 Welcome. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawaii's live stream series and assisted as always by our engineers Rich and Ray. My guest this morning is Dr. Will Scruggs. He's the chair of the emergency department at Adventist Health Castle. I almost said Castle Medical Center, but the name has evolved. It reflects the fact that Castle is part of a larger network, mostly on the mainland. Welcome. Thank you. Thanks for having me. We've invited Will here today because he is among other things. He wears many hats. Will let him tell you a little about them. But among other things, he is the legislative liaison for our emergency medicine group. And as such has been involved with both some successful pieces of legislation and looking at next year for some others. So I thought now is a good time to kind of summarize the notable events of this season and talk a little bit about a few of them and then talk about next year. Sounds good. You should say many failures too. Well, you know, that's how legislation goes. Absolutely. I've been involved personally over the years of some and don't be in a hurry if you're trying to get a bill passed this month. I mean, don't be in a hurry. I mean, have a several years timeline in your mind. Oh, anyway, it's true. Well thanks for having me. Oh, it's great. I'm happy you're here. So yeah, it has been an interesting session as always. I'm dominant primarily by the advocate our choice. Yeah, Bill, of course. So that's huge, honestly. It might as well start with that. That's huge in my mind. Well, the background is it's been 21 years. So speaking of timelines in the making, I believe were something like the sixth state to approve a medically assisted end of life procedures. And there's obviously also some, this is done internationally longer than 21 years. In fact, I don't know if you saw the story. There was a 104 year old Australian scientist who just flew to Switzerland because he was done but hadn't died and had medically assisted end of life in Switzerland with the last couple of weeks actually. I did. Yeah, it's certainly has been something that's driven the conversation as there's over the last few months is some of the things that the countries in Europe are doing even beyond kind of what we would consider physicians assisted suicide related to medical conditions. Right. So it's been fascinating to watch. Yeah, it is. And I understand it's polarizing. And clearly anything carried to extreme is risky. However, no action is also action in my opinion. And we're both emergency doctors. And we see this. I don't mean medically assisted end of life, although we may have seen some of that too. But we see people who have no reasonable prospects for anything but increasing misery followed by death. And that's awful to watch. And it's a difficult situation for everybody. The physicians involved want to want to be able to alleviate suffering. They want to help people want to give people choices. And frankly, they've been limited. And it should be said, I mean, there are good arguments on all sides. And personally, it's I supported this bill. And I grew up in Oregon when they were passed the first in the country, the first state in the country to pass their death and dignity bill. And it's really the bill that all the states, my understanding is, all the states have passed it since have based their legislation on. And part of that's because there's a good number of protections in their four part. Why don't you describe the both sort of the process and the protections a little bit? And then I have a story to tell you. Sure. So and I'm not I'm not an expert in this, but in the field. But my understanding in the process is there's a couple of waiting periods. The patient has to request it from their primary physician to be eligible. In the state of Hawaii, you have to be a resident of Hawaii. You have to have a terminal illness. The expectation is you're going to die within the next six months of this particular illness. And it specifically a clue excludes age and other disabilities has to be this specific illness, such as cancer is going to kill you in the next six months. And you have to go to your primary provider and ask for a prescription. And the primary provider has to first provide you with a long list of information. You have to give your informed consent. You have to understand that we believe that if you take this prescription, it's going to kill you. It may not. You have to understand that there have been poor outcomes and unexpected outcomes related to this. You have to have another physician who's not affiliated with your primary physician also corroborate the diagnosis and your prognosis. You have to see a counselor either a psychiatrist, psychologist or a licensed counselor who can say that you don't have untreated depression. You can have depression, but it just can't be untreated or under treated. And then you have a waiting period. You have to submit a I believe it's a verbal request first and then I believe more than 20 days later you have to make another verbal request and you have to