Friday, January 17, 2020

Let’s Be Wise About Smartphone Use

Andrew Brooks, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

Since their invention in the seemingly distant past of 1992, smartphones have evolved from a clunky curiosity the size of a brick to sleek, superpowered machines that fit in our pockets and purses. Ownership of smartphones has skyrocketed from 35% of Americans in 2011 to 81% in 2018 according to the Pew Research Center, and  95% of American teens have access to a smartphone. In the pediatric clinic setting, we see the effects of smartphone usage by our young patients nearly every day: the good – occupying our patient’s bored siblings during a clinic visit; the bad – having to repeat questions to our patients because they’re busy checking social media; the ugly – patients with anxiety and depression associated with problematic smartphone usage; and even worse – motor vehicle accidents associated with distracted driving, often because of smartphone use.

So while often beneficial, these devices can pose problems – so much so that scientists are focusing on the potential negatives.

What is problematic smartphone usage?

The psychologic study of problematic smartphone usage is still a newborn science. Doctors use a resource called the DSM (Diagnostic and Statistical Manual of Mental Disorders) as the gold standard of identifying and diagnosing psychologic problems. Smartphone addiction hasn’t officially been added to the DSM yet, but these major criteria – negative behaviors found to be highly suggestive of addiction – have been proposed in research journals:
According to the Pew Research Center, 95% of American teens
have access to a smartphone. But scientists are focusing on the
potential negatives that result from excessive usage. 
  1. Continued inability to resist the impulse to use the smartphone;
  2. Symptoms of dysphoria (sadness), anxiety, or irritability after a period of withdrawal from use;
  3. Using the smartphone for a period longer than intended;
  4. Persistent desire and/or unsuccessful attempts to quit or reduce smartphone use;
  5. Heightened attention to using or quitting smartphone use; and/or
  6. Persistent smartphone use despite recurrent physical or psychological consequences.

Researchers also recommend assessing people for these functional criteria, which indicate the negative effects of the addiction on a normal lifestyle:

  1. Excessive use resulting in persistent or recurrent physical or psychological problems;
  2. Use in a physically hazardous situations (such as while driving or crossing the street) or situations that have other negative impacts on daily life;
  3. Use that impairs social relationships or performance at school or work; and/or
  4. Use that is very time consuming or causes significant distress.

In their paper, Proposed Diagnostic Criteria for Smartphone Addiction, scholars recommend that for someone to be classified as addicted to their phone, he or she should exhibit at least three of the major criteria above, and two of the functional criteria. So if you experience three of the major criteria and two of the functional criteria, your condition would justify being labeled a mental disorder.

What are the effects of problematic smartphone use?

Research studies have blamed excessive smartphone use on mental health problems. They have linked excessive usage with increased risk of anxiety and depression, poor sleep quality, lower daytime function, and poor performance in school.

The danger of phone use while driving is well documented (and honestly, quite shocking). About 25% of motor vehicle crash fatalities are associated with distracted driving, the largest culprit of which is texting or other use of electronic devices. More than half of all accidents involving teens are directly caused by distracted driving.

What can pediatricians and parents do?

Smartphones have become an integral facet of modern culture and communication, and that won’t be changing soon. This begs the question:  What do we do about the problems these devices can bring?

The American Academy of Pediatrics recommends that parents not allow infants and toddlers younger than 18 months old to use screen media devices (including smartphones) and strictly limit screen time for older children under age five. For older children and adolescents, parents need to firmly and consistently place limits of the type and duration of screen usage, as well as designate smartphone/media-free times and places, such as the dinner table and bedroom. The current generation of parents have a responsibility to guide the development of healthy offline behaviors for children, and healthy online behaviors as well.

As pediatricians, it is our responsibility to be aware of the risks of problematic smartphone usage, and to encourage parents to take control of this new facet of social development.

Wednesday, January 8, 2020

DR. ROBERTS: Modifying your Alzheimer’s risk

By Sid Roberts, MD
Lufkin Radiation Oncologist
Member, Texas Medical Association

Editor’s Note: An earlier version of this article was originally published on Dr. Roberts’ blog and The Lufkin Daily News.

One of the most feared illnesses today is Alzheimer’s disease. Aloysius Alzheimer, a German psychiatrist and neuropathologist, first described the characteristic brain changes and associated dementia more than one hundred years ago. Despite the rapid advance of medicine and technology over the intervening century, we still know far too little about this devastating and incurable disease.

