Articles of Interest

The Good Death points us toward a great article from "Scientific American" that discusses consciousness after death.
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Voodoo Medicine Man gives us pointers on "How to Know You're in the Wrong ER".
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Sallysue, a new nurse-blogger at Sallysue's Soapbox, is singing the "Night Shift Blues"
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Leo Levy at DNR/DNI gives us all his trademark, reality check with his post, "Tie Me Up, Tie Me Down".
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Last and definitely NOT least... It's been waaaay too long since I last visited Pallimed's Arts & Humanities section. Very stupid on my part (I'm subscribing to the site as I write this). Here are just a couple tidbits to entice you to visit: "Postmortem Photography - A Lost Art?" and a great post featuring artist "Laurie Lipton".

The article about postmortem photography completely jogged my memory about an adventure that I need to write about. Yay!

"Cascadian Green Is People!"...

I was going to take us on another Ghost Tour for Halloween, but this was too irresistible...

The authors of the lovely food blog, "Bread and Honey", recently noticed something quite odd about the packaging for Cascadian Farms Broccoli. Here's a link that will take you to two posts about their discoveries. It's somehow, both disturbing and endearing.

Early Voting: Sweet, Sweet Release

I voted last week and I cannot begin to describe the feeling of having the burden of this election removed from my shoulders. I am no longer required to watch the ads, follow the polls or read the latest "dirt" on our candidates. My vote is cast... my mind can't be changed. It's over. I'm free!

This is me AFTER voting...



This is me BEFORE voting...

Fun-filled Funereal Facts

"Suzy From Dubuque" Syndrome*

"Suzy From Dubuque" Syndrome (SFDS) is an affliction that often attacks family members of the elderly and/or dying. It specifically attacks those family members that have NOT been in recent contact with the patient. SFDS does not make itself manifest until its victim sees the patient after an absence of least 6 months to many years. Here are some common signs/symptoms:

• Uncontrollable fits of criticism aimed toward the "hands on" caregiver's ability to properly meet the needs of the patient.
• Irresistible desire to undermine the wishes of the caregiver and patient by insisting on hospitalization, lab work, invasive testing, IV fluids, tube feeding, etc.
• Feeling of superiority in medical knowledge and caregiving techniques directly proportionate to the amount of time spent away from the patient.

Of course, SFDS has a profound impact on the caregiver who is most likely letting the visiting, long-absent "Suzy" stay in their spare bedroom. Some common effects of SFDS on the caregiver:

• Marked decrease in confidence about one's ability to care for their loved one.
• Marked increase in guilt related to their new-found "inadequacies".
  
• Loss of ability to advocate for their loved one as they increasingly cave in to the demands of the SFDS afflicted family member.

This syndrome is extremely difficult to treat. Medical professionals can play an important part in helping to shore up the caregiver's confidence and aiming reality checks toward the "Suzy". However, if SFDS is to abate at all, it is usually due to one of the following:

• The "Suzy" has no more time off from work and must return home.
  
• The caregiver has finally developed the "huevos" to tell the "Suzy" to "eff off" and sends them packing.
  
• The patient has died. (Probably the most common cure for SFDS)

(The old, two by four up the side of the head of the "Suzy" has potential, but has never been tried by myself or any caregiver that I know of.)

*My sincere apologies to any literal Suzy from Dubuque that may be reading this

Almost Better Than a Death Match

I am beyond sick of this nasty, political campaign... From now on, I'm only gonna pay attention to stuff like this!

Your Moment Of Awwwww...

Ninja Cat (As scary as Tripod, but with more legs)

Pallimed: Hosting Grand Rounds

Pallimed is hosting Grand Rounds this week. Absolutely fantastic reading to be had by all! Don't forget to check the comments section for a listing of more, excellent submissions.

I also want to thank Pallimed, from the bottom of my heart, for including Dethmama Chronicles in this issue of Grand Rounds. What an honor!