make a written request. And the written request has to be witnessed. It has to be witnessed by two people, one of whom could be a family member or somebody you know. The second person though cannot be a family member. They can't be anybody who's going to benefit from your death. So you can't be a part of their state or their will. And the idea being that you provide protection so we don't head down the slippery slope of euthanasia and try to address some of the concerns that people have related to others wanting to die. Exactly. And that seems like a reasonable process to me, sort of threading the needle between too difficult and too hard. Now, well I'm just going to tell you a story. Because I've been an emergency doctor in Hawaii since 1983. And early on in one of our more rural hospitals, obviously dying patient came in to see me. And I ended up calling his primary care provider who cared for him for many years. And that guy is actually now deceased, well the patient clearly, but also the provider. This was a long time ago and at the time he was probably about my age now. And I said, Bill, this guy, where are we headed here? This is not going to end well. He's miserable. He knows he says, ah Craig, I have a plan for this. I'm like, really? Because those doctors are like, oh we're going to do this, we're going to do that. It's going to be fine. There's a lot of evidence that doing too much near the end of the life is actually more often harmful than helpful even if the goal is prolonging life. And particularly if the goal is having a comfortable life. And he says, no, what I do is I, and I said I have done that in this patient already. I write a prescription for narcotic pain medicine. I caution the patient that taken in large amounts it can cause respiratory suppression or even death. It should be taken, you know, one every six hours is needed for pain, etc. And I give it to him. And he said, as far as I know, no one's ever used it, but at least they have the option. And this seemed actually wise to me. And I have to say that, well, I'll tell you what happened. One of my neighbors, we were friends at about that period of time and for the next about 20 years. And he's a little older than me. As a smart guy, we talked about lots of things, including what we didn't, didn't want done at the end of life. And for the record, will. I probably told you this before. I certainly don't want heroics. And if there's no hope, please help me slide away. This is in case I'm in capacity. I tell this to everybody. In fact, we can talk about that tattoo thing. Yeah, we should go there. Let's not go there quite yet. So anyway, we were no longer neighbors. And I hadn't spoken to him in no probably four or five years. And I get this phone call. And it says, this is won't say his name. How are you? I said, Well, I'm fine. How are you? And he says, I had a pain in my side. I ignored it for a few weeks. It got pretty bad. I went had a cat scan. I've got terminal liver cancer. Oh, and he said, Remember our conversations. I do. So I went over and we had a nice visit. He was bright yellow. He had lost probably 30 pounds. He was not a large man. And he was awake and alert and cheerful. And he said, Look, I don't know how my end is coming. I'm prepared for it. I've talked to my doctors. There's nothing to do. And I don't want to suffer. And I said, Well, I'll write your prescription for some pain medication. And you have to be careful. It gave him the same spiel I'd heard from my friend, the wise primary care provider country dot guy some years before. I wrote him the prescription. I don't think he used him. But I have no idea. And he passed on pretty quickly. He had clearly terminal disease. But it struck me at the time that we do a much better job with our four legged family members than we do with our two legged family members. Yeah. Thanks for sharing that too. And that's, and I say that because it's kind of an unsaid part of palliative care medicine, I believe, coming from two approaches, either from the physician who might put things into those terms. But patients are smart. And if you have, you've been given the precautions about the medications that you're on and patients under palliative care hospice care with severe illness, painful conditions, they have these medications available. And they're smart enough to know what they can do with them. And that's one of the reasons I supported this bill is I think this provides some structure and hopefully some safety to this issue. I agree. You know, it's because what you said is reality. I'm sure that story I just told has happened many times. And we know that it actually happens in structured palliative care settings all the time too. So we should actually recognize it. And as you said, provide structure and safety. Right. I think the other thing that's hard for us in medicine to recognize is sometimes comfort is all we have to offer. There's nothing wrong with that. It's just it's hard to it's hard for us to own that verse geared up to we can fix this. It's hard for patients often to recognize it. That was not