Diagnosing Alzheimer’s dementia requires expensive testing looking for particular brain damage due to accumulation of beta-amyloid and tau protein, which cause the signature plaques and tangles there. Because of the expense, many patients with dementia never get tested and their condition might not get labeled Alzheimer’s disease. Regardless, most dementia – 80% – is the result of Alzheimer’s.

Alzheimer’s disease can last more than a decade, starting with mild cognitive impairment and relentlessly progressing to more difficulty solving problems, personality changes, getting lost, forgetting people or significant life events, and ultimately losing the ability to care for oneself, to toilet, to speak, and to walk. Some people’s condition progresses more rapidly than others. The Alzheimer’s Association website can be a great resource for caregivers or those wanting more information.

Unfortunately, currently available prescription medications, which may help somewhat with mental function, mood, behavior, and ability to perform activities of daily living (like bathing, dressing, eating, etc.), do little to change the course of the illness or the rate of decline. We don’t yet have a magic bullet.

Genetic factors can increase risk of dementia, but most dementia cases occur sporadically in older adults in whom multiple genes influence risk. We cannot – yet – modify our genes. Changing our lifestyle, however, is one way to reduce the odds of developing dementia, even for those with high genetic risk. Many common dietary and lifestyle habits and activities recommended to improve overall health (think heart disease, cancer, diabetes) may also be of some benefit with dementia.

One Mediterranean-type diet, which researchers named the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet, focuses on consuming foods that help brain health: leafy green vegetables, berries, nuts, olive oil, fish, wine in moderation, and avoiding red meat. The point is, these broad dietary recommendations are not new and not exclusive to affecting Alzheimer’s risk. Let’s just call it healthy eating.

In addition, physical and mentally stimulating activities – such as reading or crossword puzzles – are important as we age. Both diet and exercise may help with Alzheimer’s risk by virtue of preventing conditions like diabetes, hypertension, and coronary artery disease that can exacerbate cognitive decline. Understandably, most older adults cannot keep up the same rigorous workout routine they might have when they were younger. But exercising at least 150 minutes a week, whether by biking, walking, swimming, gardening or doing yard work, can increase the flow of blood to the brain, improve the health of blood vessels and raise the level of HDL cholesterol, which together help protect against both cardiovascular disease and dementia. One study found that people who engaged in more than six activities a month—including hobbies, reading, visiting friends, walking, volunteering, and attending religious services—had a 38% lower rate of developing dementia than people who did fewer activities. Along with physical and mental activity and a healthy diet, individuals who avoid smoking tobacco also have a lower dementia risk.

There is mixed evidence about the use of fish oil supplements to improve thinking and memory in Alzheimer’s. Given the benefit for cardiovascular health, it is reasonable for most people to take a fish oil supplement. Vitamin D deficiency has been identified as an independent risk factor for the development of dementia of any cause, and supplementation is recommended for patients in whom deficiency is diagnosed. However, no dietary supplement has been proven to be effective in boosting memory or preventing dementia.  It is wise to talk to your doctor about the risks and benefits of any over-the-counter medications or supplements you are taking.

As with any recommendations, we must acknowledge that playing by the rules will not guarantee we will prevent Alzheimer’s (or any other disease, for that matter). Probably two-thirds of the risk of developing Alzheimer’s simply can’t be modified. But adopting a healthy lifestyle with heart- and brain-healthy diet and exercise habits will lessen your chances of developing any number of chronic and life-threatening illnesses. When we all work toward that goal, our entire community is healthier. That’s worth striving for!

Thursday, December 19, 2019

How Do Vaccines Prevent Us from Getting Sick?

Editor's Note: This video is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. posts a video about a different disease/public health issue each month. Some of the topics featured include: FluMeaslesPneumococcal diseaseHuman papillomavirus (HPV)Chickenpox and shinglesPertussis (whooping cough), Hepatitis ARubella (also known as German measles), RotavirusPolioMumpsTetanusHepatitis B, and Meningococcal BDiphtheriapregnancy and vaccines, benefits of vaccinations, and more. 

TMA designed the series to inform people of the facts about these diseases and to help them understand the benefits of vaccinations to prevent illness. Visit the TMA website to see news releases and more information about these diseases, as well as physicians' efforts to raise immunization awareness.

