Finding Peace in Medical Decisions: An ER Physician's Guide with Dr. Lamb

Here we are, again for another interview with another very, very special guest here. Once again, I'm Lisa Skinner, your host, and we have here for you, Dr. Brittany lamb, Dr. Lamb, and she actually is an emergency room, physician. And you can tell us a little bit more about that backstory, and then how you became involved with, you know, trying to be focused on people living with cognitive decline in cognitive impairment. But before we do that, which will just be in a second, I just want to give a little background about you. So, again, Dr. Lam is an emergency room physician, she witnessed firsthand the overwhelm, and stress that comes with being thrust into a sudden need to make critical medical decisions. And I'm sure many of you can relate to being in that situation. I know I can. Recognizing the unique challenges that come with decisions in people living with dementia, Dr. Lam felt compelled to extend her expertise beyond the walls of the hospital. I love that to bridge the gap. Dr. Lam works online to empower medical decision makers with the knowledge and tools they need to make informed choices. Through her free audio training blog, and her comprehensive online program, which she calls make your plan with Dr. Lam. She aims to alleviate the stress and uncertainty that comes with decision makers desire to choose medical care, that is both what the person living with dementia would want. And, obviously, what is the best option for them what's in their best interest? So without further ado, I'd like to introduce our very special guest, Dr. Lam. And I think I'm going to start off asking you, what are some of the issues that you've seen in the emergency room, and in your years of practicing emergency medicine, with advanced directives for people living with dementia, and this is a really, really, really important subject. Yeah.

Dr. Lamb: Hi. Well, Hi, Lisa, thank you for having me. I appreciate you giving me the time to be here and talk to everybody. Um, yeah. So in the in the emergency department, we have to make decisions sometimes very quickly. And we oftentimes look to paperwork to help us make those decisions. And one of the reasons why I came online was because of the holes that I see in advance directives, especially for people living with dementia. And there's lots of issues with them. I mean, the purpose of these directives is one to tell us who you would want to speak on your behalf when you're not able to. So if someone doesn't do that, and then they have multiple family members, or people don't agree, that can make things very, very challenging. Also, when the family members know that they're the medical decision maker, but they don't feel comfortable doing it, and they want other people to be involved. And there's not been a lot of thought and discussion ahead of time about the medical issues that we're dealing with. So it's just because we know who we want to speak for us doesn't mean that they're prepared to do so that they know what you would want that conversations have been had. So that's one of the purposes of advanced directives is that piece of things like who do you want to speak for you. But the other purpose of advanced directives is actually giving us direction about what type of care would be okay, and not okay. And advanced directives, like the livingwell, Five Wishes, the generic forms that come out of our states, and they have all different names, you know, Advanced Health Care Directive is very common. They usually have very generic language that typically focuses on end of life. And people living with dementia oftentimes live for decades. And so it's not about end of life. It's about the whole journey living with this disease in the brain, whichever disease is causing dementia in the brain. And so I find that advanced directives because they're so geared towards end of life, they don't really help us in does the person want to be in the hospital? Do they want to have surgery? Do they want to have treatment for cancer? When is it okay to stay in the hospital and not what medications are okay and not do we want to keep doing tests for the heart what what what workup is okay, and not okay, and so, I feel like there's a lot of holes in them. And there's a lot more planning that we can do in advance because we know the person living with dementia is going to lose the ability to make decisions at some point. And unfortunately, once you lose capacity and you No longer can make decisions. Now medical decisions are kind of a separate thing. But in order to update your Advanced Directive documents, you have to be able to understand what it is that you're signing and what the right you have to know. So you have to know what the effects are of what you're actually writing down in a document. If you can't do that anymore, you can't update your documents. So another issue that I find is that they're often out of date, and they don't go along with what a person would want if they were able to assess their brain or assess their use their brain and assess their situation and what's going on right now. So it's, there's a lot of issues, I could talk about advanced directives for hours, probably. So this

is really good information. I'm sure that a lot of people in the audience would want to know, what steps should a family decision maker go through to know that they're making the right decisions? You know, I always recommend have those conversations early. But what what do you advise from a medical perspective, because you know, that he knows when somebody will no longer be considered a sound mind. Right. So there's a to this.

