How Alternatives Such as CBD Oil Make an Impact on the Opioid Epidemic

As the opioid epidemic continues to wreak havoc on the United States, we take a look at the viability of cannabidiol as an alternative.

According to the Center for Disease Control and Prevention (CDC), 40 percent of the opioid-related deaths that occurred in the United States in 2016 involved a prescription opioid. Opioids are a form of medication prescribed by a healthcare professional that are used to treat unrelenting pain, typically caused by an underlying illness or as a result of surgery. With so many patients in the United States abusing their opioid prescriptions, it is hard to comprehend why many doctors nationwide continue to prescribe these highly-addictive pain medications. However, with the easily-accessible nature of these drugs and given the severity of a patient’s pain or suffering, opioids such as Oxycodone and Hydrocodone have become a popular choice for both medicinal and recreational use.

Fortunately, alternative, non-addictive forms of pain relief are becoming more frequently prescribed to patients. While Cannabis Sativa still has a negative stigma revolving around it and receives political backlash, the pain relief it provides for users may be enough to help patients shy away from opioid use.

What is Cannabidiol (CBD)?

Cannabidiol (CBD) is one of the many compounds created by the Cannabis plant, and it is often recognized alongside Tetrahydrocannabinol (THC). The difference between these two compounds is that CBD is non-psychoactive, providing the same benefits as THC without the euphoric feeling that THC produces. This has allowed for the legal sale of products such as CBD oil, as it does not contain THC and cannot be abused or cause a dependency.

CBD oil is still a fairly new product, which has limited the scope of existing research into the health benefits of this substance. However, scientists and doctors are starting to introduce this form of pain relief amongst select patients and new data is being continuously gathered as to exactly what benefits CBD oil can provide to patients.

How Does CBD Oil Relieve Pain?

CBD oil is believed to behave the same way that opioids work within a user’s body. By interacting with pain receptors in the brain and the immune system, CBD provides relief from the pain. However, it should be noted that the CBD is not directly causing a patient pain relief. The human body contains an endocannabinoid system, which allows it to regulate substances such as CBD. According to a study conducted by Neurotherapeutics, CBD actually promotes other compounds within the endocannabinoid system from being absorbed, such as anandamide, a compound known for reducing pain. This creates an abundance of anandamide in the body, which results in pain relief.

Evidence of CBD Success

While CBD is a potential alternative to opioid pain relievers, it is also showing success amongst patients who suffer from serious diseases. In a recent study published by the New England Journal of Medicine, 76 patients with Lennox-Gastaut Syndrome, a rare and severe form of epilepsy resulting in seizures, were given 20-mg of CBD twice a day for 14 weeks. As a result, this group of patients had a 41.9 percent decrease in the number of seizures they experienced.

Epilepsy has shown some of the greatest success for CBD usage out of all diseases that have utilized this treatment method. Many epilepsy patients have to take multiple pills a day to reduce the frequency of their seizures, and some patients even have an implant that sends electrical pulses throughout the body to regulate seizures. For patients with such severe epilepsy, CBD is a breath of fresh air.

While these trial results are very promising, some researchers are still skeptical about its success amongst cancer patients. CBD has not been scientifically proven to reduce the size of cancerous tumors in humans, but studies have shown that it may be effective in treating symptoms and side effects of chemotherapy. For cancers such as mesothelioma, whose treatment options are intensive, this may be a safe and effective way for patients to relieve pain without the health risks of opioids. Aggressively spreading cancers tend to cause a severe amount of pain for the patients, and patients’ overall quality of life will improve if they do not have to worry about becoming dependent on opioids while also receiving treatment for their diseases.

The Future Of CBD

As the stigma associated with Cannabis diminishes and more countries around the world begin to legalize it, more research will be conducted involving CBD as a form of pain relief. Too many people have fallen victim to opioid addiction, and with non-addictive pain management alternatives gaining in popularity, the number of yearly opioid-related deaths is predicted to decrease.


David Haas is a health advocate specializing in mesothelioma. He works to ensure everyone has access to information about the disease and advocates for a complete ban of asbestos in the United States.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Entry Level Positions with Surprisingly High Pay and Demand

Healthcare is a notoriously stable industry, making it a smart career choice. Here are some great positions to consider, if you want to get into healthcare.

Healthcare is known for being a stable and, beyond that, a constantly growing industry, even in times of economic uncertainty, making it a safe bet as a career choice. But which career should you choose? Here are five entry level healthcare jobs that are not only in demand, but also come with a solid annual salary, making them viable options to consider, if you are looking to get into the field.