true of my friend. He knew his situation very clearly. But we owe it to people, I think to share the likely next steps. And we should recognize as in the rest of life, inaction is also action. Right. And I think we should give some voice to the other side of the argument too, because certainly there are people who make very reasonable arguments who disagree with this, would disagree with this conversation entirely. Absolutely. In fact, it's possible. So I'm on low college. That's true. And so we should say there are two things. The bill does provide protection for facilities and physicians who don't want to partake in this. And of course, I have no problem with a physician who says I don't want to be a part of this type of practice, or a facility doing the same thing. And there are there are protections within the bill saying the facility does not have to allow a provider at their facility to do this. And a provider at a facility who wants to be able to do this for the provider to say I want no part of this. And I think that's perfectly appropriate. Because there are a number of very reasonable arguments. I think the slippery slope argument related to this has some credibility to it. I think there are ethical arguments that do make sense to me that resonate with me about just dignity of life. And if you're willing to take it in any capacity, that you don't you don't believe in the dignity of life. And so I understand that I personally, I feel especially in medicine, if you have a situation where you have good arguments on both sides, I think it should be patient and provider choice in that case, as long as it's not going to harm somebody else. I agree. And when I said inaction is also action, I was specifically referring to the fact patients need to know what their likely prognosis in course is. And if there are choices and the fact that we could be wrong, when we make these prognoses, that's the likely outcome. But there are cases where people live years past terminal diagnosis and prognosis. I'm aware of at least one person who's been on and off hospice care for the last five years, she's doing pretty well. After the break, we're going to talk about a little more about end of life and maybe some unique ways of telegraphing wishes. And then we'll go on to some of their legislative issues. So we'll see after the break. This is Think Tech Hawaii, raising public awareness. Hi, I'm Dave Stevens, the host of Cyber Underground every Friday here at 1pm on ThinkTechHawaii.com. And then every episode is uploaded to the Cyber Underground. That library of shows that you can see of mine on YouTube.com. And I hope you'll join us here every Friday. We have some topical discussions about why security matters and what could scare the absolute bejesus out of you. If you just try to watch my show all the way through. Hope to see you next time on Cyber Underground. Stay safe. Welcome back. This is Craig Thomas, your host on Much More on Medicine. And with me is Dr. Will Scruggs, the director at Adventus Health Castle Merge Department and our group's liaison to the legislature. And before the break, we were talking about the medically assisted dying bill that recently got signed, which honestly is the big medical bill of the recession. It led to something that's been a kind of hot topic recently in emergency medicine. And we got to talk about it. So because it's associated with a great photo which anybody who wanted to Google and find online, there is a and this has been a joke sort of an emergency medicine for many years. Hey, I don't want to be coded. So people talk about getting a tattoo on their chest that says do not resuscitate. Well, a guy did it. And this was not any little obscure tattoo. It's like about from here to here. Exactly what we're looking when we're doing chest impression. And it said do not resuscitate. In my understanding, it even had his signature on it. And guess what? He rolls into an emergency department somewhere. I don't know where it was on the mainland. And people look at that and they say, well, that doesn't look like an official living will. I don't see a post form. I don't I think we better resuscitate. And they did for a while. And then they sensibly got some ethicists involved and I think changed course. But it's generated a whole bunch of commentary. And before the break, we were talking about choices matter. And you can choose to resuscitate, you can choose not to resuscitate. But you have made a choice, you shouldn't be saying, oh, I just did the default. We resuscitate. Everybody doesn't matter. It's a safe thing to do. No, it's not. It has consequences also. So I'm like, well, until you get better evidence than a cat to on somebody's chest, I'm going with it. But we haven't talked about this. That's an interest. I would say I agree with it. If that's all the evidence you have. At the same time, I believe and listen to family members and I had a family member who came in a wife, child, father, mother who came in and said, yeah, he really believed that. And I think you should stop. I think I'd be okay with that. I'd be