This is what (almost)
60 years looks like for our 50th state from my recent wikiwiki (super fast) trip to Hawaii.
“In
some circles, Hawaii’s admission to the Union was opposed because of its racial
diversity; only about one-quarter of residents here were ‘white.’ So it was, in 1959, that Martin Luther King,
Jr. pointed to Hawaii ‘as a place where we see the glowing daybreak of freedom
and dignity.’ … Hawaii has among the highest housing costs nationwide. It also
has among the lowest wages when accounting for cost of living.” —"King
also sought economic justice,” Honolulu
Star-Advertiser (January 21, 2019)
Hawaii State Capitol's statue of Queen Liliuokalani (1838-1917), Hawaii’s last monarch who was
illegally overthrown on January 17, 1893, leading to Hawaii’s annexation to the
U.S. in 1898, and then statehood on August 21, 1959 … almost 60 years ago. At age 72, Queen Lili was granted a lifetime monthly pension of $1,250 effective July 1911 by the Territory of Hawaii Governor Frear. Descendants of Hawaii’s monarchy claim sovereignty over the islands, and the
Hawaiian Kingdom Government wants the U.S. to return lands to Native Hawaiians.
Don’t
worry, eat happy 😊
On the day
before the 126th anniversary of Hawaii Kingdom’s overthrow,
I joined folks of all ages for the 30th Biennial Legislature Opening at Hawaii State
Capitol (where I had been a teen executive intern at the State Attorney General’s Office). There was music by 70-year-old Henry Kapono inside the House chamber, tabling by community advocacy groups (Raise Up Hawaii seeks to increase state hourly minimum wage of $10.10 to living wage of $17)
and poi pounding in the courtyard,
and a complimentary smorgasbord of prepared local foods and fresh produce offered in the
offices of local politicians.
Talofa to
71-year-old Mike Gabbard, Hawaii State Senator and vegan, who was born in American Samoa! He is father of Hawaii’s U.S. Representative Tulsi Gabbard, who announced her campaign
to run for U.S. President in 2020; no longer like her father, she apologized
for her earlier support of her father’s stance against gay marriages. (In 1972, U.S. Representative Patsy Mink was first person from Hawaii to run for President ... Honolulu’s airport should have been named after Patsy Mink, co-author of Title
IX Equal Opportunity in Education Act, instead of an “accused serial rapist.”)
Gabbard Ohana (family) prepared vegan
food: mock chicken drumstick "bones" were made of sugar cane! Mike’s family operated
Natural Deli in Down to Earth Natural Foods store, near University of Hawaii.
Hawaiian Airlines pilot Kai Kahele was appointed Hawaii Senator from Big
Island to take the place of his late father.
His office offered build your own mixed plate: futomaki (sushi), chow mein, meat
and macaroni salad.
Kai played ukelele with two other performers outside his office.
Kai's family joined the party
Later on MLK, Jr. Day, Kai announced his 2020 bid for U.S. Representative
seat held by Tulsi Gabbard.
Buffet of local foods including sushi, rice, noodles, fried jun, mochiko
chicken …
Poke with carby
rice, noodles and French fries!
Representative Cedric Gates offered green onions and bananas from Waianae.
Across from Hawaii State Capitol is Hawaii State Library, where no eating ...except maybe in its courtyard!
Geriatric care
After the Library closed at 5 pm, strolled over to Queen’s Medical
Center (QMC), founded in 1859 by Queen Emma and King Kamehameha IV (and where
I had volunteered as a high school student exploring health care profession). QMC ranks in U.S. News & World Report’s top 10% of hospitals for Geriatrics!
Also, QMC is the first
hospital in Hawaii and only the fifth in the nation to receive Level 1 Geriatric Emergency Department Accreditation (GEDA), recognizing
the highest level of excellence in care for older adults, by the American
College of Emergency Physicians (ACEP). QMC’s Geriatrics Housecall program for homebound elderly rocks —mahalo nui loa to awesome
staff (nurse practitioners Joan Maeshiro and Jake Moore, and Dr. Sarah Rasca)
who keep me posted (long-distance caregiver, not to be confused with “Daughter from California” syndrome)!
