where the patient codes, as we say in medical terminology, where they stop breathing and the heart stops beating, do they want to be revived, or resuscitated.

Dr. Wanner: That could be one example. Another example would be if a person were in a coma that was expected to last forever, would they want a feeding tube and artificial hydration and nutrition to keep them alive even if they were unable to communicate or move or function in any independent way.

Dr. Miller: I know that they offer advanced directives to be filled out when they enter our hospital, but how would a patient most reliably get started in filling one out? Do you have suggestions on that for the audience?

Dr. Wanner: What I would recommend is using the advanced health care directive that the State of Utah has created. It's a very helpful form that isn't terribly hard to understand.

Dr. Miller: Would they be able to just Google that and find it?

Dr. Wanner: They can, yes. If you just Google Utah advanced care planning or advanced health care directive you can fairly easily find it.

Dr. Miller: And do they give tips at that website about how to fill it out, or what sort of pertinent things one might want to put down to complete an advanced directive?

Dr. Wanner: There are some tips for that, and we could certainly provide a link to that.

Dr. Miller: Where should a patient once they fill out this form, should they keep it on their person, or do they keep it at home in their safe? Do they take it to the hospital? What's the best way for them to have this to show to their physicians?

Dr. Wanner: We recommend that they keep a copy for themselves somewhere where they can find it when they need to. Probably it's a good idea to give a copy to a family member as well, specifically the person that you would want to be your decision maker if you become unable to make decisions. It's also a good idea to give a copy to your primary care doctor. And those would be the most important steps. But I think it's also worth mentioning that people often think that because they've given one bit of information to one doctor that all doctors have access to that. And unfortunately that's just not the case often. And so having a copy handy if you're in the hospital is a good idea to be able to show the doctors there who may not have access to all your information from your primary care doctor.

Dr. Miller: I think that's a really good point, because a lot of times medical records are not immediately transferable between facilities from one ED to another hospital for instance. And if the patient keeps a copy at home they could easily have a family member bring that in and show it to the health care team, which is a good idea.
Now if you fill that advanced directive out, does that also stay on a website with the state so that they could look it up that way or not?

Dr. Wanner: I don't think there is anything like that right now, but that is being worked on. I don't believe that's in place yet, but I think there is hope that it will be soon.

Dr. Miller: Eventually with cloud technology all of our records will be available to physicians wherever we get treatment within the United States, I think, but we're still a few years away from that, I understand. Any other thoughts about advanced directives and the way that more people could be involved in filling out advanced directives?

Dr. Wanner: Well, I think this is a discussion that people should encourage their family members to have and loved ones. It's something that allows people's wishes to be honored, and it also takes a major burden off of the loved ones who would otherwise have the task of making those decisions.

Dr. Miller: Does the advanced directive also allow the patient to designate someone, a power of attorney, to make those decisions in a particular situation where they are not able to make the decisions?

Dr. Wanner: It does, and that's one of the things that I like about the State of Utah form. It offers an opportunity to say certain things about actual wishes of what kinds of care you would want to receive. And then it also provides an opportunity to assign someone who would be your decision maker if you became unable to. And one misconception with that is some people have is that by designating such a person, a health care power of attorney is the official name for that, that they are somehow giving up control. And that's not the case. Any advanced directive only goes into effect once the person themselves is unable to communicate their wishes clearly. It doesn't give anyone the opportunity to make decisions for you unless you become unable to make your decisions.

Dr. Miller: Some patients might be under the impression that they need a professional to help them fill it out, and I don't think that's the case. They don't need to hire an attorney to fill out an advanced directive or to send a power of attorney to another family member, right?

Dr. Wanner: You're exactly right. And so if you use the state form in particular, it's a legally binding form that's been approved by the State of Utah, and all it requires is a witness who has to have some independence from you to sign and say that they witnessed it. It does not require any need for a lawyer, and it's kind of a funny thing that in America we go to a lawyer for health care planning, I think. It's kind of like going to me and asking for legal advice.

Dr. Miller: So it sounds like the bottom line is to think about how you would want to be treated if you were unable to make your own medical decisions. Go to the website and again, what would they Google if they were going to fill out an advanced directive from the State of Utah?

Dr. Wanner: The official title of it is Utah Advanced Health Care Directive, and if you type that in you shouldn't have any trouble finding it. And it's a four-page form that has one section that allows you to assign someone to be your decision maker if you become unable to. And then it has a second section for expressing certain wishes regarding your health care. And then it talks a little bit about how to change or revoke that in the future if you want to. And then it has a place for signatures to make it legal. So it's a very simple form.

Dr. Miller: So fill it out, and then keep a copy at home, and then maybe give one to your primary care physician, and then each time when you have to go into the hospital bring it in with you so you can have that on file in the hospital where you're being treated. And you would also say that you don't have to be older; that's not a requirement. You could be any age, and probably should have an advanced directive if you're receiving medical care. Would that be your advice?

Dr. Wanner: Yes, and it's certainly a much more important issue for people who are older and have very serious medical problems. But even young healthy people can have unexpected tragic things happen, and if you look at some of the cases that have been in the media and in the legal system that have prompted laws addressing this type of issue, in general they've been young, healthy people who have had terrible things happen to them, and then their family has been put through the wringer trying to figure out what to do.

Dr. Miller: Trying to figure out what they wanted. Because, it does service to your family and your loved ones as well to fill out an advanced directive and keep that on file.

Dr. Wanner: Definitely.

Dr. Miller: Thank you very much, Nate, I appreciate it.

Dr. Wanner: All right, and thanks for having me.

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