When Should We Die?; Quality of Life & Living Wills; Euthanasia; Zostavax shot; Protein in Diet; Birth Control & Blood Pressure.

This blog corresponds to the May 4, 2012 broadcast of Let's Talk Medical with Doctor Gigi.  Feel free to refer to the podcast of that show via www.SkipShow.com if you want to hear us speak about these issues, & as always, please feel free to leave comments here or call us during the live show on Fridays at 1PM Eastern time... (866)-TAN-1340 tollfree.

When Should We Die?:

All machines break down at some point, so when should the human body break down?  Are we really doing good to make discoveries that increase one's life expectancy? 

I believe that the human body can certainly live well into the 90's or even longer, but at some point it does become frail & ill, & there is little if anything we can do to reverse or cure that.  Also, if you want to be the lucky person who lives a healthy life to that age, you must make good choices in your life!  You must eat rightsleep wellexercise routinelyfind joy in life, & love & be loved!  You also pray that you received great genes from your parents, as some issues that effect your life expectancy are not within your control.  Even environmental issues such as where you live will have tremendous impact on your health, as we unfortunately learned from the Love Canal incident in New York.

Obviously we spend a lot of money trying to find medications which impact our health.  The best option however is to stay healthy... so we should all aspire to do that!  Realize that you have but one body, & affirm to take great care of it, as we can not always reverse the damage a poor or risky lifestyle causes. 

So we all want to live to be old & die of old age, but "old" seems to get older as we age.  I guess that "old" might even be more defined by one's quality of life than by a distinct number of years which they have lived.  Thus a sick 50 year old person might be "older" than a healthy 70 year old.

But when should we as humans die?  Obviously no one wants to die if they have good quality of life.  But, without older generations dying, how can Earth support the overpopulation?  So life & death become not only a health issue but a socio-economic one as well.  If we want to live longer lives, we need to use birth control appropriately & thus decrease over-population.  Thankfully, we seem to be doing a better job at that as the birth rate has recently declined.  We must also realize that if we live longer, we will need more money for those elder years, thus retirement age will have to go up.  This means the work-force will not have as rapid a turn-over, so jobs for younger people will be hard to find.  Again, a population issue! 

So one of our listeners posed a question:  Do I support the one-child policy?  I really don't like laws which restrict choices, but I would like it if people would adopt this belief.  People should make choices to not over-populate the world, & at the very least, we should be responsible enough to not have more children than we can comfortably feed, educate, & love.  So judge your own circumstances & make your own choices, but keep these issues in mind!

Quality of Life & Living Wills:

A study several years ago discovered that the majority of the Medicare money is spent in the last 90 days of a person's life.  While we do not want to give up hope when a person gets ill, we do need to recognize when treatment becomes futile.  At the present time, our government & health insurance plans are looking at ways to cut costs.  They are toying with the idea of withholding certain treatments based on age.  I would rather that we withhold care based on the likelihood of a good versus bad outcome, as this would take into account more important issues than simply a person's age, & certainly seems more scientific to me.  Thus a 35 year old with a brain injury who must live in a nursing facility, & who cannot talk or travel might not qualify for aggressive chemotherapy for cancer, whereas a healthy 75 year old who lives independentlycares for himself, & continues to drive might qualify for the treatment.  I propose that before we get arbitrary guidelines, we need to start using common sense & make our own good choices! 

We also need to make Living Wills which express our wishes to not be kept alive if there is no chance for meaningful recovery, & we must discuss this with our families so they are prepared to honor our wishes when or if the time comes.   When a physician approaches a family member to ask if he can abide by the Living Will & thus withhold treatment, he is not really asking you to decide about heroics for your family member.  In fact, your family member has already made that decision, & you can only decide to allow the doctor to follow your family's written wishes or not.  So you are not letting your family member dieyou are simply following their wishes as expressed in the written instructions we call a Living Will. 


Though I believe in euthanasia, I am not certain that I could actually perform it.  I have had my pets euthanized, & though I know it alleviates suffering, I don't know that I could do it.  I am thankful however to have Hospice available, as they too ease a patient's suffering, & their pain medications likely expedite death a little... as they suppress respiratory drive.  If you or a loved one has a terminal illness, you likely qualify for Hospice.  You could instead have "the dwindles" which is not truly a disease, but rather a "failure to thrive."  In this instance, we simply know that you are slowly dying, for whatever reason.  There is a thought that you must have only 6 months of life left to qualify for Hospice, but that does not mean that you have to die in 6 months.  Hospice can provide longer term care if needed, so ask your doctor if you think you need their services, or if you prefer, call Hospice directly to speak with them yourself.