Medical Secretary
Average Base Salary: $39,527
Education Required: High School Diploma or Certificate
Projected Job Growth from 2016 to 2026: 15%

Medical Billing Clerk
Average Base Salary: $37,529
Education Required: High School Diploma or Certificate
Projected Job Growth from 2016 to 2026: 13%

Medical Assistant
Average Base Salary: $34,594
Education Required: High School Diploma or Certificate
Projected Job Growth from 2016 to 2026: 29%

Pharmacy Technician
Average Base Salary: $33,841
Education Required: High School Diploma or Certificate
Projected Job Growth from 2016 to 2026: 12%

Certified Nursing Assistant
Average Base Salary: $32,048
Education Required: State-Approved Certificate
Projected Job Growth from 2016 to 2026: 11%

Ready to start your search? You can find these positions and thousands of others on HealthJobsNationwide.com.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

10 Steps to Nurse Entrepreneurship

Many nursing professionals would like to be business owners but aren’t quite sure how to get started—if that’s you, this guide is here to help.

From Nurse Keith’s Digital Doorway

I recently attended the 2018 annual conference of the National Nurses in Business Association (NNBA) and I was reminded that many nursing professionals would like to be business owners but aren’t sure how to get started. That lack of business acumen is both prevalent and understandable.

While I’m not specifically a business coach for nurses, my career coaching practice and experience as a nurse entrepreneur has taught me a thing or two about getting a business up and running.

What Does A Business Do?

Before we get to my top tips for launching your nurse-run business, let’s talk about what a business actually does.

A business identifies a pain point, problem, or need, and then delivers a product or service to solve that problem to a customer willing to pay for that solution.

Since the days of people living in caves, nothing has really changed about the nature of business. When a particular cave dweller found that he had a skill for making weapons out of bones, other cave dwellers may have realized that they really wanted to “own” one of his “products”. Since money had yet to be invented as a means of exchange, barter was likely the way of the world. So, a cave woman who was skilled at making herbal remedies may have traded her herbal salves for a knife made of bone. In this way, both parties received a product that solved a vexing problem.

When money came along, barter was no longer necessary, thus those with the financial means could essentially trade currency for a product or service.

As a “nursepreneur”, you may not be making knives out of bones, but you may have developed a product that solves a problem, and you’d like people to give you money for it. Take Wayne and Dawn Nix of RNVention as a prime example: this husband-and-wife nurse team invented the Multinix, a brilliant tool that solves many problems for busy nurses with only so much room in their pockets.

Basically, Dawn and Wayne saw a problem (nurses running around their units looking for various tools to perform a multitude of tasks) and they created a product that makes those nurses’ jobs easier by combining functions that would decrease nurses’ need to seek out different tools throughout the course of a shift. And voila, the Multinix was born.

This exemplifies the process of identifying a problem (nurses’ myriad tasks to accomplish), identifying the target market (nurses in busy clinical settings, generally hospital-based), and creating an affordable and well-made product that solves the identified problem(s). Of course, a brilliant product sometimes doesn’t fly off the shelves for various reasons, but those who see or work with the Multinix feel strongly that it’s absolutely the bees’ knees and a godsend to busy nurses everywhere.

Now that we’ve reviewed one example of how a product or service can solve an important problem — specifically for nurses — let’s look at my top 10 tips for those desiring to jump into the world of nurse entrepreneurship and nurse-run business.

Tip #1: What’s your idea?

A business almost always begins with an idea or a story. Perhaps you’ve invented a physical tool like Dawn and Wayne Nix, or maybe you’d like to start a home health agency targeting homebound seniors whose adult children would like a private duty nurse like you to manage their care. And maybe you have a gripping story that explains your motivations for starting this new venture — those stories can communicate so much about your passion for your project.

  • Identify your idea
  • Ascertain if there’s a compelling story behind your idea
  • Solidify and sharpen your idea and story

Tip #2: Do your research

Most people do a fair amount of research before they go to the trouble of launching a business venture. You need to be fairly certain that there’s a viable market for your product or service; this includes making sure that the people for whom you’re solving a problem are actually seeking a solution for that problem. A great product without a target audience is a product that may never see the light of day.