A Day in the Life of a Claims Examiner-- Part One

Insurance Guru

I've had this rant bouncing about my brain for many years. I processed health insurance claims for several years and trained examiners for a couple more.

There seems to be a perception out there that examiners are routinely told to deny, delay or otherwise hinder paying claims so that the Company can hang onto its bucks for some nefarious world domination scheme.

I've worked for four, very large insurance companies and this has NEVER been a policy. Who wants to work a claim more than once? A claims shop is all about inventory and days on hand. A claim that's been in the shop over 10 days will have someone stopping by your desk and tapping a toe until it's processed.

We are also people. The claims that create the most difficulties to process are, of course, the ones for the most catastrophic cases. The last thing we want to do is add stress to patients and families by not doing everything in our power to get that claim paid. We had an informal rule that if a claim came in for a patient now deceased, it got paid. Now. We would run it up the food chain until it got released by whomever had the security to get it past whatever edits we were facing.

The average claims shop is not run by Scrooge McDuck nor is it full of claims processing Gremlins with popcorn bags on their ears. They are just like me and want nothing more than to process your claim timely, accurately and only once.

Bad Kitty and the Hospice Nurse

2250 hrs. -- After being, seemingly, on his death bed for several days, Stanley L. has "rallied". Not only is he now up and about, but he's also being abusive, paranoid and is refusing to take his meds.

I sit at the cluttered, kitchen table with the patient and his wife. Marie looks disheveled and exhausted. Stanley is painfully gaunt, grizzled and exuding obstinance. Frankly, I'm a bit surprised that this frail, dying man has made the trip from his bedroom to the kitchen. Note to self: never underestimate the power of the near-death "rally".

"Please, take your pills, Stan", I beg. "I know that you'd feel so much better."

"Forget it. I just want you to call the police and get that crazy woman out of my house! She has no business bein' here!"

All of my pleas and logic are for naught. Our conversation is going in circles. Stan vehemently refuses to take his medications and then returns to his delusional train of thought. I look at Marie... she rolls her eyes and gives a little shake of her head.

Suddenly, a cat jumps onto the table and positions itself directly in front of me. Its face is within inches of mine.

"Don't touch him!", shouts Stanley. "He's mean!"

I can take a hint. The cat is matted and filthy. Its left, front leg is missing, his left ear is nearly bitten off and the left eye is also gone. Good grief... no wonder the cat is so ill-tempered, it's missing at least one of everything.

"Hello, Tripod," I say.

"How the hell did ya know that's his name?", laughs Stanley. I feign surprise about my "lucky" guess and manage to get him to chat a bit about his beloved cat. Maybe now, I can take advantage of Mr. L's improved mood...

Taking the small cluster of pills in my hand, I explain the purpose of each one to Mr. L., hoping that he'll realize that no harm is intended.

"Okay, I'll take them.", he says, reaching for the pills. I hand them over and Mr. L. promptly flings them to the floor. Tripod immediately makes a three-legged leap from the table and heads for the medications.

"Gahhh!", I screech as both Marie and I dive to the floor to retrieve the pills. I mutter and curse myself for my stupidity as I crawl on all fours under the kitchen table.

Once again I am face to face with Tripod as I fumble amid the piles of fur and petrified cat turds. The cat has found one of the small tablets and is batting it around. With some hesitation, I reach for the pill and Tripod smacks me across the face with his paw. I jerk back and hit my head sharply on the underside of the table.

"Oww! Crap! Ohhh... that hurts." I'm seeing stars and need a few seconds to clear my head. The fog lifts and I see that both Tripod and the pill are gone. Still on the floor, I peer over the edge of the table and look at Mr L.:

"Mr. L., I'm pretty sure Tripod took off with your Ativan. It'd be awful if something bad happens to him!"

"Yeah, I'd feel real bad. I'm really sorry about all this."

Marie and I do a pill count. We're missing just the one Ativan and the cat is nowhere in sight. For now, all we can do is hope that Tripod has no interest in eating it.