Zostavax Vaccine:

If you have had chicken pox, you are prone to getting shingles, as shingles is a reactivation of the chicken pox virus which continues to live in your spinal cord area after your initial infection.  Shingles is a painful, red, blistery rash which wraps around your body in a nerve distribution.  This means it will cover a stripe of skin on the right or left side of your body, & it never crosses the midline or middle of your body.  It can cause pain before the rash even appears, & usually the pain is pretty severe.  The older you are the more likely you will get it, but thankfully most people only get it once.  Younger people usually get better, but older people can end up with chronic pain, called post-herpetic neuralgia, which can be so severe that it is debilitating.

Zostavax is the vaccine which helps decrease the chance that a person will get shingles (also called herpes zoster).  Thus, it is indicated for people 50 years old or older, as they are prone to the disease, & if they get it, it is possible that the pain might never resolve.  Generally we believe you only need one Zostavax injection in your lifetime.  The vaccination costs about $250-$300, & most insurances do not pay for it, but Medicare Part D (which pays for the Medicare recipient's medications) will pay.  Thus many people wait to get the shot when they are 65 years old as that is generally when they get Medicare benefits.  If you really want to get a Zostavax shot, call your insurance to see if they will pay, but if they won't, you have the option to pay for it yourself.  Though $250 or $300 is a lot of money, it is probably money well spent to avoid chronic pain.

Protein in Diet:

Linda asked about the amount of protein a woman should have in her diet.  First, realize that very few doctors understand nutrition very well as we do not get a lot of nutritional training in medical school.  Dieticians are the specialists who know this stuff, so if you have tremendous concerns, see a Dietician for input.  I think that a person's diet is supposed to be composed of 40% protein30% carbohydrate, & 30% fat.  As everyone has different caloric needs due to their age, sex, weight, genetics, activity, medications, etc., you must first determine how many calories you truly need each day.  You might discuss this with a Dietician or perhaps you can get a guesstimate by using on-line calculators.  Once you have the total calories you need in a day, you multiply by 0.4 to get the 40% of calories which should come from protein.  Lastly, you must know that 1 gram of protein = 4 calories, so you must divide the protein calories by 4 to get the number of grams of protein you should have per day.  You should also know that 1 gram of carbohydrate = 4 calories, but 1 gram of fat = 9 calories

For example:
Let's assume I need 2,000 calories per day to maintain my weight.
     2,000 calories X 0.4 = 800 calories which should come from protein.
         800 calories of protein divided by 4 calories/gram of protein = 200 grams of protein needed/day.
     Based on the above, you would need 2,000 X 0.3 = 600 calories from carbs, & 600 from fat.
          But due to the different calories in these, you would need 600 divided by 4 = 150 grams of carb, but 600 divided by 9 = 66 grams of fat.

Lastly, if you have certain diseases, the above might not apply to you.  In particular, people with liver disease must limit their protein intake as otherwise they produce excess ammonia which acts a bit like alcohol to make them not think clearly.  Thus a person with significant liver disease should see a dietician to learn how to eat properly as their needs are somewhat unique.

Birth Control & Blood Pressure:

A patient was recently told that her blood pressure was high, & that due to this she needed to stop her birth control pill.  Birth control pills are usually a combination of estrogen & progesterone, & estrogen can increase blood pressure

First, as she had never had high blood pressure, she must stop the birth control pill, but she must also look for other things that might have caused the high blood pressure.  She should stop any products for weight loss as these can elevate the blood pressure.  Similarly she should limit decongestants (such as SudafedPseudoephedrine, & Phenylephrine) & caffeine, as well as alcohol.  She should try to exercise & perhaps lose weight (if she is over-weight).  She might need to consider a sleep study to look for sleep apnea, especially if she is obese & snores a lot. 

If the blood pressure normalizes, she could then re-try the birth control pill, but if the blood pressure again increases, she probably should not take the pills any longer.  There is a progestin-only pill which she might try, as this should not effect the blood pressure, or perhaps she could simply use condoms & a spermicide.  If she is older & in a stable relationship, an IUD might be a good option or perhaps even a diaphragm or a cervical cap would be acceptable.  There is a new procedure called Essure which is a permanent, non-surgical, non-hormonal procedure that will cause blockage of the Fallopian tubes thus preventing pregnancy as the sperm cannot get to the egg.  It is basically a non-surgical tubal ligation which is performed in several minutes in the office, but it is NOT reversible, so it is considered a form of sterilization

Obviously there are many good options in this situation, & the final choice will vary based upon the patient's age, relationship status, & desire for pregnancy in the future.  As always, a discussion with her GYN or Family Practitioner should help her make the most appropriate choice for her.

I hope you learned something useful in this blog, & please consider listening to Let's Talk Medical with Doctor Gigi on Fridays at 1:00PM Eastern time.  We are broadcast locally on WTAN 1340-AM in the St. Petersburg/Tampa area, but you can also find us on the web via www.SkipShow.com where you can listen live or to the podcast at your convenience.  Keep in touch & don't hesitate to contact me with questions or comments: (727)-441-3000 or (866)-TAN-1340 which is toll-free, or DoctorGigi@SkipShow.com

Here's to our health!

Doctor Gigi