If you plan to manufacture a physical product, you’ll need to do deep research regarding:

  • Developing a prototype
  • Finding a trustworthy manufacturer
  • Understanding how distribution will take place
  • Applying for a patent or trademark
  • And so much more

Tip #3: Identify your target market/niche

Your research will reveal who your target market or niche is, and your mentors and other advisors may have helpful information for you in that regard. The general idea has always been that “the riches are in the niches”, meaning that a narrower niche will often be more successful than a business that tries to serve anyone and everyone.

For me, the niche that I’ve identified for my career coaching services is registered nurses, and that’s a pretty big niche! I even work with some APRNs and nurse practitioners. As other coaches and counselors begin to enter this same market, I may choose to narrow my niche to, for instance, mid-career nurses who need career counseling and support; so I watch the market, see who’s coming to me, and continue to monitor if my target audience needs to change in some way. Being willing to pivot and flex is certainly the order of the day.

Tip #4: Seek support in setting up your business

Starting a business can be a complex undertaking, so getting support is essential. You can seek out a mentor, hire a business coach, or discover if your local municipality provides any services for new business owners.

I cannot recommend the National Nurses in Business Association highly enough. The NNBA provides access to a national community of like-minded nurse entrepreneurs, and the annual conference in Las Vegas is the flagship event that any business-minded nurse would be prudent to attend.

There are plenty of business coaches out there, including some who are nurses associated (or not) with the NNBA.

If you need to find out if there’s a small business support center in your local area, try Score.org, and they’ll pair you with a local mentor who will often be a retired businessperson who volunteers their time to help people like you.

Finally, just talk to people who run businesses and pick their brains!

Tip #5: Choose a name for your business

Your business will certainly need a name, so think carefully about this. The name of your company will be on your website, social media platforms, business cards, letterhead, checks, credit cards, etc. also

Tip #6: Create a structure

An important part of your business startup is creating a business structure. This is an important decision in the process. Your business will generally be an LLC, S-Corp, J-Corp, or sole proprietorship. Seek out advice from legal counsel, your local Score office, or other reliable sources.

Tip #7: Set up your finances

Once you’ve decided on a structure, you’ll probably want and need to separate your personal and business finances. In my own experience, this was simple: after forming my LLC, I went to my favorite local credit union where I do my banking and I opened a business checking account, a business savings account, and applied for a business credit card. For my own peace of mind, I keep track of transfers I make between my personal and business accounts, but you should definitely check with your accountant or bookkeeper about what data they would like you to make note of.

Tip #8: Create your web presence

Every business needs a web presence, even if that business is a “brick and mortar” entity. Designing and building a website isn’t rocket science, but it’s admittedly complicated. I chose to hire a web designer to build my site, and I’m happy I did. If you have the wherewithal to build your own, go for it but be sure you ask for help when you need it!

Your business will also need to be on social media — it’s just the way that 21st-century businesses operate and it’s what consumers expect. Don’t feel you have to set up an account on every platform known to humans — choose the places where it seems your target audience hangs out. Twitter, Instagram, Facebook, SnapChat, LinkedIn — these are the main social media sites that average Americans use regularly, so see what makes sense for you.

Tip #9: Hire reliable help

Aside from your mentors and other helpers in #4 above, you will also likely hire contractors or employees at some point in the course of running your business. I currently have a podcasting coach, a social media coordinator, a web designer, a tax preparer, and a podcast producer. In the past, I’ve also hired a graphic designer and a business coach. I actually did almost all of these things on my own at first, but quickly realized that I couldn’t do it all and needed to focus on earning money, not learning a thousand new skills all at once.

Being able to hire people takes cash flow, so having some reserves is helpful, or you may need to take out a small business loan. Or you may simply do it all until there’s enough money coming in to cover expenses.

Tip #10: Be nimble and willing to pivot

My final piece of advice is to be willing to pivot as you move along in the life of your business. In this economic climate, businesses need to be nimble — markets shift, consumers change, and your needs or goals may also evolve over time.

Nimbleness is paramount — can you be a flexible business owner ready to roll with the changes and punches?

Bringing it All Back Home

This list of my top 10 tips for launching your nurse-centric entrepreneurial endeavor is not exhaustive by any means. Again, a business coach or other mentor is often essential to getting things jump-started, and I’ll repeat that the National Nurses in Business Association (NNBA) is a great resource not to be overlooked — where else can you find other nurses with an entrepreneurial mindset?

Good luck, and remember to reach out to skilled professionals who can support you on this exciting road! Go forth and conquer!


