Search for tag: "outcomes"

Interviewer: It's a conversation we're not used to having or starting. I'm talking about planning for end-of-life care, and if you are planning for end-of-life care because of a diagnosis with Alzheimer's or other sort of dementia, it becomes even more complicated whether it's for yourself, or whether it's a loved one that has that diagnosis.

So to help out with that process, we're talking to Kara Dassel. She's in the Gerontology Interdisciplinary Program in the University of Utah Health College of Nursing. And her research team has developed this thing called "The LEAD Guide," which stands for Life-Planning in Early Alzheimer's and Dementia. So everybody should have an end-of-life care plan. But from what I understand, if you have Alzheimer's or some sort of dementia, that end-of-life care plan is going to look a little different. Explain why that is.

Kara: There's more of a time crunch in a broader context within Alzheimer's disease or other types of dementia where there is a limited window where you're able to engage in your family member with dementia and learn about their preferences and wishes before they get too cognitively impaired where they're no longer able to have those conversations.

Interviewer: Wow. So after the diagnosis comes in and you find out that maybe a loved one or even yourself has dementia, how soon should that conversation start?

Kara: The earlier the better. It shows that you have better care outcomes as far as having your medical decisions match your preferences if you have those discussions and document it. You're less likely to be hospitalized if you don't want to be. You're less likely to be shuttled in between nursing homes and hospitals and rehab facilities. And it's a better outcome for the people making the decisions for you because they don't have the burden of trying to guess what mom would want.

Interviewer: When it comes to advanced care planning, I thought this was interesting. I tend to always think of just medical preferences, like this is what I want medically done or not done. But it goes beyond that. And "The LEAD Guide" is based on what you call value-based decisions. Explain what that means.

Kara: Yeah. So sometimes just checking a box of whether you want a ventilator or not doesn't give you the full context of end-of-life values and preferences. And in dementia, in particular, someone may be physically very healthy but lack decision-making abilities. And so you need to make decisions about if they need long-term care, is that going to happen in the home? Is it going to happen in assisted living, a nursing home? You needed to decide where their location of death is going to be, because with dementia people live on average 8 years after diagnosis, but they can live up to 20 years. And so there's a lot of care decisions and medical decisions that need to take place within that long death trajectory.

Interviewer: So this can be a tough discussion to have. So I guess I'm thinking from the perspective of maybe a family member wanting to bring it up after that diagnosis. Are there other reasons why it's just really important to have that discussion? Again, it's not a discussion we're used to having.

Kara: Right. Not a discussion you're used to having, and I think just knowing that your window is limited puts the time pressure on having these discussions within a context of progressive dementia. And I like to frame it with families as it is beneficial for the person with dementia and the family members to have this discussion for two reasons.

One, the person with dementia has the comfort and peace knowing that they were able to communicate what they want currently and then also what they want when they have advanced dementia. That might differ. They may want something different today versus five years from now when they're in a nursing home. And so being able to communicate that can bring a lot of peace and comfort to the individual.

And then also, family members can approach it as, "Do me a favor. I want to carry out your values and preferences, but I need to have this conversation with you in order to do that." And that would relieve a lot of burden or guilt or disagreements among family members. So it's really a service to the family to have this conversation.

Interviewer: I was surprised to see in the research that you and your team did to make this guide that, for some people, the emotional burden can last months or even years, the caregiver emotional burden.

Kara: Right. If you're in a situation where you really don't know what your husband or partner wants, or mom or dad and you have to, it's an acute situation in the hospital and you have to make a decision, you may question whether you made the right decision for years. There might be a lot of lingering guilt and stress of not knowing.

Interviewer: Yeah. So I'm looking through the guide here. What I really like about it is it seems pretty simple. And this is a point where I want to say this does not replace, if I understand correctly, an advanced directive. This is not an advanced directive. This works with.

Kara: Right. This is a supplemental guide that's not legally binding, but it provides additional information about a patient's values and preferences and some of those questions that are unique to dementia, like location of long-term care and preference for location of death.

Interviewer: It starts out with a little checklist of the end-of-life documentation that you should have, which is great because that can get confusing. So I like that. And then when you start getting into some of these end-of-life value questions, I found this fascinating because I think we put ourselves in the situation by not having these conversations. Like the very first question, I'm concerned about being a financial burden to my family or close friends. For my mom, like I would spend the money to continue to make her live if that's what she wanted. But then how often is there a disconnect that that's not actually what the person wants?