Kokua Mau’s Palliative Pupus’ Learn and Mingle at Queen's
Conference Center began with potluck food and introductions by attendees. After hearing from woman visiting from Japan
and yours truly from San Francisco, Kokua Mau’s Executive Director Jeannette
Koijane asked if we were on palliative tour?
Island Hospice team presented case study of a 90-year-old Korean patient
diagnosed with liver cancer and memory impairment, felt she was in prison at
her foster care home, issues with language and finding willing power of
attorney for health care.
QMC Medical
Director of Palliative Care Dr. Dan Fischberg announced upcoming events, which are posted at Kokua Mau’s website. Wished I could extend visit to attend workshop on Critical Communications with
Seriously Ill Patients and Families presented by Dr. Anthony Back.
Participated
in free Applied Suicide Intervention Skills Training (ASIST) at Sutter Health Kahi Mohala in Ewa Beach. As participants were mostly military
personnel, they knew OCOCA (Our Care, Our Choice Act) as mnemonic OCOKA for
survival (versus aid-in-dying)? Older veterans age 55+ have the highest incidence of suicide, representing nearly 60% of all veteran suicide deaths.
Housing/homelessness
Homeless
encampments were visible (though I took no photos to respect privacy, instead took photos of murals around Kakaako area) because Honolulu Mayor Kirk Caldwell decided
to suspend enforcement of “sweeps” or removing homeless people from streets during January 14 to 25, to facilitate a more accurate Homeless Point-in-Time Count
over four nights, January 22 to 25. I viewed the online training, surprised
to learn Oahu’s annual Count was more like U.S. Census involving face-to-face
interviewing. In contrast, San Francisco’s biennial Point-in-Time Count was one night only,
driving through streets.
“Drug dealing, intimidation, violence, crime,
filth and an overriding disregard for others are not the elements that make up
a healthy environment for children. …. Those who use our walls, doorways and
steps as toilets, who openly deal in drugs, who are mentally ill, and ignore
those outreach officials who want to get them into transitional housing,
rehabilitation and jobs programs. They
are the ‘hard core’ homeless who really need tough love.” –Loretta Yajima, CEO
of Hawaii Children’s Discovery Center in Kakaako, “Homeless may force center to close,”
Honolulu Star-Advertiser (January 16, 2019)
Like San Francisco, the high cost of living in Honolulu can push older adults on fixed
income to lose their housing and become homeless.
Hawaii has
the highest per capita rate of homelessness in the nation: 51 homeless per
10,000 people. Roughly 85% of Hawaii’s
homeless are local born, or “made in Hawaii.”
In response, Hawaii earmarked $30 million for Ohana Zones: designated public lands with easy access to
sanitation, clean water, and social services where homeless individuals will be
allowed to set up camp and live temporarily.
Ohana Zones bill also includes a pilot project to treat those with severe
mental illness. In the long run, this
measure is intended to save money from reduced usage of emergency services,
fewer sweeps and less cleanup.
Last year, as Hawaii State Senator (elected Lieutenant Governor in
November 2018), emergency room Dr. Josh Green introduced a bill that would allow doctors to prescribe
housing as a cure for chronic homelessness, which would be classified as a medical condition and require insurance companies to cover treatment.
Lucky you die Hawaii?
In 2014, terminally ill
cancer patient Brittany Maynard traveled from California to Oregon to avail
herself of the state’s Death with Dignity Act (DWDA). Effective January 1, 2019, Hawaii became the
8th U.S. jurisdiction to legalize medical aid-in-dying (MAID) … will Hawaii become the latest travel destination for terminally ill people
seeking MAID?
