Dr. Alan Lindemann: A lot of experience, and we met on this when I wrote this article about temporary dementia or reversible dementia and gave those examples, and you’re one of the ER doctors who responded to that. So I’m wondering how exactly, I know that right now you’re done with the ER because that’s how you’re listed on LinkedIn.
Dr. Kevin Haselhorst: Correct.
Dr. Alan Lindemann: How did you get to be interested in temporary dementia in the emergency room?
Dr. Kevin Haselhorst: Well, obviously I see a lot of patients with dementia, and I think temporary dementia might be a little confusing for the audience because if it’s reversible, that’s a little uncharacteristic of most dementia. Most people see it as a progressive illness that becomes very debilitating for people and also becomes a struggle with end-of-life issues.
Dr. Alan Lindemann: It certainly does. In the article that I wrote, we have a lot of what I call, like I said, temporary or reversible dementia. For example, many people will come in with a bladder infection, and they just don’t even recognize their family members. But if you treat the bladder infection, they return to normal in a day or two. So that’s what I was talking about when I was looking at reversible dementia.
Dr. Kevin Haselhorst: Sure. We definitely see a lot of confusion amongst the elderly population. And so, there is a unmasking as to what the causes are of the confusion type of thing. And many times, yes, if it’s simple as a bladder infection, that can be.
Sometimes it’s medications that people are taking that cloud their memory. Sometimes it’s stress and the anxiety that they’re overwhelmed with. So I get that there are many variables in terms of patient diagnoses and trying to pinpoint the root cause of the problem.
And my area is more in the realm of end-of-life care. So when the patient with actual dementia comes in, not reversible dementia, they have this sort of expectation that perhaps the system might make them better. And so, that’s a little unrealistic because we all know there’s no cure for dementia. It is typically a progressive illness. And with that, we always kind of hone into what are people’s wishes at that point, particularly when the medical system has so much available to treat people. COVID was a perfect example of, what do you do with a demented patient who has COVID, and at what point is that a reason to put them on a ventilator kind of thing?
Dr. Alan Lindemann: How much do they understand of that? Yes. And what’s going to happen? I mean, how good can you get? So anyway, you are out of the ER now, and you’re into other things. You did your TED Talk. How did that come about?
Dr. Kevin Haselhorst: The TED Talk was a personal initiative to get my information. I really wanted to speak to hospice organizations regarding, how do we enroll more people in the idea that hospice would be okay, an acceptable decision or pathway for people to choose? Most people, the stigma with hospice prevents them from choosing hospice because they feel like you’re giving up kind of thing. So there’s always two sides to the conversation when you’re dealing with a serious illness, particularly when it personally affects you and a family member.
I set the stage regarding this topic as to how we talk to parents about a serious illness. So as a doctor, I talk to parents like any other patient, “This is what we have to do, and we’ll put you in the hospital, and we’ll treat this, that, and the other thing.” As a family member, I want that family member to stand on the other side of the stretcher, that says, “Dad, you don’t have to do anything.
You’re perfect as you are. There’s no judgment here. There’s no expectation that you have to do any of these treatments.” That is only many times add more stress and hurdles that they can’t overcome. So my heart goes out to these poor patients who don’t have free choice, if nobody’s standing on the other side of the gurney saying, “It’s okay to let go.”
Neil Haley: And that’s a difficult conversation, Dr. Kevin, to have with people, that you’d rather have a good end of life, or suffer through end of life. Right?
Dr. Kevin Haselhorst: Exactly. It’s a very binary choice. You’re in it to win it, or you’re okay with life as it is. And this idea of what we don’t know isn’t settling for me. Who has to know how I treat you when you come into the emergency room? What do you consent to? The PBS Frontline does some amazing documentaries on facing death and death in America and being mortal, all these that put people in the room of being challenged by, how do we talk to, how do we care for these people who have chronic illness who end up on a ventilator and nobody knows when it’s appropriate to stop the treatment? It’s appropriate at the beginning. If you’re a family member, you always side with this. No is okay to treatment. Saying no is okay.