Kara: Right. And so a lot of these questions here about values, they help inform decisions. So if you know that your mom is really concerned about being a financial burden, then that will help you make decisions about her care in the future. And the same with being an emotional burden or a physical burden. You know, if your mom's really concerned about burdening you physically with day-to-day care tasks, then maybe that makes you feel a little more comfortable about placing her in a 24-hour skilled-care facility when that time comes, knowing that that's your mom's value.

Interviewer: Have you seen this actually in action?

Kara: Yes. So we have . . . A part of the process of developing this guide, we held multiple focus groups with healthy adults, caregivers of people with dementia, and people with early dementia themselves. And the feedback we got was very valuable about, "Wow, this is great. I hadn't thought about this." Or, "I never knew mom cared so much about not dying at home." So it really raised a lot of questions that they hadn't discussed before.

Interviewer: Yeah, that's fantastic. Is there anything else that we need to talk about this? I think this is such a fantastic tool, especially for somebody . . . You know, I know what we need to talk about. We need to talk about somebody with dementia, not only just the deterioration after the diagnosis, but end-of-life wishes tend to be different for patients that know that they're going to have dementia versus maybe somebody that knows that they're going to have cancer.

Kara: The dementia preferences were different from those other ones as far as not wanting medical treatment interventions in a situation of dementia versus cancer. And then, having a preference not necessarily to die at home, being more comfortable dying in a nursing home or at the hospital. And so a lot of the qualitative data that we got showed that the loss of sense of self, of independence, of memory really defines quality of life. And people didn't want to extend that type of life in general.

Interviewer: Understood. My last question is this is such a great tool. Is it something that anybody could use for planning end-of-life, even if it wasn't Alzheimer's or dementia? Because I know it was specifically designed for that, but could it be used for other cases as well?

Kara: Of course. So people may lose the ability to make decisions at the end of life for a variety of reasons, due to other medical conditions, head trauma. So you can use this guide to help with any sort of advanced care planning. It's just meant to facilitate the conversation.

updated: April 29, 2022
originally published: May 13, 2020

Interviewer: You get some sort of a cut and you go to the emergency room. What determines whether you get stitches or staples? Find out next on The Scope.

Announcer: This is From the Front Lines with emergency room physician, Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. So if something happened and I end up in the emergency room, I've heard that somebody can maybe get stitches, maybe somebody gets staples, but how do you as an emergency room physician decide what it's going to be? Or do I get to choose?

Dr. Madsen: I kind of just randomly pick and then I just go for it.

Interviewer: I don't believe that. I don't think that's really what goes on.

Dr. Madsen: Yeah. No. I think of different things for different parts of the body. So you're right. We've got staples. We've got stitches. And we've got glue. So we got all kind of choices.

Interviewer: Oh, there are three. It sounds cooler though, I think, if I could tell my friends, "Yeah, I had 16 staples." as opposed to, "They glued me up."

Dr. Madsen: Oh, I know. Oh, yeah. Someone's like, "They put superglue on you. You weren't hurt."

Interviewer: Yeah.

Dr. Madsen: They're all options. They all work great for different types of scenarios. So the times I use staples are on the scalp. That's where it really comes in helpful. And the reason I use it there is because the scalp is really thick skin. Those staples hold it together really well. And scalp wounds bleed like crazy.

Sometimes people come in, they just think they're bleeding to death. You clean their head up, you look there and you see a wound that's maybe an inch long. But they just bleed a ton. And the best thing you can do sometimes is just staple it up right there. Like, we might even throw three staples and not even numb it up because the numbing medication is going to hurt more than the staples are. And I always tell patients that if you want me to numb it up, I can, or we can just get this done really quickly. So that's where staples are great.

Interviewer: All right. I have put a staple through my finger, those kind of hurt though.

Dr. Madsen: They do hurt. I'm not going to say it doesn't hurt. I'm just saying the lidocaine, the numbing medication hurts worse.

Interviewer: Okay. So in the scalp, you do staples because it's good thick skin and it really seals things up better than stitches.

Dr. Madsen: It does. It just brings it together so quickly. It's nice and tough. That scalp skin is really thick skin, so it just pulls it together and holds it there really well. And you're not as concerned about scarring there. On the face, you put a bunch of staples on the face, you're going to look like Frankenstein versus on the scalp, unless you're bald and you're really concerned about how your scalp looks, it's not a big deal.

Interviewer: All right. So then, what about stitches?

Dr. Madsen: So stitches are kind of our go-to. Pretty much anywhere else we're going to use stitches. And then it becomes what kind of stitches. On the face, we use really thin sutures, really thin stitches because they lead to less scarring. They're tougher to handle, tougher to work with, but you want them really thin and very close together, versus someone comes in with a laceration in their leg, on their lower leg. I'm going to use a thicker suture there just because I want it to hold together that skin, particularly, say over their knee, over their joint. Something that's going to be tougher, and you're not as concerned about cosmetic issues there.

