Left Behind

When a person leaves us, their lives must achieve closure. We arrange their funeral, we manage their finances, and we take care of the things they leave behind.

The job of handling personal and legal details of the dead falls on the living. It could be an overwhelming task for the inexperienced.  You may still be grieving, yet work must be done fast to facilitate a smooth transition for everyone.

But one must not carry the burden alone. Help is needed and must be provided.  Professionals such as lawyers, physicians, and accountants may need to be on-hand to give advice. It might be costly to make a mistake at times, so one must be well-versed.

Friends are an indispensable resource for unknown surprises. One may be the decision-maker, but the execution must be considered as a team event.  You may take the lead in planning, while others pitch in for execution. Even loners may find it difficult to pass through this stage in solitude.

If your loved one was confined in an institution with medical experts on hand, the medical staff can take care of the paperwork to complete the death certificate. This is important because the death certificate will allow permission to process the remains.

If someone dies at home, a medical professional must be contacted to ascertain death. You can call a doctor when you do not detect any sign of life, such as the absence of breathing or pulses. Since most often, you do not have a death certificate form on hand, you may need to contact the physician again to have the form signed on another day. That is why it is advisable to have this form handy in case you are expecting a deteriorating condition, no matter how morbid it sounds.

It is not recommended to do cardiopulmonary resuscitation on a patient who is in the terminal phase of their condition. However, it is strongly recommended to have advance care directives. The decision on resuscitation must come before the actual need to carry it out arises. Keep in mind that resuscitation is not to be offered by clinicians when it is deemed to be futile.

Immediately after the declaration of death, spend some time with the body. This is a moment of peace, quiet, and rest. Reminisce and work on accepting the inevitability of the moment. It is not bad to cry or show emotion, but it is also fine to be just a listener and a stabilizer of feelings.

Tell friends and family about the demise so they can pay their respects. One may need to go through the deceased's email and phone contacts. Inform co-workers and the members of any social groups or church the person attended and tell them to spread the word. A word of caution: never spread word on a patient’s demise unless the family gives instructions to do so.

If you know about the person’s wishes for funeral or burial, start looking at ways on how to carry it out. Contact the funeral services. Look for and secure any papers pertaining to purchased memorial lots and services. Call the funeral services once you are satisfied with the time spent after demise, so they can come over at home and prepare the body.  Call a family meeting to have the first conversation about what the funeral will look like. Will it be cremation or not?  This is critical if the deceased left no instructions.

Secure the property and belongings. Finances must be looked into, including any last wills. Don’t forget social media portals – they may need to be archived so that posers or scammers will not use them. Even pets must be cared for.  Cancel any services like phone or internet services that are no longer needed. Close all financial accounts that are available

If the deceased is employed, inform the employers. He or she may be entitled to some benefits, so make sure to do this early as it can help in your initial planning.

Doubting Thomas

In the Bible, there is the well-known story of the apostle Thomas, a man who doubted the resurrection of Christ. He tried to look for evidence by saying, “...unless I see the wounds on His hands, I will never believe.”  Of course, we know that his Master eventually showed Himself to Thomas and let him touch and feel His hands. He also said – “...you believe because you have seen Me. Happy are those who have not seen and yet believe…”

We are beset by many doubts in our existence. This may be due to our desire to make sense of the environment we are in. Humans are naturally inquisitive, looking for reasons in things. However, there are also times when we throw away all reason and jump in without thinking much. Love, for example, makes us do this.

Scientific reasoning and the instilling of doubt makes us question how things are done, and this makes us understand things better and innovate. In the case of vaccine development, we are now beset with doubts on its efficacy. There are also discrepancies in the research findings for the vaccines, but will this stop us from procuring them?

We may not have much of a choice given the existing circumstances.

Doubts are part of how we humans are wired to decipher and comprehend what is in existence. It is this inquisitiveness and critical thinking that separates us from other animals. It is also our curse, when we second guess ourselves due to external influences. Sometimes we just need to follow our gut and hope for the best.

To erase doubt, one has to find out the consistency of outcomes. Will it be the same even if the process were to be repeated? This we can see by the number of samples analyzed, or the number of witnesses who testified to the veracity of the event.  The facts that can be gathered must also be subjected to scrutiny before they are disseminated to ensure that they are authentic. This is how we are able to counter the effect of fake news.