fine. But there is a permanence to death that, unfortunately, you can't confirm if do they still believe they, they don't want to be resuscitated. Did they do this when they were sick with cancer before? And now they're not sick anymore? There's too many questions to just accept that it face value. I think it's challenging. And I agree that you should always look for more information that are there for those out there listening to this, there are better ways. Get somebody with durable power medical attorney, get an advanced directive. If you're in a certain circumstances, get a pulsed form. But but in our line of work, I got to say, I would feel like somebody's playing a prank on me. I would, if I saw that, it would be hard. Well, with our morbid sense of humor, not to look around and wonder where the camera. Well, maybe the first thing is to get like an alcohol swab and see if it rubs off. But but in all seriousness, we're often faced with inadequate data. And lot not a lot of corroboration. And so that the airing on the side of when in doubt resuscitated back is entirely reasonable. Because as you say, if you don't, you've made up, you can walk it back later, you can almost always walk it back later and and withdraw care if you need to. Yes. But it's not that easy sometimes. True. So that was that's been the last month or six weeks circulating through the emergency literature and circles the topic. And I'm kind of on the side of if you really went to trouble, get tattooed. Sure, if somebody says, you know, guy is nuts, he changes mind. Or if it looks to you like a clearly self limited condition. Sure, I'd manage it. It looks like the progression of an untreatable condition. I probably wouldn't. Hopefully you'd have family with to share. Anyway, let's talk about some other well, firstly, anything to add to that. Otherwise, let's talk about it. I'm glad it's driven the conversation. It's an important conversation for us. It really is, you know, and actually, a plea, which is, let your friends know, let your family know, get the documentation, have a trusted person to speak on your behalf. Because the real question isn't usually an emergency department. The real question is a week later up in the ICU. Right. And having someone to help make decisions for you, if you can't, it's huge. Let's talk about other legislative items of the session and then maybe where we think there's opportunity for next year. Sure. So I think the other big one, at least in, well, nationwide in medicine is the opioid issue. And we did have a couple of bills last year than this year, working the way through the legislator, trying to address that as legislators are very understanding and we're concerned about this. It's a big issue in Hawaii, deaths from overdose involving opioids increased by, I think it was 30 some percent or 100 some percent. It was a significant amount of people, I think over on the order of 100 people died last year, as my understanding, related to opioid overdoses. Yeah, we had Dan Galanis here a few weeks ago and the numbers are a little unclear. But yes, the it's a multi-fold increase. It peaked in Hawaii, I think like 2014, 2015, but it hasn't gone down significantly. And compared to southeastern U.S., we're pikers. But sadly, well, I'm happy for us. I'm sad for them. But overall, you're right. It's a huge problem. In fact, a whole interesting topic in itself. I don't think we'll talk about how this might have had the roots laid years ago. Although maybe we should come back and do that sometime. Let's talk about the legislation that's trying to unwind. Yeah, so this year's legislation was SB 2646. And it essentially requires all physicians, when you write for a controlled substance, first you have to check the prescription drug monitoring program of the database. And just to explain what that is, it's a repository. Any controlled substance prescription that's filled in Hawaii, the pharmacy has to submit it to the PDMP. Any physician who supplies the medication from their office, they have to submit that to the PDMP. So in an ideal world, the physician, if a patient comes in and I'm going to write them a prescription for another controlled substance that might put them at risk for overdose or other complications, I can look up in this database, whether they've had recent prescriptions filled, look to see if somebody might be abusing medications, they might be overusing them, if they might be diverting them. There are some issues with the PDMP, as you all know, in working with it. But in general, it's a good repository for information. Some of the limitations include the fact that it takes seven days, it can be up to seven days before something gets on there. The military prescriptions, prescriptions filled on military bases or military institutions aren't there, it's a big deal for us in Hawaii. But how this bill would say we would have to check that database with a few exceptions, and the primary exception being for a prescription for three days or less, coming from an emergency department, basically, our emergency situation. But all other