Video: How Vaccines Work

Most people choose to vaccinate to protect themselves from infectious diseases. But many may not know how vaccines actually work.

It starts with the immune system, which defends our bodies from bacteria and viruses that can make us sick. After a physician or other health care worker gives someone a shot, the patient's body believes the vaccine is an invading disease, so it builds a resistance against it. This prepares the body for any future encounters a person may have with a real disease.

According to the Centers for Disease Control and Prevention (CDC), vaccines contain a small number of weakened or dead antigens, the parts of germs that cause a person's immune system to activate. After a person receives a vaccine, the key proteins in their immune system (called antibodies) will recognize that antigen and attack it if ever enters the body again.

Scientists make vaccines from a weakened or dead version of a germ, so people are highly unlikely to get sick after getting vaccinated.

Historians believe the idea of vaccinating emerged in Asia and Africa before the 18th century, from a practice called variolation. The technique exposed a healthy person to an infected person's smallpox blister via an open wound or by inhaling through the nose. Many people who underwent variolation avoided smallpox, but several got sick and died.

In the late 1700s, English physician Edward Jenner introduced the procedure we now know as vaccination after learning that dairy maids who got the cowpox virus from infected cows were immune to the highly contagious smallpox virus. He successfully injected an 8-year-old boy with matter from a cowpox blister and later, smallpox, to find the boy did not get sick from either virus. Mr. Jenner coined the new practice vaccination from the Latin word "vacca", which means "cow". Vaccination quickly became a widespread approach to disease prevention.

Doctors today want patients to understand how vaccines work so they can take steps in protecting themselves from preventable diseases. The chart below answers common questions about vaccines.

Monday, December 9, 2019

Science: Vaccines Do Not Cause Autism, But Physicians Fight to Reassure, Immunize

Editor's Note: This video is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. posts a video about a different disease/public health issue each month. Some of the topics featured include: FluMeaslesPneumococcal diseaseHuman papillomavirus (HPV)Chickenpox and shinglesPertussis (whooping cough), Hepatitis ARubella (also known as German measles), RotavirusPolioMumpsTetanusHepatitis B, and Meningococcal BDiphtheria, pregnancy and vaccines, and more. 

TMA designed the series to inform people of the facts about these diseases and to help them understand the benefits of vaccinations to prevent illness. Visit the TMA website to see news releases and more information about these diseases, as well as physicians' efforts to raise immunization awareness.

In this video, Jennifer Shuford, MD, a consultant to TMA's Committee on Infectious Diseases and infectious disease medical officer for the Texas Department of State Health Services, says there is no connection between vaccines like the measles-mumps-rubella (MMR) vaccine and autism. She emphasizes the surplus of well-documented scientific research dismissing the claims popularized by antivaccine advocates.

The MMR vaccine protects against measles, mumps, and rubella - contagious diseases caused by a virus. Patients who contract any of these diseases can suffer from symptoms like fever, cough, runny nose, fatigue, and swelling. The U.S Centers for Disease Control and Prevention (CDC) recommends children get two doses of the MMR vaccine: one dose at age 12 to 15 months and another dose at 4 to 6 years old. Teenagers and adults are also urged to be caught up with their MMR vaccination.

Opposition against vaccinations grew when a former British doctor, wrote a now-debunked study claiming a link between MMR and autism spectrum disorder (ASD), a developmental and neurological disability that affects a person's behavior, communication, and learning skills. The publication later retracted the paper after finding the physician skewed his research, abused the children he studied, and hid financial incentives for the report. (He eventually was barred from practicing medicine.) More than 25 scientific studies since that time have found no casual link between the MMR vaccine and ASD.

While more parents are resisting vaccinating their children with shots like the MMR vaccine, a national measles outbreak has occurred in 2019. Texas health officials reported 21 confirmed measles cases as of September.
According to the CDC, the majority of people who got measles were unvaccinated.

Meanwhile, vaccination rates across the U.S. and Europe have dropped. There are currently more than 64,000  school vaccination exemptions recorded in Texas – however the state's overall exemption rate is 1.2%, meaning more than 98% of students are vaccinated.

Vaccines like the MMR vaccine are not only scientifically proven to be effective, they protect you and your loved ones from infectious diseases.