Now, there are situations where doubt is instilled. Fake news items are one, and they can be particularly harmful to the uninitiated. The irresponsible spread of misinformation creates a scenario of disbelief that can poison the efforts of those seeking for truth. This is why those with knowledge and integrity must work doubly hard to dispel these non-truths. It is these people with integrity whom we must believe and not those who seek to spread chaos and uncertainty.

Another thing that can provide the seeds to remain doubtful is the inconsistency of decisions and outcomes. When there is a discrepancy in the things that are said and done, there will be doubts, and it would take more effort to correct the fallacy. Just think about how inconsistencies in relationships can spell doom for couples or business partners. We must make every effort to analyze these outcomes not just based on singular findings, but on how consistently they come out.

Finally, there is always a science to reason based on logical-mathematical reasoning. In the eyes of an ordinary individual, some facts may be twisted by emotions or biases. But science can remove those blinders, making the results more objective and believable. The progress that we now have in the medical field is brought about by this untiring adherence to the scientific method. If medicine did not progress to become more evidence based, who knows what kind of treatments we may be made to suffer all because of some unfounded practice?  Science has made the art of treating disease result in better outcomes.

 But science can remove those blinders, making the results more objective and believable.

However, where science ends, there is this one aspect that can erase doubt. Thomas experienced this. And we have too. The overwhelming love that we experience can erase all doubts as to what is truly essential.

And when we seek the truth, at times, we make this leap of faith. That faith is what will eventually save us all.

 

Gene Therapy In Hospice Care

As I was reading some articles on gene therapy, I was astonished at how far we have progressed in pursuing applications of this technology. Immunotherapy, oncolytic virotherapy, and gene transfer has been revolutionary, and there is no let-up in the number of researches being done. Using genetically modified cells or altered DNA sequences from different viruses, common cancers of the lung, pancreas, and prostate may be given another chance for survival. Considering that the 5-year survival rates of these diseases hover around 5 to 15 percent, any increase in the life span could mean a lot to these patients.

According to Christine Karim, “It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.” The beauty of gene therapy is that it treats the problem right at its source. As current treatments have a lot of adverse effects, it offers a ray of hope for those who feel resigned to the ravages of tumor metastasis. These methods can alleviate death and suffering once they are developed and incorporated into mainstream medicine.

“It is tremendously rewarding to see how our work, starting in the test tube, can positively impact society by creating the groundwork for new medical treatments.”

— Christine Karim

 Mechanisms to decrease cancer aggression include lysis of the tumor cells, decreasing the blood supply of the neoplastic cell, and introducing genes that will restore the normal phenotype. In other words, gene therapy may not kill the cell directly like chemotherapy does, but it will cause subtle changes that will annihilate the cancer.  Gliomas, pancreatic cancer, and liver cancer are leading candidates for these types of treatment.

Just as in any new modality, there are safety concerns. Patients have died due to gene therapy in the past. While the death was not due to gene therapy for cancer, but due to a metabolic illness (a urea cycle deficiency called ornithine transcarbamoylase defect), safety remains of paramount importance. Flu-like symptoms, just like that being experienced by many who have taken the COVID-19 vaccine, are very common in gene therapy.

At present, gene therapy is being used to create recombinant cancer vaccines. Unlike for infectious diseases, these vaccines are meant to provide cure, not prevention.  The immune system is trained to recognize the cancer cells by presenting it with highly antigenic and immunostimulatory cellular debris. Cancer cells may be harvested from the patient (autologous transfer) or from established cancer cell lines. Cytokines may also be enhanced by gene therapy to recognize the abnormal cells as foreign bodies. Hopefully the genes would produce proteins that will promote synthesis of antitumor antibodies.

The challenge in the medical community is to utilize these processes prudently. They give hope, but they are not yet accepted as mainstream treatment. The issues of safety and beneficence need to be revisited, not to mention the justification of the expense involved for such novel treatments. There are stories regarding unproven alternative methods which are quite expensive, and in the wrong hands, these genetic technologies may be manipulated for selfish motives.  It is quite disturbing to think that one would take advantage of the desperation that hospice and palliative care patients are feeling, and giving them unwarranted treatments could erode their trust in the medical field.