Interviewer: Got you. And then glue. How long has glue been around as an option?

Dr. Madsen: Well, glue has been around . . . it's funny. It really started to be used about 10 to 15 years ago. So when I was in training, I actually had one of my attending physicians, I remember, ask me how to use glue. He was like, "What's this new stuff?" [inaudible 00:03:05] So it just kind of really came out around then. But glue works great. It's essentially just superglue. And it's changed a little bit, so it doesn't sting like superglue does. But when you look at the formulation, it's very similar to superglue, just a medical-grade sterile superglue.

And it works great for wounds that are not super big, something where it's not a gaping wound, where you really need to get that wound together. I find it works really well for kids because you don't have to try and sedate them and numb them up. You can just put some of this glue on. Personally, for me, when I travel, that's my go-to. I carry it with me because I figure if I have a laceration, it's easy enough to use. I can wash that off, glue it up. It's quick. It does a great job.

Interviewer: As a patient, if you end up in the ER, can you request glue or stitches?

Dr. Madsen: Sure. Absolutely.

Interviewer: You could always request.

Dr. Madsen: You can always ask for it, yeah. And the doctor may tell you, "Hey, this is a wound I'm concerned about. It's a gaping wound. I think we need to use sutures." But sometimes, I'll even use, say, one or two absorbable sutures, dissolvable sutures just to get that wound together. Once it's together, then I just do the superglue, just the medical glue over the top of that. And it's a nice combination, a little bit quicker. It avoids a lot of the pain. And [inaudible 00:04:20]

Interviewer: What about scarring? Does glue scare even less than sutures?

Dr. Madsen: It's similar. Studies that have been done that looked at outcomes after gluing versus suturing showed similar cosmetic outcomes. I can't say . . .

Interviewer: Oh, really? Okay.

Dr. Madsen: Yeah. People would be a little more concerned, maybe the stitches are going to hold the wound together better, but the studies that looked at outcome showed that it was similar.

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Interviewer: How can you prepare for surgery so you have a better recovery? That's next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: For a long time the responsibility of the outcome of a surgery was kind of placed on the surgeon's shoulders. But more and more, we are learning that the things you do or that you don't do as a patient can significantly impact the outcome of surgical procedures. Dr. Thomas Varghese is head of the section of general thoracic surgery at the University of Utah Health. What do you tell your patients that they can do to prepare for upcoming elective surgeries?

Dr. Varghese: The reality is that patients have much more power in determining the outcome of the surgery. It's not just the surgical technique.

Interviewer: The skill of the surgeon or the facility you go to, which are important . . .

Dr. Varghese: And don't get me wrong. Absolutely, there is a lot of data out there saying that going to an experienced surgeon, going to an experienced center really makes a difference. But there's also specific aspects where the patient health really makes a difference. So let me give you some examples.

One thing is nutritional status. We know there's over 40 years of literature in the surgical field where if a patient is malnourished coming into the surgical intervention, they are starving, they've had unexpected weight loss, their protein levels are abnormally low, those will lead to higher morbidity and mortality and complications, you know such as after G.I. surgery where there is a hookup or osmosis in the leak, those complications go up significantly after surgery.

We know in the area of blood sugar control that the best way of framing it is not just for diabetics but in patients who respond poorly to the stress of surgery and have abnormal blood sugar levels. If you have higher blood sugar levels around the time of surgery before, during and after, those patients have increased levels or increased incidents of infections after surgery as well.

Smoking is another area. We know that there's so much evidence that it's not just respiratory complications that smokers are at risk for. It's also increased risk of strokes, increased risk of heart attacks, increased risk of death after surgery. And so getting smokers to stop smoking before their elective surgery makes a huge difference.

And probably the final area where there's a lot of evidence that has emerged is also a direct correlation with medication. There are certain medications and supplements which increase the risk of bleeding after surgery. And getting those patients to understand what those medications are, what those supplements are and getting them to stop before surgery really makes a difference.

Interviewer: And how far in advance would someone have to start kind of optimizing these before their surgery for it to really make a difference?

Dr. Varghese: Historically, people mistakenly thought that these type of interventions took months before surgery. But the reality is that a lot of these things may take even as little as a couple of weeks, two to three weeks. Probably the longest time period is for smoking cessation. If you look at the recent literature, for example, in 2011 there was a meta-analysis in the Archives of Internal Medicine, where they really said that three weeks of smoking cessation.