Dr. Alan Lindemann: Yeah. So you’ve spent a lot of time, you’ve left the ER according to your LinkedIn page, and basically now with end-of-life treatment or talk discussions.
Dr. Kevin Haselhorst: Correct. It’s really about having these conversations. So again, let’s go back to that COVID. You’re in the emergency room, and you’re having trouble breathing. Do you want the ventilator? Nobody knew what the answer was. They were unsure. I mean, some people are very clear. In my mind, I was very clear, I do not want the ventilator. If I got stuck in that situation, I actually signed a DNR at that point saying I’m not in it for it because I knew I wouldn’t be off the ventilator in three days. I don’t want to sort of pretend that my life would be normal after being in an ICU for a month, given the quality of my life now. And because I’m so grateful for the life I have, I don’t feel like I need anything more to complete my life. I’ve had such a good run.
So yeah, there are some people who can choose no ventilator. There are some people who are going to take the ventilator no matter what. But then, there’s a middle ground of the people who want it for a short duration. But what does that short duration mean to them? That’s where my coaching comes in to helping people discern, are there reasonable alternatives without actually getting on the ventilator, and just saying it in a way that says, “It’s okay not to take the ventilator,” because people saying not take the ventilator seems like a shame. You ought to do something.
Neil Haley: So it’s really educating the patient to speak up for themselves or to have people around them speak up for them.
Dr. Kevin Haselhorst: Give them permission.
Neil Haley: And having these conversations years before you get to that health issue, and you never know what it is. We have to have that conversation.
Dr. Kevin Haselhorst: But it’s got to be reviewed every year. I have a big pitch with my representative now trying to get Medicare advanced directives. This idea that every time during Medicare enrollment, you select an advanced directive for you. You don’t create your own directive. You create one care plan. So you’re either in it for plan A, which is aggressive medical intervention, or you’re going plan B, which is benevolent care plan, and then plan C is more considerate, which is more the palliative care route. You may not go in for the chemotherapy, but you may want some other treatments, or you want some other sort of attention given to the situation, but more as an outpatient rather than an inpatient, given your serious illness that you have.
Neil Haley: That’s huge because having those conversations are so important because you never know when a serious illness or accident happens to you. And what do you want to do if you don’t have that advanced directive put in place?
Dr. Kevin Haselhorst: If I have a head injury tomorrow in a car accident, driving home from work early in the morning, I was at risk for always being that person who had a head injury, who might end up on life support. So I made my directive very clear. If I’m brain damage for a certain period, I can’t function, I’m in a care facility, three months, and that’s all the recovery I get. Whatever you’re doing to keep me alive at that point, please stop it. There’s no reason I want to prolong my life for 10 or 12 years just because I’m extremely healthy physically. If I don’t have a mind to have any kind of a quality of life that I choose, I don’t want the extended version of life in that realm.
So that’s where my book, Wishes to Die For, really allows people to fine-tune those sorts of increments of three in terms of, for me, “If I’m traumatized to whatever degree, well, if I can’t breathe, you get three minutes. If you can’t eat, you get three weeks. If you can’t have water, you get three days,” kind of thing. If there’s certain rules of survival that can apply to your decisions as you’re recognizing that, if I can’t do these things at certain benchmarks, I don’t want to live beyond that period. No hope in a nursing home. If I’m in a nursing home, and I’m still alive, there’s no hope in my mind that the quality of life will return. So I’m not pretending somehow that there’s a miracle on the horizon. I’m keeping it very real, and for people to sort of engage that concept or perception.
Dr. Alan Lindemann: Are most of your patients in a nursing home, or you see them before that time?
Dr. Kevin Haselhorst: Oh, I see. ER is inundated with people from the nursing home, and that’s the revolving door. We all know their frequent visits that occur at the end of life. And most of the people that come in, they bonk their head. They fall and bonk their head. They’re required to come in and get a CAT scan over their head just to make sure there isn’t a reversible cause. Well, in my situation, if I were in a nursing home, if there were a reversible cause, I wouldn’t want you to reverse it. I would want nature to take its course. There’s nothing wrong with making that choice and for me to have that say.