To find out this and
more, I spent Saturday morning attending MAID Workshop, hosted by Hawaii
Society of Clinical Oncology (HSCO), at University of Hawaii School of
Medicine in Kakaako. On April 5, 2018, Hawaii
Governor David Ige signed Our Care, Our
Choice Act (aka OCOCA, HB 2739) into law, allowing mentally capable,
terminally ill (prognosis of six months or less) adult residents of Hawaii to
request aid-in-dying medication from their physician so they can
self-administer to bring about a peaceful death.
The American Medical
Association officially remains opposed to MAID, stating in its Code of
Medical Ethics (2016): “Physician-assisted suicide is fundamentally incompatible
with the physician's role as healer.”
“The debate is over. Medical aid in dying is now an authorized
compassionate end-of-life care option in Hawaii, and now we need to focus our
attention on successful implementation so that dying people have real access to
the law. Doctors should be putting their
patients’ autonomy and needs first.
…Hippocratic Oath is an ancient
Greek document that is no longer used at any U.S. medical school graduation
ceremony…many of its important principles endure while the application of those
ideals has evolved over time.
Modern
standards of medical ethics can be found within it: Patient autonomy.
Beneficence. Non-maleficence. Social justice. And most of all, duty to one’s
patients and the patient’s desires and goals.
As medical professionals, one of our greatest challenges is to respect
our personal commitment to do no harm in the face of the ambiguities resulting
from advanced medical technology.
My
perspective is that ignoring a patient’s suffering or autonomy is harm. We can no longer fight disease at any cost,
but must help patients weigh risks, benefits and quality of life as they make
their own medical choices…
The
confusion created by continued use of the phrase ‘assisted suicide’ among those
who oppose the practice of medical aid in dying… These patients are not
suicidal. They want to live, but have been handed a death sentence by their
disease. This law allows them not to be forced to prolong a painful dying
process and to choose when, where, and with whom it will happen.
…Coming face to face with a
patient who knows that he/she is dying is profound, and I believe it is my
highest calling to be able to take their hand and say: ‘I am here to help you.
I will not abandon you.’”—Dr. Chuck Miller, “The oncologist explains the benefits of a new law that allows medical aid in dying,” Honolulu Star-Advertiser (January 18, 2019)
Breakfast and agenda. Someone from Palliative Pupus recognized me,
“Wow, you’re really on the palliative tour!”
Welcome by Charles F. Miller,
MD, FACP, retired oncologist from University of Hawaii Cancer Center. He presented Review of OCOCA:
·
History
from 1998 Blue Ribbon Panel, then 20 years later HB 2739 passed with huge
majorities, signed by Governor Ige into law
·
Detailed
requirements: 3 voluntary requests for drug (2 oral requests made 20 days
apart, 1 written request signed by 2 witnesses); both attending and consulting
physician must agree patient is eligible; 3rd provider
(psychologist, psychiatrist, or LCSW) must confirm patient’s mental capacity
·
Informed
consent after receiving information about all other end-of-life options
·
Complete
statutory Final Attestation form within 48 hours prior to ingesting
aid-in-dying medication, reiterating intent to take medication
Dr. Miller discussed
challenges such as some cancer patients not making 20-day waiting period between
two requests, 3rd provider confirming patient’s mental capacity, and
6 required forms. In his 39 years as an
oncologist, not a single patient diagnosed with cancer was not depressed,
clarifying that depression does not preclude mental capacity.
Dr. Miller introduced Health
Professionals’ Roles and Responsibilities with professionals from Oregon and California:
David Grube, MD,
Compassion & Choices,
disclosed that he has practiced family medicine for 35 years in Oregon. Since Oregon’s DWDA became law in 1997, he
has worked with 30 patients who requested it—15 as attending physician and 15
as consulting physician. Oregon’s experience has improved hospice and
palliative care with 95% of dying using hospice and at home, and one-third who
obtained prescriptions did not take them.