Thursday, December 5, 2019

Walking the Walk with My Patients

Amanda Mohammed, MD
Dallas Family Physician
Member, Texas Medical Association 

Editor's Note: An earlier version of this article was originally published on Women in White Coats.

The idea behind not only talking the talk but walking the walk: Daily I have conversations with patients on how to improve their medical conditions by implementing dietary modifications and routine exercise. I try my best to give patients the tools to succeed, including what exercise routines they may be best suited for given their medical conditions. But I felt like there was more I could do to implement change.

I believe strongly in living a life that mirrors what I advocate in my work. When I discovered “Walk With a Doc,” I realized it fit my goals. Walk With a Doc is a doctor-led walking group that is a part of a national grassroots movement dedicated to encouraging healthy living. It provides a safe, fun and free environment that allows for discussion with doctors about topics that there seldom is time for during an office visit. In addition, it creates a relaxed atmosphere to get to know your patients outside of a white coat.

How It All Began

This program was started in 2005 by Dr. David Sabgir, a board certified cardiologist in Columbus, Ohio. The TMA (Texas Medical Association) sponsors the walks for its member physicians in Texas. It is one of the many ways being a TMA member has opened opportunities for me to be involved in my community. I believe with the demands of a full time physician, we can get distracted from advocacy and feel we don’t have enough time in our day.

However, the reality is we have to incorporate our passions in our work, or it will never be an “ideal” time start anything. I joined Walk With a Doc in June of 2019 in my first year out of my medical residency, and now have now lead 4 walks in the Dallas area. I’ve met wonderful people in the process that ordinarily I’m sure I would not have encountered otherwise.

What I Have Found

What is most satisfying is having my own patients walk alongside me outside of the office setting. It is truly inspiring communities through movement and conversation. Being able to connect with others in your own neighborhood and establish connections that extend beyond chronic medical conditions and medications is essential for overall wellness.

Dr. Mohammed (second from right) walks alongside patients
at a Walk With a Doc event in Dallas.
Photo courtesy of Amanda Mohammed, MD
Exercise is critical for maintaining a healthy body and lifestyle. Not only does walking at least 30 minutes a day help lower the risk of obesity, it also enhances your mental health, blood pressure and reduces your chance of developing diabetes.

Walk With a Doc  events take place all over the world. Medical students, resident physicians, practicing physicians and community members are involved in making this program a success.

If you are interested, and want to learn more, please come out for our next walk! For more information regarding Walk With a Doc and how to get involved please visit contact me via Instagram @dr.mandamo

Dr. Amanda Mohammed, MD is a practicing Family Medicine Physician in Dallas, Texas. She enjoys traveling, visiting local coffee shops, volunteering, photography and live music. You can follow her on Instagram @dr.mandamo.

Wednesday, November 27, 2019

“Everyone else is doing it”: A Breakdown of Vaping, the Dangerous Trend Among Teens

By Emily Hazen, DO
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

Make no mistake, vaping – the inhaling of a vapor produced by an electronic cigarette (e-cigarette) or vaping device – is becoming increasingly more common in our society.  So much so, medical professionals believe it’s caused a deadly outbreak of lung-related illnesses across the country. Among all the different age groups, adolescents are the most susceptible to developing an addiction to vaping. If you aren’t familiar with the dangers of vaping, here’s what you need to know:

What is vaping, in the teenage cultural sense?
Vaping is considered to be the new “behind the dumpster” – and, for that matter, in front of the dumpster, in the car, in the classroom, at the football game – favorite teen activity.

The Facts
  • Vaping is associated with using electronic vaping products (EVPs) or electronic nicotine delivery systems (ENDS), like e-cigarettes (e-cigs), vape pens, e-hookahs, tanks, mods, and dab pens (devices used solely for vaping THC, the ingredient in marijuana that makes people high).
  • What is JUUL? JUUL is the most popular brand of battery-powered e-cigarette among young people. It’s shaped like a USB flash drive, so teenagers who use them can be very discreet. People who vape JUUL products commonly refer to vaping as “Juuling.”
  • A JUUL “pod” has the same amount of nicotine as a pack of 20 regular cigarettes.  
  • E-cigarettes work by heating a nicotine-containing liquid to produce an aerosol that is inhaled.
  • E-cigarette aerosol is NOT harmless “water vapor.” It can contain: nicotine, ultrafine particles, flavorings such as diacetyl (a chemical linked to a serious lung disease), volatile organic compounds, cancer-causing chemicals, and heavy metals such as nickel, tin, and lead.

