ARROWHEAD REGiONAL MEDiCAL CENTERS - END OF LiFE DiRECTiVES

By Michael Palecki

On August 24, patients at Arrowhead Regional Medical Center in San Bernardino County – were given something to read while undergoing dialysis treatment. With no prior counseling to renal patients, nurses distributed Questions & Answers literature for people who choose to stop dialysis. On each handout, a supervisor of the dialysis center – had written the patients initials.

The document suggested that major religions believe it is acceptable to stop dialysis, the act is not considered suicide, and insurance companies will pay survivors. Continuing, it was explained that death is not painful after stopping dialysis and most patients die in their sleep.

According to, End-Of-Life Care for Renal Patients: Questions & Answers-prepared by the Southern California Renal Disease Council, “Patients often say that just having made the decision takes a burden off their minds, and they feel more relaxed”.

As Pamela Jean-age 56, continued reading, she was stunned and felt betrayed by the county hospital. After experiencing kidney failure nearly two years ago, she had been undergoing dialysis treatments three times a week. She was confident that her life had been prolonged indefinitely – until she became a kidney transplant candidate. But now, everything seemed uncertain.

While being interviewed, Pamela Jean requested that her last name, not be used in this article. That’s because she did not want to alarm friends and associates- who were unaware of her medical condition. Well-read and upbeat, Pamela Jean was very much alive and determined to research a solution to the dilemma, without causing worry to those around her.

However, she expressed concern for her fellow patients. Before their next treatment, other patients confided, “They were more than shocked and had lost sleep since reading the handout”. Many in the multi-ethnic group did not fully understand the literature or why they had been singled out.

During a second interview conducted to obtain another opinion of what had occurred at Arrowhead Regional, Doctor Gina Mohr-Director of Palliative Medicine for Loma Linda University Medical Center – expressed concern. She explained that a much different set of procedures is in place at Loma Linda, where palliative care has been administered for 10 years.

She first disclosed that dialysis treatment – is not considered to be an End-Of-Life situation. She regarded it as the first bridge to a minimum of 10 to 15 years of additional life. Doctor Mohr then stated, “It’s a shame that End-Of-Life Directives have been used at Arrowhead Regional as supportive documents, without discussion. Communication skills were lacking”.

Doctor Mohr then continued, “In the current Healthcare discussion, very sensitive religious and ethical questions have been propelled to the forefront. However, End-Of-Life counseling has been in existence since the late 1970’s and is reimbursed by Medicare”.

She concluded the interview by detailing procedures at Loma Linda. Doctors, nurses and social workers first discuss the medical situation with each patient. Next, standardized information for renal patients and another publication generated by the hospital for those with “low literacy skills”, are given to all patients. And then, staff is available to answer any questions, a patient may have.

On September 1, a third interview then transpired via a telephone conference call with Arrowhead Regional. Included in the interview were: George Valencia-Director of Business Development & Marketing, Khim Fugate-Associate Administrator and Chief of Nursing, and Docelin Tamba-Dialysis Supervisor.

Prior to 4:00 p.m. on August 31 when an interview was requested, the three were apparently unaware that distribution of End-Of-Life Care for Renal Patients: Questions & Answers – had created an issue with patients.

Starting off, Khim Fugate disclosed that Arrowhead Regional had just initiated palliative care on July 1 of this year – after receiving a $30,000 planning grant from the California HealthCare Foundation, in 2008. She then explained it would take eight months to educate nurses in all departments. When asked if she considered dialysis to be an End-Of-Life procedure – Fugate responded, “No. Some patients have been known to live up to 40 years longer, with treatment”.

The next question: “Were patients counseled before receiving the literature?” – was answered by Docelin Tamba. He replied, “No. Patients were not counseled. We need to explain things further to patients. Maybe my nurses needed more direction”.

Concluding the interview, Khim Fugate commented, “I want to assure you that we will revise our process to serve patients – who represent an underserved medical population. Everyone has potential – we want to make it right”.

Given the fact that administrators and staff at Arrowhead Regional were not on the same page during the planning grant timeframe – it was premature to involve patients. According to Spreading Palliative Care In Public Hospitals published by California HealthCare Foundation, “Palliative care seeks to optimize quality of life and relieve physical and emotional suffering through pain management, comfort care, and spiritual support. With a focus on both patient and family, palliative care begins when a life-threatening illness or injury occurs and it continues through the bereavement process”.

Later in September, Arrowhead Regional received an additional $245,000 to implement the palliative care program – they planned during the first grant. While death is an occurrence that everyone needs to prepare for, Arrowhead Regional should “optimize quality of life”- rather than emphasizing End-Of-Life Directives, without counseling.

Michael Palecki can be reached @ imagesculptor@verizon.net