·
Liability/professional
protections: no duty to participate; no liability for medical providers if act
in good faith under Hawaii OCOCA; no disciplinary action against licensed
physician by any state medical boards for participating/declining to
participate
·
How
to respond to request: be prepared; listen; clarify request; listen; affirm
commitment not to abandon; listen; assess ‘root causes’ of request while
respecting patient autonomy/decision-making; provide education to
patient/family; seek counsel of peers/mentors if need support
·
Clarifying
request: immediate, nonjudgmental, empathetic; open-ended questions (“what do
you mean by…” “What type of assistance do you want?” “How do you envision your
last day?”); inquire of suicidal thoughts, plans; be cognizant of personal
biases, body language, counter-transference, etc. (Atul Gawande said, “We want
autonomy for ourselves, safety for others.”)
Dr.
Grube related how UCSF palliative care physician BJ Miller’s greeting, “Good
morning mortals,” is a reminder that we all die; death is not the enemy, but
terminal suffering is the enemy. He
discussed barriers to MAID from different parties: patient’s family, physician,
hospice, hospital system, pharmacy – objections may be faith-based
conscience. He emphasized that patient
seeking MAID needs to have volition to begin/rescind self-ingestion, including
feeding tube, using straw (someone else can hold cup), rectal catheter;
injection is not legal. Compassion &
Choices resources:
·
Doc2Doc
·
Pharmacist2Pharmacist
Tracey Bush, LCSW from
Kaiser Permanente Southern California, discussed coordinator’s clinical roles:
·
process navigator: referral and linkage with palliative care/hospice, identification
and linkage with attending physician/consulting physician/psychiatrist,
coordination with pharmacy for medication consultation and home visit,
facilitate video visits
·
compliance:
ensure patients meet minimum requirements per statute (age, decision-making
capacity, residence, voluntary request, documented 6 month prognosis, physical
and mental ability to “self-ingest” aid-in-dying drug); ensure physicians
complete assessments and document in medical record; ensure state mandated
waiting period adherence; ensure completion and submission of state required
paperwork; ensure patient completion of written request paperwork, including
appropriate witness signatures as final attestation and submission to state;
support pharmacists in reinforcing education about medication preparation,
ingestion and disposal
·
psychosocial
evaluation: family involvement and support; religious/spiritual/cultural
considerations; patient motivation for MAID; initial decision-making capacity
assessment (psychiatrist referral recommendation; California does not allow
LCSW to make mental capacity determination); financial assessment (medication
affordability, apply for patient assistance fund); bereavement services
referral & coordination (post MAID)
·
physician/staff
education and debrief
Tracey reported that
about 3,000 Kaiser patients have inquired about MAID, but one-third “drop off” during
stages because they may be too ill, die before completing process, or change
their mind: 1,000 patients from Southern California, and 2,000 in Northern
California, with 65% actually ingesting.
According to DOH, no
pharmacies in Hawaii can make DDMP2, a compounded medication, and Hawaii law
prohibits compounded medications from out-of-state. (Read Jennie Dear’s “The Doctors Who Invented a New Way to Help People Die: The two lethal medications used by terminal patients who
wish to end their own life recently became unavailable or prohibitively
expensive,” published in The Atlantic,
January 22, 2019.)
Barriers to dispensing
include: identifying participating physicians and pharmacists; time to complete
process (20+ days); controlled prescription requirements; availability of
drugs; expense of drugs; preparation (compound); insurance billing; documentation;
dispensing (delivery, pick-up, mail).
Integrating &
Implementing the Act into Health Systems – locals unite!
