We are the first to acknowledge how complex and challenging this topic is. Thus we seek to share our experiences and insights gained from clinical practice and research about this important issue, more as a starting point rather than as a “gold standard” . The series was created after in-depth discussions with over 40 multi-lingual medical interpreters. Our hope is that trainees and health personnel everywhere will use our microlecture series as a tool to pause and reflect about their own practice.

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GIVE ME THE DEETS:

Methadone causes glycemic dysregulation
Methadone maintenance patients have blunted prolactin responses to insulin-induced hypoglycemia.
Delayed and inhibited insulin responses to food ingestion have been demonstrated in methadone maintenance patients.
Only the l-isomer of methadone causes hypoglycemia while the d-isomer does not.
Commercially available methadone is a racemic mixture of the l and d isomers.
Mouse models have demonstrated that the hypoglycemia can occur one hour after methadone ingestion.
The hypoglycemic effects of methadone are reversed by naloxone and mu selective antagonists β-funaltrexamine and naloxonazine.
Propoxyphene, an opioid drug structurally related to methadone, causes hypoglycemia, especially in patients with renal failure.

RECOMMENDATIONS:

1. Educate all patients about the risk of hypoglycemia when starting them on methadone.

2. Watch for unexplained sweating, palpitations, or lethargy in patients on methadone.

The Veteran population is rapidly aging with 9.2 million veterans who are 65 years of age and older. 1.4 million Veterans are “old-old” i.e. 85 years or older. Like the late Mr. Martin Wise (US Coast Guard Veteran) shown in the video, most of the illness burdens borne by Veterans are due to chronic illnesses like cancer, heart disease, lung disease, stroke and Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease). Due to exposure to toxins like Agent Orange, Veterans are at high risk for diseases like ALS and Prostate Cancer.

In additional to the cultural needs based on ethnic background, there are specific behaviors more common in Veterans due to the training and experiences related to serving in the armed forces which can manifest with specific behaviors like battlemind, for example.

When faced with physical threats due to serious illness, Veterans often work hard to meet the illness related challenges with courage and stoicism. Data show that Veterans, as a cultural group, are at a higher risk for post traumatic stress disorder, depression, and substance abuse. The cluster of these experiences will likely influence how pain, illness and end of life issues are experienced and interpreted.

More than 20 million Americans, one in 10 adults, have some form of chronic kidney disease. For those suffering from chronic kidney disease or end-stage renal disease, dialysis is a commonly recommended treatment. But a story published today in the New York Times reports that for older patients the treatment is increasingly being seen as an choice, not an imperative, and “a growing number of nephrologists and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis.”

The moving story , which was produced by Dr. VJ Periyakoil, tells the story of one older man’s decision to stop dialysis after 12 years. (“It takes a lot out of you – it’s a long drawn-process,” Christopher Whitney explained in the piece. “If I would get a kidney now, it would be a waste… I’m not the person I used to be.”) About the difficult decision-making process that faces patients like Whitney, Periyakoil said:

“Persons with kidney failure often struggle with making decisions related to dialysis. These decisions impact not only the patient but also their family members. For some, these decisions have ethical and moral implications as well. You may have questions like “Should I start dialysis right away or can I wait? Is it okay to refuse dialysis? I have been on dialysis and feel tired all the time and have poor quality of life – is it okay to stop dialysis? If I stop dialysis how long will live?”

Periyakoil urges patients to “think about what your life goals are as well as what matters most to you at life’s end. Be sure to discuss these important issues with your doctor so you can make your wishes known and make decisions that are right for you and your family.”

This short film (13 minutes) tells the real life story of Jim Ray Cooper and his experiences during the last six years of his life with advanced lung disease. Mr. Cooper was a Navy Frogman in the Korean War. The frogmen were predecessors for the modern day Navy Seals. Frogman training requires much higher levels of fitness, and during the course there is often a high elimination rate of trainees who do not make the grade. Mr. Cooper held a record for holding his breath for five minutes! It was indeed ironic that he developed severe lung disease and was chronically breathless and oxygen dependant.

In 2005, Mr. Cooper was told that he was dying of advanced lung disease and that he had less than six months to live. At that time, he was suffering with severe breathlessness and pain and was terrified that he was going to suffocate to death as his lung disease worsened.

Mr. Cooper was referred to Dr. Periyakoil’s Palliative Care Clinic for pain and symptom management. Dr. Periyakoil and her team began providing intensive palliative care and were able to control his pain, depression, breathlessness, PTSD and other distressing symptoms. Once his symptoms were under control, Jim regained his desire to live and spent the last six years of his life with his family.

As palliative care experts had helped him live longer and feel better, Mr. Cooper became passionately committed to increasing public awareness of this new and important medical sub-specialty. To this end, he asked Dr. Periyakoil to film his final years and use his story to teach patients, their families and health care personnel about the process of serious illness and the benefits of palliative care. He was particularly committed to facilitating access to Palliative Care for seriously ill Veterans and their families.