physicians would have to check that database. I think that's real progress and it circles to something we're going to talk about in a minute, namely information in general. The days, I hope, of seeing somebody at one emergency department and walking in the next day, hearing them give the story, oh no, I haven't been anywhere in a while, no, my shoulder pain is really acute, and it's the guy you saw yesterday. Maybe at the other facility? Happened to me a year ago. Several times at Waikawa and Castle. Yeah, yeah, well this was Waikawa and Kahuku, but same idea. Hopefully those days are nearly behind us. Just so everybody knows, I think the assumption among most people is that medicine is sort of like banks, information is readily available, it doesn't matter which branch you're at, etc., and sadly it's not true. No, it doesn't work that way, and it's complicated information, and you're dealing with complicated situation, too, with patients who often are really trying to alleviate their pain and suffering, maybe not going about the right way, but you want good information, and you have to be able to get there easily, and that's the big issue we've had with this, that's why I haven't supported the PDMP mandates, because it's not a system that's easily usable, and there are some holes in it. Now, the legislature, I think, did a nice job. They put a sunset clause in with this bill, for example, so in five years, unless they re-up it, it will sunset, and hopefully by then, we'll have the mechanisms in place that will, information will just kind of pop up for us, and we won't have to go hunt it down. You know what? Let's talk about information popping up. So, the back story to this is that, I think it was 2011 in Washington state, they recognized that there were a small group of people that were using emergency departments over and over again for a whole variety of reasons that could have been better served in other care settings. And initially, there was a rather draconian plan, I believe it was limiting patients to three ED visits a year. Well, that's fine if you're not sick, but if you're sick, it may not be okay at all. Or just worried that you're sick. Or just worried you're sick, which ultimately should be dealt in another setting, but I, but you got to figure out if they're sick first, and that's not always easy. They came up with something called EDIE, ED, Emergency Department Information Exchange, which my understanding has now been adopted in Washington, Oregon, is spreading through California. 13 other states also. So, it was a part of a larger process. They called it seven best practices. And the ED Information Change, it allowed for a quick dispersal of information to emergency providers primarily, and it's grown to other providers as well. It wasn't really limited to Washington State, just to give the credit to the people who put it together. It's now owned by Collective Medical Technologies at the time. It was put together by a social worker in Idaho. Which is awesome actually. Right, who said, I have all these care plans. How do I get this information out to people? And so, this is potentially a huge win. And something that at Venice Health Castle now has signed on to, and we hope Kaiser will soon. And eventually, hopefully the entire state, all hospitals in the state will have this. The idea being, as soon as somebody checks into our Emergency Department, I get some information about that patient if they're at risk for, if they have concerning features. If they've been to multiple emergency departments recently, if they have more than five recent prescriptions on the prescription drug monitoring program. And so related to the opioid issue, it gives us rapid access to information. It pops up right on our tracking board. At the hospital, it's one click and I get a one page summary about this information. Then I can go to the PDMP if I have other concerns and need more information. But it also provides more than just information related to opioids. It also provides care plans from other facilities. Most of the time that deals with patients who are on long-term care plans, who we want to treat their pain, but we want to do it safely. And usually, adding more medication from the Emergency Department is not a safe way to do that. No. Basically, if someone's going over and over again, something isn't getting solved. Right. The patient's not comfortable and we might be putting him at risk by adding more medication. Exactly. Let's hope the legislature takes this up next year. The cost is honestly pretty nominal. I went to the University of Washington over to Christmas holidays and went to the Emergency Department and watched this happen. It was awesome. So let me know how I can help push for this. And now is the time prep for the legislative season, because what gets set up now is what gets to become a bill in January. So listen, I'd like to thank you very much for coming on the show today. We should do this again. We should. Thanks for having me. Thanks. Thank you everyone. It's Craig Thomas, much more on medicine with guest Will Scruggs.