Done in by all the excitement, Stan is happy to let us tuck him back into bed. Marie, satisfied with this turn of events, bids me "goodnight". So I head for home... covered in fur, smelling a bit "cat pissy" and sporting a new bump on my head.

Two days later, Mr. L. passed on and Tripod is still among the living. I'd like to say that, thanks to Ativan, he's now sweet, cuddly and anxiety-free...but I'd be lying.

The Mean Kitty Song

Pallimed: Bringing Initiative 1000 To The Front

Image via WikipediaI couldn't be more pleased to see Dr. Rosielle and Dr. Sinclair of Pallimed expanding on Washington state's upcoming vote on their "Death With Dignity Act". The publicity on this issue has, indeed, been very poor. Please take the time to peruse their posts on this very important initiative. Below is a partial excerpt from one of their articles:

 (See standard disclaimer at the end RE: Hastened Death)

"I wanted to highlight some of the editorials and articles regarding the upcoming Washington State I-1000 Death With Dignity Act. (You can get some basic info from my previous post, if you are not familiar with the proposed legislation)

The issue of hastened death and specifically physician-assisted suicide is important for the palliative care community as it highlights many of the concerns we (legally) deal with on a daily basis: autonomy, adequate symptom control, the personal nature of suffering, conflicting values among patient, family and staff, conflict of faiths, the loss of control in the dying process, the possibility for personal growth during times of crisis. These concerns are in a complex dynamic in palliative care and so the many heated arguments about hastened death highlight the turmoil involved in caring for dying patients. This allows the general public some insight into what hospice and palliative care teams would call Wednesday afternoon.

Dan Savage wrote an editorial last week titled, "In Defense of Dignity
I Hate to Play the I-Just-Watched-My-Mother-Die Card—But, Um, I Just Watched My Mother Die." Please go read it then come back here. Pallimed linked to his eulogy for his mother last April. (An excellent read with great insight into family loss.)

His piece focuses mostly on control over the dying process and the issue of choice. I think the selection of the word 'choice' is important and I am surprised more has not been made of this initiative from the national press or even medical blogs. This would seem to be a very polarizing and political issue which would have have the press salivating, no?"Drew Rosielle MD, Member, Oct 2008

You should read the whole article.

Articles of Interest

This coming fall, Washington state will be voting on Initiative 1000 or the "Washington Death With Dignity Act".
If approved, the act will allow terminally ill patients the option of choosing to end their lives by way of physician assisted suicide (PAS).

Jessica Knapp's blog,"The Good Death", has posts discussing this initiative. She also includes a very good link, in her "follow-up" post, to the University of Washington's Bioethics website where both pros and cons of PAS are discussed.

Initiative 1000-Physician Assisted Suicide

Physician Assisted Suicide--Follow-Up

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The Happy Hospitalist has his own version of the Mini Mental exam..."What is the significance of 9/ll?" He says it works "like a charm" and is a real time saver!

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Completely off topic...

On September 30, Jalopnik.com posted "Ten Best Vehicles for the Coming Financiapocalypse". My absolute favorite is, without a doubt, the Mini-Winnie. It just boggles my mind when I think of all the possibilities that a vehicle like this would have for an on-call hospice nurse! Not to mention the incredible satisfaction I would get by merely driving my "home" off into the sunset when the bank decides to foreclose.
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and...

Buck's Ghosts and Hauntings has a great post titled, "My Spirit Guide". See how you, too, through the magic of Google, can become an uncanny psychic! This is a must read for anyone that watches "Haunting Evidence" on TruTV.

A Final Request

When 71 year old Sally Barton died in August of 2003, her obituary requested that "memorial gifts may be made to any organization that seeks the removal of President George Bush from office".

I can only imagine her posthumous disappointment when he was reelected in 2004! Alas,poor Sally, only time and the end of President Bush's term of office have made her request come to fruition. I wish Sally could tell us what she thinks of this year's Presidential election campaign. Because I know she'd have an opinion!