Keith Carlson, RN, BSN, NC-BC, is the Board Certified Nurse Coach behind NurseKeith.com and the well-known nursing blog, Digital Doorway. Please visit his online platforms and reach out for his support when you need it most.

Keith is co-host of RNFMRadio.com, a wildly popular nursing podcast; he also hosts The Nurse Keith Show, his own podcast focused on career advice and inspiration for nurses.

A widely published nurse writer, Keith is the author of “Savvy Networking For Nurses: Getting Connected and Staying Connected in the 21st Century,” and has contributed chapters to a number of books related to the nursing profession. Keith has written for Nurse.com, Nurse.org, MultiViews News Service, LPNtoBSNOnline, StaffGarden, AusMed, American Sentinel University, the ANA blog, Working Nurse Magazine, and other online publications.

Mr. Carlson brings a plethora of experience as a nurse thought leader, online nurse personality, podcaster, holistic career coach, writer, and well-known successful nurse entrepreneur. He lives in Santa Fe, New Mexico with his lovely and talented wife, Mary Rives.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Inspiring Nursing Quotes to Get You Through the Day

When you’re a busy, tired nurse, it’s sometimes easy to lose sight of just how amazing you and your profession are. Here are some quotes to remind you.

You’re busy, you’re tired, your feet and your back are likely aching. But let us not lose sight of the wonderful, caring, and incredible people you, as nurses, are. Kick back, relax, and take a quick moment to stand in awe of your chosen profession with these inspiring quotes about your calling.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

PCPs ‘Not Doing Enough’ as STD Rates Skyrocket

There has been an “explosion in STD rates,” due, in part, to primary care physicians failing to screen their patients and discuss sexual activity.

Anna Gorman, Kaiser Health News

Julie Lopez, 21, has been tested regularly for sexually transmitted diseases since she was a teenager. But when Lopez first asked her primary care doctor about screening, he reacted with surprise, she said.

“He said people don’t usually ask. But I did,” said Lopez, a college student in Pasadena, Calif. “It’s really important.”

Lopez usually goes to Planned Parenthood instead for the tests because “they ask the questions that need to be asked,” she said.

As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.

“We know that doctors are not doing enough screening for STDs,” said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely “is leading to an explosion in STD rates,” he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse.

The federal government’s Centers for Disease Control and Prevention has set guidelines for annual screening for sexually active individuals. Among them: women under 25 should be tested for gonorrhea and chlamydia, and men who have sex with men should get tested for syphilis, chlamydia and gonorrhea.

However, testing does not always happen as recommended. For example, only about half of sexually active women ages 16 to 24 with private health plans or Medicaid were screened for chlamydia in 2015. The rate was slightly better in California.

Nationally, reported cases of chlamydia, gonorrhea and syphilis are at an all-time high, CDC data show. In one year, from 2016 to 2017, nationwide rates of chlamydia rose by 7 percent, gonorrhea by 19 percent and syphilis by 11 percent.

Rates of congenital syphilis, which passes from mother to baby during pregnancy or delivery, increased by 44 percent during that time. Nearly one-third of the congenital syphilis cases are from California. The state also saw a record number of STDs last year: more than 300,000 cases of gonorrhea, chlamydia and early syphilis among adults.

Because sexually transmitted infections are often asymptomatic, screening is essential. Untreated STDs can lead to serious health problems, such as chronic pain, infertility or even death.

“Providers and primary care providers play a crucial role in combating these rising STD rates,” said Dr. Laura Bachmann, chief medical officer for the CDC division of STD prevention. “If providers don’t ask the questions and don’t apply the screening recommendations, the majority of STDs will be missed.”

State governments don’t have enough money to combat the rising number of cases, in part because federal STD funding for them has remained stagnant, Harvey said. Last year, he said, $152.3 million in federal funding was appropriated for prevention, the same as eight years earlier.

Experts cite several reasons primary care physicians don’t routinely diagnose and treat STDs. They may worry that they won’t be compensated for providing STD services, or they may not be familiar with the most up-to-date recommendations about testing and treatment. For example, the CDC in 2015 updated the medications it recommends to treat gonorrhea.

Perhaps most commonly, many family physicians are reluctant to discuss sexual health with their patients. One study showed that one-third of adolescents had annual visits that didn’t include any discussion about sexuality.

“We’re in this situation with health care providers and patients — each waiting for the other to start [the conversation],” said Dr. Edward Hook, professor at the University of Alabama-Birmingham School of Medicine. “Doctors worry if they ask patients about their sexual history that it will somehow be offensive to them.”