The Stats

The Attraction of Electronic Vaping Products
  • EVPs are considered by users as a trendy way to smoke. Cigarettes are now considered unfashionable.
  • Electronic vapor products are sleek and inconspicuous.
  • They are available in many flavors, including fruits, menthol, and mint. 
  • They’re taxed at a lower rate compared to conventional cigarettes
  • Advertising companies easily target and manipulate youth by using celebrity promoters to fulfill powerful psychological needs like popularity, peer acceptance, and a positive self-image, while marketing EVPs as products to help people quit smoking, a claim the FDA has dismissed
  • Young people have described the feeling after smoking as a “little head high” or “little buzz.”
  • These devices also can be used to vape THC liquid and other drugs.

The Catch
  • Vaping is just a new, easier way of becoming addicted to nicotine. It makes teens statistically more likely to go on to use real cigarettes and increase the risk for addiction to other drugs.
  • Surprise! Nicotine harms adolescent brain development, which continues into the early to mid-20s. This is a crucial time for development of brain synapses related to attention, learning, mood, and impulse control. 
  • Users may not know what is in the vaping solutions. Many of the products and substances can be modified by suppliers or users. They can be obtained from stores, online retailers, from friends and family, or “off the street.”    
  • There is not enough vaping history for scientific evidence regarding what will happen in 10, 20, or even 50 years – which makes the dangers of vaping all the more concerning.

The Impact 
  • New outbreak of pulmonary (lung) disease related to THC-containing vape products. 
  • As of Nov. 20, 2019, there have been 2, 290 cases of lung injury (EVALI) associated with use of e-cigarettes or vaping products, reported to the CDC.
  • Forty-seven deaths have been confirmed in 25 states and the District of Columbia.
  • As of Nov. 5, 2019, 15% of these patients are under 18-years-old and 38% of patients are 18 to 24 years old.
  • On Nov. 8, the CDC identified vitamin E acetate – a compound used in many foods, supplements, cosmetics, and vaping products – as a “potential toxin of concern” after it was found in 29 patients from ten different states. The CDC says it will continue investigating other substances and products because there could be more than one cause of this outbreak. A new report released by the CDC points to more evidence vitamin E acetate is a factor in the EVALI outbreak and why the illnesses are appearing in 2019 specifically.
  • Extremely high levels of the chemical vitamin E acetate have been found in many cannabis-containing vaping products. 
  • The outbreak is occurring as the popularity for e-cigarette products rises. Companies are producing and marketing EVPs with a mix of ingredients, complex packaging and supply chains, and with that, potentially including illicit substances.

The Federal Government Steps In
What’s the government doing?

What can parents do?
  • Set a good example by avoiding nicotine-containing products. 
  • Learn about the different types of e-cigarettes available and the risks for using them.
  • Talk to your children openly and without judgment. 
  • Refer to this Tip Sheet for Parents, published by the CDC

How are physicians and other health care providers getting involved?
  • As physicians educate themselves about the different types of e-cigarettes, vapes, and substances, they may warn all patients, especially young ones, about the risks of all forms of tobacco product use, including vapes. 
  • A primary care physician might ask if you’ve used e-cigarettes or similar devices and ask about symptoms when screening for the use of tobacco products.
  • If patients admit to using any of these products, a physician may ask: The type of vaping they do (nicotine, THC, or both); Source of the product (location purchased and whether its commercial or homemade or otherwise); and the type of device used.
  • Doctors may encourage patients who use these products to avoid buying from informal sources or “off the street,” and advise against modifying or adding any substances to these products that are not intended by the manufacturer.
    A physician could consider vaping-related lung disease for any young patient complaining of coughing, shortness of breath, or chest pain. Often these symptoms are also accompanied by nausea, vomiting, or other stomach-related concerns.
  • Physicians will report any case of confirmed vaping-related pulmonary disease to your local or state health department.
Resources for further reading and guidance for parents:

“The Real Cost” Campaign 

Safer ≠ Safe 

Wednesday, November 20, 2019

ROBERTS: How, where people die – is it good?

By Sid Roberts, MD
Lufkin Radiation Oncologist
Member, Texas Medical Association

Editor’s Note: An earlier version of this article was originally published on Dr. Roberts’ blog and The Lufkin Daily News.