The "Inhalinguisher"

1800 hrs -- Telephone conversation:

"Hello... is this the hospice nurse?"

"Yes it is. How can I help you?"

"Well, we keep a little fire extinguisher by Marvin's chair because we're afraid that he'll forget to take off his oxygen when he smokes. He's so confused nowadays."

"Okay..."

"Well, he just took a big puff off the extinguisher because he thought it was his inhaler."

"Oh, my God! How's he doing?"

"Well, he's rolling around on the floor right now."

"Ma'am, please call 911 right now! There's nothing that I can do for him. He needs to go to the hospital!"

"Well, he says he doesn't want to go to the hospital."

"Does he have his oxygen on?"

"Well, no."

"Get his oxygen back on and turn it up to six liters. I'm going to hang up now. Keep your phone line free because I'm going to call you back in less than ten minutes."

"Well, alright."

Lucky me... I just happen to have the phone number for our community's Poison Center on speed dial. The news isn't good. The knowledgeable woman on the other end of the line tells me that the effects of inhaling the contents of a fire extinguisher can be devastating even to much younger, healthier lungs. That's all I need to know. I immediately call Marvin's wife:

"I've just talked to the Poison Center. You've got to call 911 and get Marvin to the hospital now!"

"Well, okay."

The next day I call my supervisor to get report before the start of my shift. Marvin, I am told, is doing great. In fact, he hasn't felt this good in a very long time. My supervisor laughs and tells me that the hospice is considering issuing little fire extinguishers to all patients with respiratory problems. Well, well...

Pardon Our Progress...

Dethmama Chronicles will be undergoing a facelift!!

The tech crew (that would be me looking baffled at my Mac) will be installing a new banner and working with fonts and link colors so everything will match and be all pretty 'n stuff. So this weekend, do not be taken aback if the colors on this site are in a constant state of flux. It's just me trying to make up my mind.

My sincere thanks to Cullan Hudson for his banner design. I feel that his work will, indeed, reflect the spirit of the story-telling,"off-topic" posts and occasional irreverence displayed by both myself and Insurance Guru. (Note: the "nurse" image in the new banner is a dead ringer of me in all my post-menopausal gloriousness... ask anyone)

Thanks,
Dethmama

Your Moment of Awwwww ...

Insurance Guru: Sending Hospice Visit Data to the Big Bad Wolf (Part 2)

So Medicare is insisting on all sorts of visit data from Hospices...

This brings to mind the sweeping coding changes that Medicare launched several years ago for Skilled Nursing Facilities. They moved from 6 simple revenue codes to 50+ "RUGS" rates. RUGS stands for Resource Utilization Groups and the codes are things like RUX, SE3 and RMC. Sounds like we've stepped into a Dilbert cartoon or found a new rap star!

I've yet to work for an insurance company that could automate the payment mechanism for the RUGS calculations. To start with - it's system suicide to replace numeric codes with alpha characters. Thankfully, we didn't have many contracts based on Medicare reimbursements. We still use the simple 6 revenue codes in the contracts offered to our providers. Check out this article for an exercise in "quantum RUGS mathematics".

Take the approaching Hospice funding cuts, add the data scavenger hunt and you will see Medicare revamping all Hospice billing in an attempt to save money. Of course, Medicare in their perverse, logical fashion will attempt to convice the Hospices that all their number crunching and new, magic codes will get the hospices more money.

I think it will look something like this:

Code VC98.^*347 - Respite care in the home not to exceed 3 hours for ambulatory patients that like to dress in blue. For patients in other colors see code VC98.^*348 and above. For non-ambulatory patients see coding that begins with nine million and above. For more than 3 hours, too bad.

Code ZB.,;) - Inpatient care per day. Anywhere. This is it - all you get. Don't care what services you provide.

Code JUS24?& - Routine home care - per 15 minutes for patients with dentures.

Code JUS25?& - Routine home care - per 15 minutes for patients with houseplants.

Code JUS26?& - Routine home care - per 15 minutes for patients that live less than 10 miles away.