Dr. Lamb: Yeah, absolutely. So I mean, there's kind of two different trains of thought, I think the first, I think, two different pathways, I should say. So the first thing that you really have to do is take a hard look at whether or not your person is still able to make medical decisions. So in order to do that, you have to understand the situation that's happening to you. From a medical standpoint, you have to be able to hear all the different treatment options, the pros and cons, the risks and benefits of each option, apply that to your situation, choose what's best for you, and then be able to explain why it is that you're making that choice. That's how we make medical decisions. So So I find a lot of people don't haven't really realized that their person or not come to terms with the fact that their person can't do that anymore. And the system doesn't usually say, doesn't usually rubber stamp and say, give you a hard yeah, your person can't make medical decisions anymore, that doesn't really happen. It's a very, there's no, there's not usually a time where we declare that this person can't do that from a medical standpoint. So we really need families to help us realize that this person doesn't have capacity anymore. And I'm stepping in to do this. So before a person loses capacity, conversations are extremely important about what quality of life means to them, you know, do do we care more about the way that we live on a day to day or being alive for a very long time, like, which which thing do we value more, most of us value both. But at a certain point, a lot of people value quality of life a little bit more. And then knowing what that means to the person as an individual is extremely important. So those conversations and understanding what a person wants on a day to day what they do not want what is okay and not okay. There's something that would be ideally done before they lose capacity. Now, if a person's already lost decision making ability, you want to gather all the documents that you have that could potentially help you make decisions. So things like advanced directives, you want to talk to people who know them well, that they may have had conversations with, so other family members or friends about what's important to them. So you want to gather documents, and then you need to determine what your person's goals of care are. And this is something that I teach online. This is when I say goals of care, I basically mean, how aggressive Are we being in treating this person, depending on the medical situation going on? Are we doing every medical thing available to this person that could keep them alive, all the way down to are we focusing all of our care on comfort first, and there's, there's there's kind of a scale on there. And so that's extremely important to determine what quality of life means to a person so we can figure out what their current goals of care are. And then you have to gather their medical history. So if you don't know your person's medical history, you're not going to be able to, to think about the future and what decisions you might have to make for them. This is something that I get a lot of pushback on, because people say, Oh, it's all on the computer. But you have to know it, you have to understand your person's medical history. Because when someone's living with dementia, things are going to happen because of dementia, because of aging, and because of any underlying medical problems that person has. And this is all a window into what's going to happen in the future. And people have way more control and can become way more knowledgeable and informed about what they might have to make decisions about if they just would look at their person's medical history. So this is something that I teach. I teach and work with clients on on doing. So once you learn medical history, once you gather that information, then you can start learning about how those things can get worse, how they can put the person in that risk of other medical problems and how those things are treated. Because once you learn what your person is at risk for, you can learn about the treatment options, and then figure out what might be best for your person right now and then going forward in the future, depending on their goals of care. So that's kind of a big overview of a few specific

examples. Some of the things that would be very important to know, let's use Do Not Resuscitate as the first example, because that's one of the biggest questions that family members and have of their loved ones is, do you want to be resuscitated? If you know, all of a sudden you you experience cardiac arrest? I would say and you can speak to this, correct me if I'm wrong. But in my 30 years of working with family members, my experience has been that most people living with Alzheimer's disease and related dementia choose not choose that they do not want to be resuscitated based on having a brain disease. So do you want to elaborate a little bit? Yes.

Dr. Lamb: So I mean, it is that is an important conversation to have, again, that's an end of life. And do not resuscitate form only applies when someone doesn't have a pulse, and they're not breathing. So that person is actively dying, they either will die, or they are dying. If we don't do CPR, and take over their airway and breathing, all of that. It depends on it depends on the person's values of quality of life. And so if a person would judge right now that they're living with very good quality of life, and they would want the chance to continue to live that way, and it could make sense for them to have CPR, if they would say now that they're living with quality of life that they would find unacceptable, and they wouldn't want someone to intervene. If they were naturally dying, then it would make sense for them to have a do not resuscitate form. And the Do Not Resuscitate form only applies to CPR. And so I get a lot of, I get a lot of people asking me questions about it, you can still go to the ICU, if you have a do not resuscitate form, you can still have surgery, you can still be put on a ventilator, because people can have failure of their lungs or their heart, that doesn't cause them to die and not have a pulse and not be breathing. And they can still be put on a ventilator with a do not resuscitate form, because it only applies to when someone's actively dying? Well, that's

a really good point to bring up. Because then we need to take that a step farther. And I think it's on a lot of those director forums, do they want to be hooked up to anything that's going to prolong their life? And a lot of people again, and you can you know, correct me if I'm, if I'm Miss speaking here, but that's been my experience. They do not when they live with a brain disease. But these are things that you have to know, like you said that you have to address these are hard conversations, and hard decisions and conversations you should try to have with your parents or whomever when they are still healthy. So what's your been your experience with that?