Dr. Michael Munger, president of the American Academy of Family Physicians, said he remembers that his conversations around sexual health were uncomfortable at first. “There are a lot of challenging conversations you can have with patients,” he said. “But this is important. If we don’t do it, who will?”

Rob Nolan, a writer from Los Angeles, said he gets tested every six months, but he prefers to do so at the Los Angeles LGBT Center rather than during visits with his regular doctor, who rarely asks about sexual health.

Nolan, who said he has had experience with STDs, considers the clinic’s staff to be more knowledgeable about sexual health than those at a regular doctor’s office. “They just seem specialized in it,” he said. “And there is zero shame when you are in the clinic.”

Physicians also may have other, more immediate health issues to address during the short time they have with patients. Taking a sexual history and talking about sexual health falls to the bottom of many doctors’ priorities, said Dr. Leo Moore, acting medical director of the division of HIV and STD programs for the Los Angeles County Department of Public Health.

Julia Brewer, a nurse practitioner at Northeast Community Clinic in Hawthorne, Calif., said she screens for STDs as a regular part of women’s health exams. But she said her colleagues frequently refer cases to her rather than having the conversations themselves. “The family providers are overwhelmed with diabetes and high blood pressure,” she said. Sexual health, she said, can end up being an “afterthought.”

The L.A. County public health department, which identified STDs as a key priority for the next five years, recently sent representatives to doctors’ offices to teach providers how to address sexually transmitted infections. They distributed information detailing screening recommendations, sample sexual history questions and treatment guidelines.

The Los Angeles County Medical Association also plans to get the word out to doctors through social media and other efforts. “It’s an epidemic and we have to treat it that way,” said CEO Gustavo Friederichsen. “Doctors have to feel a sense of urgency.”

Dr. Heidi Bauer, who heads the California Department of Public Health’s STD control branch, said the state also is trying to educate doctors so they will screen more routinely. The department provides both in-person and online training for doctors to learn about STDs, and publishes downloadable information with current guidelines.

At the same time, Bauer urged the federal government to make its screening recommendations more comprehensive. Outside of pregnancy, for example, there are no recommendations for routine syphilis screening for women. “We are seeing this huge re-emergence of syphilis,” she said. “We haven’t been testing and syphilis is very challenging to diagnose.”

The CDC plans to review the recommendations in the next year, Bachmann said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Want to Take Your Mind Off Work? Volunteer.

Finding the time to volunteer your services to underserved populations or in times of crisis may be one way to help you escape from your day-to-day burdens.

After Hurricane Michael ravaged the Florida panhandle in early October, the American Red Cross and other relief organizations appealed for volunteer medical professionals, including physicians, to aid in relief efforts.

“Why would I want to do that? I’m already busy enough,” you may be saying to yourself.

However, physician volunteerism can have many positive impacts on your life and career, one of which can be to combat symptoms of burnout, such as stress and depression. In fact, a recent study on physician perceptions of volunteer service remarked, “Volunteering may serve as a crucial “escape hatch” from the stresses of their regular jobs—in other words, volunteering could have a valuable function in burnout prevention.”

There are many organizations with which physicians can volunteer their services—for disaster relief or otherwise. Some options to consider include:

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: “See You Down The Road”

How do you ask patients about end-of-life wishes? Kimberly Spering, MSN, FNP-BC discusses her experience with having this crucial conversation.

by Kimberly Spering, MSN, FNP-BC

How do you ask patients about end-of-life wishes? I think this is a difficult question… with difficult answers. Truly, end-of-life discussions are fraught with angst, sometimes anger, hopelessness… but sometimes, they can lead to hope, and a willingness to discuss goals of care.

“Crucial conversations.” These are the questions that providers ask, trying to elicit patients’ goals of care, fears or concerns, hopes and wishes, and wants for their end-of-life. These are oh-so-important conversations with people… yet, so few providers really ASK the questions… or listen to the answers. I fully understand this. In the busyness of a day, with metrics to meet, tons of patients to see, conversations that take time are… difficult. And uncomfortable. However, they are still important.

For me, it’s been an interesting few days, to say the least. I held hospice discussions with many patients — two signed on in the past few days, and one most likely will do so.

The first patient has fought two different cancers over the past two years. When I met her 10 months ago, she expressed a desire to pursue treatment – so long as the side effects weren’t worse than the disease itself. At that time, and in the months following that visit, I would routinely question what her wishes were. Until the visit this week, nothing changed.