All of us, at some point, have pondered what it means to have a “good” death.

A common theme is to fall asleep in one’s own bed and simply not wake up. Woody Allen famously said, “I’m not afraid of death; I just don’t want to be there when it happens.” The underlying desire is comfort, serenity, peace.

According to the Centers for Disease Control and Prevention, the Top 10 causes of death in the United States in recent years were heart disease, cancer, accidents, lung diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease and suicide.

These Top 10 account for three out of four deaths, and most are chronic diseases marked by decline over years with increasing need for medical care and hospitalization along the way. Yet all along there is this denial of illness and death.

We used to be familiar with death.

Before the 1940s – prior to antibiotics, chemotherapy, heart surgery – people usually died in their homes over the course of a few days or weeks. Sir William Osler (1849-1919), frequently described as the Father of Modern Medicine, called pneumonia – a leading cause of death in his time – the “friend of the aged” because it was an “an acute, short, not often painful illness.”

With the advent of the intensive care unit (ICU) and an ever-expanding medical-industrial complex, we now admit approximately 4 million patients to the ICU each year and we see about 500,000 ICU deaths annually.

The contrast between death at home versus in a technology-overrun ICU could not be more stark. In 2010, more than one-quarter (28.6%) of Americans died in the hospital. Yet 9 out of 10 Americans say they would prefer to die at home if they were terminally ill and had six months or less to live.

Unfortunately, death in the hospital is rarely pretty. Believe me, hospitals do not want patients dying in their facilities. It messes with statistics and quality ratings. It also is far more expensive. So, if hospitals don’t want us dying there, it costs more money, and we say we would prefer to die at home, where is the disconnect?

There are several problems. Doctors don’t like talking with their patients about death and dying. Physicians don’t want to appear to be giving up hope by talking about end-of-life care, nor do they want to appear helpless, as if nothing more can be done.

Patients, having watched one too many TV medical dramas, believe that technology and medicines are so good now that they can overcome any illness, even at the very end of life.

Perhaps the most egregious of these technological and communication disconnects at the end of life is with a procedure called cardiopulmonary resuscitation – the “Code Blue” you hear overhead periodically in hospitals. A code blue is an actual life-threatening emergency situation in which a patient is dying – typically their heart has stopped beating and/or breathing has ceased – and an entire medical team works to revive him/her with medications, chest compressions, intubation (inserting a tube into the patient’s airway to help with breathing), electrical shocks and more.

Cardiopulmonary resuscitation (CPR) can be life-saving in the community setting when a person suffers a heart attack or drowning, for example. According to 2014 data, nearly 45% of out-of-hospital cardiac arrest victims survived when a bystander administered CPR.

For hospitalized patients who suffer cardiac arrest (essentially, who die), the overall rate of survival from a “full code” procedure leading to that person being healthy enough for the hospital to discharge them is barely 10%. But most people, when asked in a scientific study, believe the survival rate to be more than 75%.

Unfortunately, the quality of life of patients who do survive resuscitation in the hospital often is not good. Rarely do the few survivors return to their previous functional status, which in hospitalized patients was probably poor to begin with. There can be brain damage from prolonged lack of oxygen, bruising and pain from broken ribs, and need for prolonged rehabilitation or nursing home placement.

But unless you – or a family member speaking for you – explicitly states otherwise, this likely will happen to you if you are coded in the hospital. And despite the resuscitation attempt, you will very probably die anyway. Is this really what you want your final minutes to look like?

The good news is that we have far more control over where and how we die than one may think.

First, talk with your spouse and your kids – and your doctor – about how you wish to die and where you wish to die if you were to find out you have a terminal illness.

Second, make every effort to write your wishes down. In Texas, there is a document called a Living Will available online at Both English and Spanish versions are available.

This directive to physicians and family or surrogates lets you, the patient, tell your doctors and others what types of treatments you do or do not want if you are terminally ill and no longer able to make medical decisions.

In addition to this advance directive, Texas law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order.

Don’t wait until a crisis to make your wishes known. It may be too late.

Finally, hospice care is available through Medicare, Medicaid and most private insurers to help patients achieve the “good” death they say they want; not by hastening death, but by helping terminal patients fully live the life they have left as comfortably as possible – and most often at home.
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