Lorrin Kim, MA, Chief of
Office of Planning, Policy and Program Development at Hawaii State Department
of Health (DOH), emphasized Hawaii’s OCOCA is the “most rigorous” in the nation
to ensure safeguards protect patients. DOH is implementing, not regulatory, agency;
Department of Attorney General can pursue penalties for violations. DOH’s Advisory Council strongly recommends
discussing all end-of-life options, including concurrent enrollment in
hospice. Lorrin spoke with first
responders, noting that coroner in neighbor islands is the police chief,
so he emphasized documentation (POLST, OCOCA) to avoid yellow crime scene
tape. He expressed concern that patients
“might want to do it (MAID) in Sunset Beach where they married” and stated that
patients should not take aid-in-dying medication in a public place. Another concern is social determinants that act to limit OCOCA access to highly
educated patients who know how to work system.
Keola K. Beale, MD
Kaiser Permanente, talked about navigator’s key role in keeping track of
timelines as physicians can be overwhelmed by patient care.
Daniel Fischberg, MD,
PhD, FAAHPM Queens Health System, talked about one-page handout is not
substitute for counseling support, no ingestion of aid-in-dying allowed on
hospital premises, and upcoming workshops at QMC and UH Medical School with Dr.
Anthony Back on communicating OCOCA.
Jeannette G. Koijane,
MPH Kokua Mau Director, said all hospice providers will continue to support,
not abandon, patients who elect OCOCA; hospice will continue to be paid by
Medicare; no hospice MD will be attending or acquiring medication for OCOCA;
recommended earlier referrals to hospice which remains an underutilized
benefit.
Panel Discussion and
Q&A with presenters plus Barbara Higa Rogers, LCSW, MPH, PsyD Hawaii
Psychological Association, and John Radcliffe, Patient Representative diagnosed
with terminal colon cancer almost 5 years ago. John said he is enrolled in hospice and
intends to be first person to obtain aid-in-dying prescription by the end of
the month.
Telehealth was gray
area: Lorrin said telehealth was ok for mental health, but law silent for
attending and consulting MD. Dr. Grube
said telehealth ok for all providers in Oregon.
Last year,
Oahu had record-breaking 29 pedestrian deaths … perhaps aided by removal of pedestrian crosswalks,
sometimes by mistake!
While walking
from Kakaako toward Ala Moana, I stopped at this intersection on Piikoi and
found no crosswalk on makai (toward
ocean, right side in photo above). So
instead of directly crossing in the direction of Ala Moana on makai side, I had to wait and cross
three separate pedestrian crosswalks, almost half-circle, to get to my
destination. Woah, why not make cars
slow down, instead of slowing down pedestrians baking in hot sun? Also learned bus stops have been removed in
the name of pedestrian safety,
and Honolulu City Council proposed TheBus fare increases: senior/disability pass from annual
$35 to $110!
Oahu’s prioritization of automobiles and parking has created
a public health nuisance: congestion,
traffic accidents/deaths, climate change, air and noise pollution, and chronic
diseases associated with sedentary lifestyles. In “Storing cars a waste of urban space” (Honolulu Star-Advertiser,
January 13, 2019), sustainable transit advocate/transportation planner Chris J. Johnson cites cities like San Francisco that are moving towards reducing driving/parking
in favor of public transit, pedestrian zones and dedicated bike lanes, thus
creating easier flow and circulation which are good for businesses.
AARP
Chinese New Year’s Celebration
At Ala Moana Hotel, Hawaii AARP Director Barbara
Kim Stanton shared her memories of celebrating Chinese New Year, thanks to her
Chinese mother (surname Leong). Honolulu ranks in the top cities for worktirement, so kupuna
continue to contribute their expertise in the workplace. In her mid-50s, Barbara launched her encore career as Hawaii’s AARP
Director since 2005 – just a year after she was struck by an SUV while crossing
the street and feeling like she had “fast-forwarded into old age” due to
injuries that left her depending on others to perform activities of daily
living. She really walks the talk when it comes
to pedestrian safety, especially for kupuna,
and she is becoming one of my favorite tourist attractions (2016 HPGS,
2017 PacRim conference)!
Judith
Graham’s article about Elder Orphans, originally published by Kaiser Health News on October 4, 2018,
appeared in Honolulu Star-Advertiser
about four months later.