Fast forward to seeing her this week. She was beyond emaciated. More weight loss… but yet, she had large amounts of peripheral edema due to her albumin being super-low. Her oncologist prescribed Lasix… which worked briefly, then had no effect. She had almost every side effect to her chemotherapy that could happen. Yes, she had medications to off-set side effects, but those meds had side effects as well.

In short, she was suffering greatly.

I noted her worsening cachexia, dark circles under her eyes, unsteadiness on her feet. “Tell me how you are doing,” I asked, guessing full-well that I knew what horrors she experienced.

“I’m DONE. I’m FINISHED fighting this cancer. I stopped my treatment one week ago,” having stopped the two medications designed to fight it.

She was resolute. We discussed her side effects, her quality of life (which was non-existent at this point), and her goals of care.

“I don’t want to die at home. He (her husband) can’t take care of me.” We discussed that inpatient hospice was for patients with uncontrollable symptoms or a limited (2-week) life expectancy, or for management of uncontrolled symptoms. It is NOT, however, for patients with a longer time to death. She wasn’t willing to consider an assisted living or skilled nursing facility. I discussed what home hospice would entail for her, with as much support as needed.

Ultimately, I connected with hospice and had services initiated.

Another patient has severe aortic stenosis, diastolic CHF, CAD, CKD 4, and a plethora of other co-morbidities. I met her several years ago, and surprisingly, she has done well for the past several years… until four months ago. She has had increasing chest pain, worsening CKD, esophageal dysmotility, and a bunch of other symptoms.

During my last visit, I floated the idea of hospice to her daughter and son-in-law, given the progressive decline I’d observed. We talked at length, but held off. Today, her daughter wanted to discuss hospice again. The patient had been to the ED & hospice was discussed with another family member.

After a robust, engaging conversation with her daughter today, I approached the patient.

We discussed the course of her disease processes over the past few years, particularly the past few months. Initially, she felt she should return to the hospital for urgent treatment. “Doesn’t everyone go to the hospital if in trouble?” she asked.

Well… no, I explained, people don’t HAVE to go. We discussed her goals of care and desires for comfort over treatment. Her AS and CKD really limited her treatment options. Diuretic increases would worsen her renal function. BP modifications could decrease her cardiac output and worsen her AS.

So… in the realm of “treat everything,” what does one do?

One option is to offer hospice as an additional option for 24/7 support. I described their services, the concerns I had that her going back to the hospital would offer limited treatment options, and their desires for extra support and aggressive symptom management.

We had a lively discussion of what that would entail. Ultimately, the patient and her family will discuss the pros/cons of hospice, and let me know if they want to start those services.

My last patient was a WWII veteran, married for 72 years, and a wonderful story-teller. Someone with ESRD, combined CHF, atrial fibrillation, and a plethora of other health problems. I spent a lot of time listening to his war stories… which over time, included his PTSD (called “shell-shock” in those days). His wife told me privately he had never shared any of his experiences with her. After his retirement, he spent years being an auctioneer… until his eyesight failed, rendering him unable to read the bids.

Over the years that I saw him, I loved listening to his stories: stories about the war, stories about his family, heart-break when family members died unexpectedly, worries about his wife’s health issues (only spoken when we were alone). We discussed his progressive disease, including CHF, ESRD, atrial fibrillation, etc. I watched, as time took its toll on this soldier.

Today, I came to his home, only to find him bed-bound, on oxygen, and extremely weak. “What happened?” I exclaimed. He was discharged home from the hospital a few weeks previously, but not in this state.

I discovered that his cardiologist (not part of our hospital network) had ordered oxygen last week. I had no notes… no idea of what had transpired. His wife was of limited help, due to her own memory issues.

Quickly, I called my staff to get records ASAP. I did an immediate assessment – nothing unstable, but still… his respiratory rate was elevated. He had pain in certain areas. He was only voiding 1–2 times daily (this… for someone with prior nocturia 3 times nightly, and voiding every 2 hours while awake). He wasn’t eating or drinking.

In my assessment, he was starting the process of actively dying.

We discussed his disease progression, his declining status, his goals of care, his fears and hopes. His biggest worry: “I want to make sure that she (his wife) is alright.” He was worried about the dying process, but acknowledged that it was his time. Meanwhile, his wife, teary-eyed, told me that their daughter was of limited support, and that she could not rely on her. She only had a nephew and nieces – both of whom support was limited.