Neil Haley: And once we look at our health in more of an important thing, Dr. Kevin, when we start to have these conversations with kids when they’re young, that you’re saying you’re young, go ahead, take those chances, do those certain things. You have to think about how long a life you want to live, and if you want to live a long, productive life, you have to choose healthy choices and do the right thing earlier. Then, you can live a longer life, not in a nursing home, not in assisted living, and enjoy life. And then, when your life ends, it’s going to be in your terms. But we don’t have these conversations.
Dr. Kevin Haselhorst: Well, this is the compression of morbidity theory that came out in 1980 or so, which talks about the idea, you want to be as healthy as you can for as long as you can. And then, when a serious illness occurs, you want to sort of stop the prolonged suffering. So again, I have a very good life at my stage in life. I set myself up with the diet and the exercise. I’ve done everything right to sustain my health, and I have a great quality of life. But if I have a stroke tomorrow, I don’t choose to want to prolong the inevitable. I want to exit fairly quickly, and my TED Talk talks about this idea of, you’re sitting in the right lane of the highway, and you’re either going to go to the left lane for more aggressive care, or you’re going to exit to the heart center, as I might say, to hospice or to being home care kind of thing, rather than the ICU.
So sitting in the middle of the right lane is where you’re choosing, at the stage of life you’re in, how important it is for you to go back to the hospital to be admitted to the ICU. Either way is okay. I don’t care which direction you go. I need to know what direction you want. I don’t want you to there be any confusion as to, when things go south, what do we to do for you? It’s very simple. You either want home care, you want outpatient care, you want hospital care. And so, it becomes a little bit like, “Well, maybe I want it all,” and that’s where it gets very confusing. That’s where the middle ground is. I want outpatient care.
So you might go to the emergency room, receive your antibiotics, maybe get your TPA for your stroke and see if it’s reversible. But you don’t really want to go to the ICU, if it’s to the point where you have a brain bleed, and you’re ending up going to the ICU. The thing is, if we don’t redline it from the beginning, we get stuck on a ventilator, or we get stuck in a treatment plan that says, “We don’t know how to pull the plug now because we are so far into this, and we feel like we’re killing them because we had not judiciously made some of these. We should have withheld the care first, rather than having to withdraw the care.” And if you look at these documentaries, you see time and time and again that we haven’t talked about withholding the care at the get go, rather than putting everybody on the ventilator like COVID and then sort of disrespecting the end of life because no one had the conversation ahead of time.
Dr. Alan Lindemann: I think it’s extremely important that your family, I have three children, and I think it’s really important for them to understand what I want. I think sometimes there’s a disconnect, that kids don’t really understand what the parents want.
Dr. Kevin Haselhorst: Well, I’ll ask you. What do you want when you’ve got COVID, and you’re in the emergency room, and you’re having trouble breathing? Do you want the ventilator?
Dr. Alan Lindemann: Well, I would say no. I mean, based on what I know now.
Dr. Kevin Haselhorst: Right. Okay. Again, that that’s important because we know that you have a sense of, “I’m not in it to be beat up at the end. I don’t want to end my life on a ventilator.” And so, it gives me a clear mindset as to that you do have some… Some people want everything done. Lots of people come into the emergency room with that intention. We love mom, we want everything done. But that’s not really practical and it’s not respectful.
Neil Haley: I understand. Best place, Dr. Kevin, we can learn more about you, purchase a book, and learn more about you. Where can we go?
Dr. Kevin Haselhorst: Kevinhaselhorst.com.
Neil Haley: Excellent. We appreciate it. And your TED Talk’s available on the website as well?
Dr. Kevin Haselhorst: It is on YouTube, Kevin Haselhorst.
Neil Haley: All right. We appreciate it, Kevin.
Dr. Kevin Haselhorst: Thank you for the time. Bye-bye.
Dr. Alan Lindemann: Thank you. Thank you, Kevin Haselhorst.
Neil Haley: All right, that was a special simulcast of the Neil Haley Show and Doctales. Take care, guys