Dr. Lamb: Yeah, I think it's extremely important to talk about I think that if we normalize to talking about what living means to us, and what a good day is to us, and what things are important to us. And what we wouldn't want to live like, like, I asked this question to my grandmother, because she's in her 80s. I said, you know, Nina Jean, what is quality of life, do you what does that mean to you. And, you know, she said, I want to be able to have a conversation with my family sit down and have a meal with them. I want to be able to tell people what it is that I need, and be able to ask for things. So even if I'm physically dependent upon others, if I can still say, This is what I need right now I'm hot, I'm cold, I'm thirsty, I'm hungry, that hurts. Thank you. You know, like if you can have that meaningful interaction that occurs quality of life, that's extremely helpful to me as a family member. And as a physician, if she gets into a situation where that's no longer going to be a possibility for her I know what to do. And it's just based on knowing what what quality of life means to her. And so I feel like as a society, if we normalize these conversations, it would be a lot easier to help people navigate making medical decisions when there's a big event happening. But I think talking about end of life is is is too much sometimes in the beginning. And I think that's why a lot of people ignore it. I mean, who wants to talk about do you want CPR? It's more about hey, look, you're living with a disease causing dementia in your brain and we know these things are going to happen. Like, you know, people are at risk of infection, you're at risk of having sepsis, right? If you have underlying heart or lung disease, let's talk about like, what that might look like if it gets worse. You know, there's the Decisions about end of life are oftentimes a lot easier to make it's these other, do you want to be in the hospital? Do you want surgery? Do you want to keep seeing all these doctors? I just think people need way more help and thinking about planning for the future. And because I see them struggling, every time I work in the ER, every single night, I'm going into the work tonight, I'm sure I'll see someone living with dementia. And so that's, that's why I came online to help people with this because no one's doing it. So well.

So that brings me to a really good question, because you have really given us a lot of valuable information about the process and the things that we need to take care of. And my next question was going to be, well, what resources are out there to help to guide people? Because we don't know what we don't know. So we don't know the questions to ask, is this what you're what you do online? You you help people with these processes and duress and things like that. So you're the guide, and you can tell them? What they don't know.

Dr. Lamb: Yes, I basically, you know, I think physicians and an all of us working inside of the healthcare system, there's so much stuff that we wish people understood when they got to us. And it's nobody, it's nobody's fault, really, it's just that the system doesn't give us enough time to educate. And so when you all show up to the ER, I wish that you already knew some of the stuff that I have to teach you. Because then we could spend the time in that moment focusing on talking about the options, the risk and benefits of each and what's actually best for that person in the moment, instead of me having to spend a good bit of our interaction, just educating. And so it's not to place blame on anybody. And maybe it's to place blame on us. But now that we have online access to online education, and being able to teach people things online, I mean, that's why I set up the course that I did. So I walk people through how to be a medical decision maker for a person living with dementia, how to assess their their quality of life, and define what their goals of care are, even when they can't engage in that type of conversation anymore, because that's extremely common. And you will be asked to make decisions. And just because your person can't weigh in anymore, doesn't mean you're not going to be asked and doesn't mean you're not going to have to live with the decisions that you make. So I teach people how to do that. I teach them how to assess their person's risk of what what is most likely to happen to this person. From a medical standpoint, what are the things that you really want to think about now that you may have to make decisions about like what we've been talking about sepsis, if your person's heart or lung fails, if they're living with cancer, whether or not we're going to keep looking for cancer, whether or not we're going to treat it all these different things. And then because they're aging, I mean, I've had clients whose their person had appendicitis. And it was just harder to figure out what was going on, because they're living with dementia. And so I teach just common medical emergencies that people living with dementia are likely to run into, because they're a person who's living and aging. So I teach people about the different medical conditions that their persons are at risk for, and then how to look at the treatment options for those and then look back and see which treatment options fall in line with their person's goals of care. And I just provide access to all this medical knowledge for people to come to have a plan. So you can plan for what's most likely to happen to your person, but also says you can come back to this information if something were to happen and, and learn in real time so that you can ask better questions, because for each of the conditions that I teach people, it's like, how do we diagnose it? How do we treat it? What questions do you need to ask in that moment with what's going on? And then, yeah, and then figuring out figuring out what's best for a person. So well, I dumped all this into my online program maker plan with Dr. Elaine. But I have lots of free resources. My blog has a ton of information. I have a free audio training that goes through the five steps of being someone's medical decision maker as much a deeper dive into what we've been talking about here. So that's it my website, if you go to be Lam, md.com, it's right at the top free audio training, you can sign up for it. The

best way to tap into your program is by going to I think

Dr. Lamb: I mean, if people are ready to purchase to purchase it, you know, you can go to it's B Brittany B Lam, md.com forward slash plan. And you can read about the program. I've revamped it in 2024. So I'm actually getting involved with each of my clients and looking at their person's medical history and then delivering them a video that tells them these are your person's biggest risks. And this is what I want you to really focus in on on the in the course so that I don't this by the time this airs, board slash plan. You can look at that but if you really just want to learn more and get like into my world and be connected with me. So I can help educate you. I think the five step audio training is a good way to do it. And then I also am sharing with you all a link to a guide, a video guide, answering 10 of the top questions I'm asked as a doctor. So I talked about advanced directives, I talked about hospice and palliative care, and, and all these things that people ask questions. And that's your