We discussed his situation and symptoms, symptom management, spiritual concerns, and we did a life review. For those unaware of the latter, it is a discussion of all of the things that a person has accomplished or succeeded at over the course of his/her life. It is profoundly moving, and often facilitates a patient’s acceptance of their end-of-life status. I reminded him of the stories that he shared over the past year or so. We chucked at some of his jokes. I laid on their bed, as he was extremely HOH, talking about these stories.

At the end, I asked him what he wanted most. His biggest concern was that his wife would be OK, able to function on her own. She teared up, but told him she would be OK.

I kissed him on his forehead and gave him a hug, telling him that I wanted him to rest. Hospice would be coming shortly, and he needed to regain some energy.

He thank me for all of my care, then told me, “See you down the road.”

I choked up, swallowing back tears. “I love that. I’m going to remember that and use it,” I managed to get out. Then, as I smiled at and hugged him, I left the room, tears swimming in my eyes.

His wife followed me. I spent another 30 minutes talking to her, trying to help her cope with the upcoming loss of someone so dear… trying to help her realize that she was not alone. Trying to help her elicit hospice support when it started.

“Will you come to see me? I have no one…” she stated.

You bet I will. Patients/families like this are few and far between. I will try to see all of the people that I’ve followed… even if I can’t be their NP. Sometimes, just being a friendly face helps.

I just LOVE being able to connect with people, sharing their stories over time. But it is so incredibly hard to direct people to the realization that they are at the end of their life. That disease-directed therapy is not working. That hospice-supportive care is the way to go to support their end-of-life needs.

In my palliative work, I am blessed in having the time to discuss these issues over time with patients and families. I am blessed to have the medical foresight to help predict their course of illness.

Death has its own timetable. It waits for no one. It is the one INEVITABLE outcome for all of us — the timing or reason unknown for most. I can estimate when the end will occur, but a higher being only knows when that occurs (God for some, HaShem for others, Allah for some, etc.).

I’m going to shout out to my hospice and palliative medicine colleagues here. They have helped initiate needed services. They work tirelessly in the trenches for patient care. They support us when needed.

Ultimately, patients and families can be supported, even when death is imminent… or prolonged.

What does a peaceful death look like to patients? Or you? Are health care providers and families willing to ask the hard questions: their goals of care, fears or concerns, wishes/bucket list items? These are tough conversations, but crucial ones.

Let’s honor patients’ wishes, by supporting them, asking the tough questions. Asking their goals and wishes, fears and concerns, what is most important to them, what is crucial to living their lives, and also, who is their support.

And a hearty, “see you down the road” as well.


Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

The Public Is Clearly Confused about PAs and NPs

As the primary care physician shortage looms, and PAs and NPs are constantly called “the answer,” it seems patients are unaware of what they can even do.

Advanced practitioners, particularly PAs and NPs, are often cited as the answer to the looming primary care physician shortage—an estimated deficiency of 49,300 primary care physicians in the U.S. by 2030, according to the Association of American Medical Colleges. However, it appears there is a large amount of public confusion when it comes to the roles of PAs and NPs in primary care, according to a new study, which is to be published next month in the Journal of General Internal Medicine.

For the study, members of the U.S. public in all 50 states were surveyed between November 2017 and January 2018. Participants were asked questions regarding their knowledge of the abilities of physicians, PAs, and NPs to prescribe medications, diagnose illnesses, and order lab tests.

Of the 3,948 respondents, an undisputable majority knew physicians were able to prescribe medications, diagnose illnesses, and order lab tests. However, they were much less well-informed when it came to PAs and NPs. About half were unaware that PAs could prescribe and diagnose, and nearly a third did not know NPs could, and while a higher percentage were aware that PAs and NPs could order lab tests (66% for PAs, 74% for NPs), it was nowhere near the 97% who were aware of physicians’ ability to do the same.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

TV Ads Must Disclose Drug Prices, Trump Administration Says

The Trump administration proposed a new rule this week which demands drug makers disclose list prices for medications in their TV commercials.

A new rule was proposed by the Trump administration on Monday that pharmaceutical companies reveal the list prices for all brand name drugs covered by Medicare and Medicaid that cost more than $35 a month in their television advertisements.

The proposed rule pushes for transparency, stating that the price should be listed at the end of the advertisement in “a legible manner” and should be presented against a contrasting background in a way that is easy to read. If approved, however, drug companies cannot be forced to comply, as there is no government-enforced penalty system in place. Instead, federal regulators would make public a list of companies violating the rule and depend on the private sector to take legal action.