And really, smoking cessation is an all or none phenomenon. You really have to work with patients and get them completely off smoking. Three weeks prior to the intervention was enough time period to make sure that they had enough better outcomes.

Nutritional interventions, probably a couple of weeks before surgery. Medication optimization especially with the supplements that lead to increased bleeding, again a couple of weeks before surgery is plenty. And then blood sugar control, the data is a little bit varied in terms of the time period, but again one to two weeks before the surgery. So we are not really talking about long period of time in terms of getting optimized prior to your surgery.

Interviewer: We're talking about elective surgeries where you actually do have the ability to control some of those things beforehand. And there've been times I've heard stories of somebody who has been in an accident and they go through surgery and then they recover and somebody might say, "It was because you were in such great shape that you recovered as well." So all of these things would contribute to that. What about physical exercise as well?

Dr. Varghese: Great question. Physical exercise has been a little bit messy in terms of the literature, and I think that there are a couple of different factors for that. Some of the clinical trials that have been conducted historically have been unrealistic. You know, they've been asking patients to report back every single day and use very, very expensive equipment with a physical therapist monitoring every single step of the way. This is not really pragmatic in the real world.

The general recommendations for the population at large is that we should be doing five days a week of moderate-level exercise, you know, 30 minutes of moderate-level exercise to improve your health. At the time of surgery what we do as a general recommendation, something as simple as starting a daily walking program where we say you set aside some time, morning noon, or night, you go for a walk, and the goal being you add on a couple of miles per day of walking in addition to what your normal level baseline level of activity is. Something as simple as that has been shown in the literature to make a huge difference in terms of your outcomes.

Interviewer: So I think the takeaway is to know if you are going in for an optional surgery that there are things you can do. Your nutrition, your smoking, your blood sugar and your medications that can really impact the outcomes. So be honest with yourself, be honest with your physician. If somebody is in a place where this isn't being . . . is this pretty commonly practiced with physicians?

Dr. Varghese: I think the honest answer is that there is increasing recognition. Unfortunately, there is still widespread variation in terms of the amount that people are doing. What we are hoping to do is not only getting more physicians involved in this movement, but the people who are the most powerful, who can really truly make a difference are the patients.

We are hardwired in all our aspects of our lives to be prepared before we embark on our journey. Why wouldn't you do the same thing for big time surgery as well? You know that if you are about to have elective surgery, you know when the surgery date is, why not empower yourself? Why not get engaged? Why not try to get into the best possible shape going into that elective surgery?

You will truly make a huge difference in your outcomes in terms of your recovery, the safe passageway through the surgery, as well as your ability to resume your normal activities. And I think that patients have the ultimate power and the more engaged your patient is coming into their elective surgery, the better that they'll do.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 29, 2019
originally published: August 2, 2017

Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.

Interviewer: Today's listener question is what should somebody look for in an orthopedic surgeon when they're having a knee or hip replacement done. We're talking with Dr. Chris Pelt. He's an orthopedic surgeon and an expert in these types of replacements at University of Utah Health Care. What do you tell somebody if they were to come up to you at a party and say, "What should I look for in a doctor when I'm considering this kind of surgery?"

Dr. Pelt: I tell them to find a surgeon that they feel personally comfortable with, someone that they connect with.

Interviewer: Even if they're really, really good at it, if you're not making that connection you say go find somebody else.

Dr. Pelt: Yeah, exactly. I think that's an important thing because this will become a lifelong relationship with a surgeon. We will follow it for the rest of your life, so you want to be able to connect with that surgeon. But the other thing is you want to find someone who's technically very, very skillful. That's often with experience. Surgeons that perform over 100 hip or knee replacements a year tend to have a better outcome than surgeons that perform fewer surgeries per year, and so often is an important question to find out how many of these types of surgeries your surgeon performs.

Interviewer: And that's something you could just ask. You can just ask, "How many do you do a year?"

Dr. Pelt: Absolutely. And if a surgeon is offended by that question, the patient may want to take pause. Most surgeons that are experienced and comfortable with their own skill set will have no problem answering a question like that.

Interviewer: Beyond the surgeon, where you go, does that make a difference, kind of like the philosophy of the surgical center you do go to?

Dr. Pelt: Just like the surgeon, the facilities are very important both in their quality and cleanliness, their infection rates. A surgical center that does more of the same types of procedures will be better at what they do, so high volume centers that perform high numbers of hip and knee replacements annually will have better outcomes than places that do it more uncommonly.

Announcer: Have a question? Ask it. Send your listener question to hello@thescoperadio.com.