gift, right? Yeah. Okay. So, so people will know how to access that in our subsequent emails. But I have to tell you, Dr. Lamb or Britney, lamb. Just an unbelievable gift I've been in this world decades. And I honestly have to say that there are not too many physicians that are willing to share this kind of information at the level that you are sharing it with, and help walk people through the process. From the medical perspective, the medical standpoint, there's lots of lawyers out there doing that there's nothing wrong with that, but to to get the instruction from a medical perspective, and all the things that you described, is not only rare, but almost impossible to find, and a true true gift for people out there specially families that are dealing with cognitive dysfunction, because it's a whole nother animal. Yeah, and being able to communicate with somebody who still has their sound mind and knows exactly what they want. There comes a time in the disease where that is no longer possible. And we all as adults, or children, or relatives, or friends, or whatever, we want to make to know that we're doing the best for the people that we love. And this is such a brilliant way to accomplish that. So yeah. Is there anything else you want to share with us before?

Dr. Lamb: We I mean, I just think that I don't want people to be overwhelmed by this. I think when I say like thinking about your person's medical future and planning, I think a lot of times people are like, Well, why isn't my doctor doing this? It's they don't have enough time. And to be honest, the reason I came online is because I was so frustrated, I was so frustrated, because I kept seeing, I kept seeing people really struggle on the ER to make these decisions. And I kept asking myself, why is why are the primary care? Why are the specialists? Why are they not teaching these people these things, because they're foreseeable, like all the things that people come into the ER for. I mean, unless it's like a car accident or freak injury or something, a lot of the times they're foreseeable, they're based on what your risk are from a medical standpoint. But what I realized is people just don't have the time. And then being a hospital based doctor who actually makes these decisions with people every day, like I'm just uniquely set up to be able to help people in this way. And I just people who are living with dementia are extremely vulnerable inside of our health care system. And you all just need more information. And so whether or not you ever worked with me, I there is stuff I have online to teach you and help you. And so, you know, just just I want people to be excited about and hopeful for the future, because I really just think that the landscape and healthcare is gonna have to shift to help people access more information on their own time to learn and become informed as patients and as advocates, because we just the system is just too pressed for time. So I'm hopeful that more doctors will come online, because a lot of us are burnt out, we want to do something different. And, and so that's, that's why I'm here. But I appreciate you for giving me the space. And I hope I can help help those of you who are watching,

I see you as being just an unbelievable gift to people out there. And as we all know, we've talked about this in some of the other interviews, the number of people who are projected to develop Alzheimer's disease and dementia by the year 2050 is expected to triple unless your treatment is found. So far, it hasn't happened. And it's been around for 100 years. Yeah, so these are really really important and valuable things for people to know and to take into consideration. So thank you so much for for doing this for everybody. Because this this is just such a gift. I don't even know how else to say it. But to me, it's an absolute gift to be out there. Thanks. I'm

Dr. Lamb: happy to do it. It's it's just my knowledge to you. That's how I see it. So, ya know, I'm Hope I'm hopeful that I hope that what I'm doing eventually doesn't become necessary. I don't think that that's going to happen in my career as a physician but it, I do, I am excited about learning more about individualized personalized medicine and trying to figure out what our individual risk factors are for developing dementia, and having some more lifestyle and diet. Like interventions, I'm really excited about some of the things I'm learning about, you know, now that I'm 10 years out of medical school, and I've been practicing in the ER, yeah, for 10 years now. So it's exciting to to hear that they're, they're some developments in slowing down disease and, and reversing even like mild cognitive impairment. So I think that people should really look for help with that as well, if you're very early on, looking for like integrative and functional medicine resources, and trying to figure out if there are things that you can intervene on in your lifestyle and diet to try to slow down and maybe even reverse the some of the,

and there have been many, many studies done about that over the last, you know, several decades. So, yeah, these are evidence based results that we're now learning about, and it can make a huge difference in somebody's life as to whether or not they end up developing Alzheimer's disease or not. So I'm glad you brought

Dr. Lamb: that up. Yeah. And it's, it's, it's not just the medical, the legal, the financial, like all these pieces go together. And so, you know, when we're thinking about planning for people, and we're, we're thinking about trying to prevent these diseases or reverse them. It's a huge impact not only on quality of life and length of life, but the types of resources someone needs for their care, and the financial situations and all the legal things with their estate and planning and assets. I mean, there's so much positive impact that can happen really by by on the prevention side, which I'm extremely excited about. So I'm like I'm, I'm, I'm kind of helping people once we've once we've lost the ability to make decisions, and we can't reverse disease and we we think that the person's not going to be able to get better, but I am for the future. I am hopeful that that we might be able to change things so

well, you've provided us all with some really, really valuable information. Thanks again so much for being here and taking the time to be here. We we appreciate you so much.