This rule is being touted as part of the administration’s “American Patients First” blueprint, their initiative to bring down prescription drug prices. However, it is unclear how disclosing list prices for medications in television ads will lower drug prices, as a drug’s list price is not often closely related to what patients actually pay for their medications at the pharmacy.

As anticipated, the proposed rule is already facing backlash from the drug industry.

“We’re concerned that if you just have the list price in isolation in the ad, it may deter patients from seeking needed care,” Steve Ubl, President and CEO of the Pharmaceutical Research and Manufacturers of America, is quoted as saying.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Mysterious Polio-Like Illness Baffles Medical Experts

A spike in cases of children with a rare neurological disease that causes polio-like symptoms has health officials scrambling to understand the illness.

Carmen Heredia Rodriguez, Kaiser Health News

A spike in the number of children with a rare neurological disease that causes polio-like symptoms has health officials across the country scrambling to understand the illness. Yet, more than four years after health officials first recorded the most recent uptick in cases, much about the national outbreak remains a mystery.

Acute flaccid myelitis (AFM) affects the gray matter in the spinal cord, causing sudden muscle weakness and a loss of reflexes. The illness can lead to serious complications — including paralysis or respiratory failure — and requires immediate medical attention.

The federal Centers for Disease Control and Prevention is investigating 127 cases of possible AFM, including 62 that have been confirmed in 22 states this year. At least 90 percent of the cases are among patients 18 years old and younger. The average age of a patient is 4 years old.

AFM remains extremely rare, even with the recent increase. The CDC estimates fewer than 1 in a million Americans will get the disease. Officials advised parents not to panic, but remain vigilant for any sudden onset of symptoms. They also suggested that children stay up to date with their vaccines and practice good hand washing habits.

This year’s outbreak marks the third spike of AFM in four years. From August 2014 to September 2018, 386 cases have been confirmed. Yet, experts still do not understand crucial aspects of the disease, including its origins and who is most at risk.

“There is a lot we don’t know about AFM,” said Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases. Here’s what puzzles health officials about AFM:

The cause is still unknown.

Acute flaccid myelitis can be caused by viruses, such as polio or West Nile. But federal officials said that those viruses have not been linked to the U.S. outbreak over the past four years. They have not isolated the cause of these cases.

Despite symptoms reminiscent of polio, no AFM cases have tested positive for that virus, according to the CDC. Investigators have also ruled out a variety of germs. Environmental agents, viruses and other pathogens are still being considered.

The 2014 outbreak of AFM coincided with a surge of another virus that caused severe respiratory problems, called EV-D68, However, the CDC could not establish a causal link between AFM and the virus. Since then, no large outbreaks of virus have occurred, according to the CDC.

Carlos Pardo-Villamizar, a neurologist and director of the Johns Hopkins Transverse Myelitis Center, said that the mystery lies in whether the damage seen in AFM is caused by an external agent or the body’s own defenses.

“At this moment, we don’t know if it’s a virus that is coming and producing direct damage of the gray matter in the spinal cord,” he said, “or if a virus is triggering immunological responses that produce a secondary damage in the spinal cord.”

It’s not clear who is at risk.

Although the disease appears to target a certain age group, federal disease experts do not know who is likely to get acute flaccid myelitis.

Pardo-Villamizar said identifying vulnerable populations is “a work in progress.”

Mary Anne Jackson, a pediatric infectious disease specialist and interim dean of the school of medicine at the University of Missouri-Kansas City, said many of the patients she saw were healthy children before falling ill with the disease. She suspects that a host of factors play a role in the likelihood of getting AFM, but more cases must be reviewed in order to find an answer.

The long-term effects are unknown.

The CDC said it doesn’t know how long symptoms of the disease will last for patients. However, experts say that initial indications from a small number of cases suggest a grim outlook.

A study published last year found 6 of 8 children in Colorado with acute flaccid myelitis still struggled with motor skills one year after their diagnosis. Nonetheless, the researchers found that the patients and families “demonstrated a high degree of resilience and recovery.”

“The majority of these patients are left with extensive problems,” said Pardo-Villamizar, who was not involved in the study.

Jackson, who also saw persistent muscle weakness in her patients, said she believes the CDC may be hesitant to specify the long-term effects of disease because existing studies have included only small numbers of patients. More studies that include a larger proportion of confirmed cases are needed to better understand long-term outcomes, she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.