In due time, targeted therapy for cancer will become the norm, changing the lives of patients with cancer and other chronic illnesses. We still have a long way to go to realize this, but it may be sooner than we expect. After all, the survival of the human race rests on the creativity of those who are in it.

Vaccine Hesitancy

Should I get the COVID-19 vaccine?

This might be a burning question in your mind today. With news of the COVID-19 virus having some unsavory side effects, one cannot but feel anxious whether to have it. After all, we have just been recently paralyzed with a vaccine scare for Dengue Fever that affected our belief in the vaccination program, in general.

Added to this dilemma is where the vaccine can be procured. We want to live out our lives as before, with social interactions unhindered. But fears surrounding the vaccine are circulating, and it is difficult to make a decision whether to have the vaccine or not.

In some countries, vaccination is in full swing. Some are being prioritized, such as the frontline medical personnel who are deemed most vulnerable. Though initially unsure of the consequences, they readily accepted the challenge of being the first recipients of the FDA-approved shots. In India, however, it was reported that some vaccines go to waste because people do not show up as scheduled. To address this, even unscheduled participants are now being accommodated for immunization. “Each vial has 10 doses, and if only five people are coming, either we have to deny vaccination for these five people or waste five doses,” said Tamil Nadu’s director of public health and preventive medicine Dr. T.S. Selvavinayagam.

Let us try to look into the issues and see whether they are based on facts.

First, the adverse effects being reported so far are not alarming. News on some deaths were found to be due to an underlying medical illness, not brought about by the vaccine. Most of the adverse effects are due to injection site reactions, which are expected, and which usually go away in a few days. The adverse effects of COVID-19 vaccine are mainly local ones including pain, itching, and redness (1).

Now comes the benefits. According to studies, the available vaccines have an efficacy that hovers around 90 percent or even better. Another vaccine candidate has a lower efficacy rate, but it is preferred by certain government sectors.  Could science shed more light on this discrepancy to make us have better decisions? Definitely.

Source: https://www.statista.com/chart/23510/estimated-effectiveness-of-covid-19-vaccine-candidates/

The hesitation comes from our inability to remove the noise and find what is relevant. Science will do this. It will remove the extraneous variables and focus on the truth. When decisions are based on scientific knowledge and not hearsay, you can be sure that whatever the outcome is, it will be consistent. Consistency produces results. Ask any athlete or marketing professional, and they will tell you how consistency produces the outcomes they desire.

Just believe in science. Shun the fears and unfounded factoids away. Remove the hesitation with evidence.

SOURCE:

Yuan, P., Ai, P., Liu, Y., Ai, Z., Wang, Y., Cao, W., Xia, X., & Zheng, J. C. (2020). Safety, Tolerability, and Immunogenicity of COVID-19 Vaccines: A Systematic Review and Meta-Analysis. medRxiv : the preprint server for health sciences, 2020.11.03.20224998. https://doi.org/10.1101/2020.11.03.20224998

By-Product

Everything is now online. Marketing businesses have gone to this route especially during the pandemic. It is said that most businesses today can no longer survive without an online presence.

This also included artists. We have seen most of them being more active in social media these days. Particularly for those from a major television station that just closed its doors.

Why is this so? When you are selling something, there is always a by-product of what is peddled. And this by-product can be extended to include more potential clients, more satisfied individuals, and more sales. This is called influence. And physical presence is not needed for this.

As a physician, there is a mindset that the only product that one has is the ability to heal. It may be the physician’s most lucrative business. But that is no longer true today. A doctor can create online teaching materials. Just look at Dr. Willie Ong, who earns more through his YouTube channel. Or a physician can write a book on his or her experiences. It does not have to be limited to non-fiction, but one can venture into fiction as well.

This is what we now have with the advent of technology, and even with a pandemic, one’s influence remains because our world has now become interconnected.

But with this comes greater responsibility. To ensure that only the truth comes out. To acknowledge your source of information. To make sure that your message reaches the right people. Companies and individuals must be conscious of this.
The best by-product of being a physician is influence. Just as marketing professionals try to exert influence to sell a product or service, it is actually a doctor’s influence that spurs patients to action. The mere act of going to a doctor for a medical consultation is a chore, even if it is done online. What would happen if a doctor does not recognize this reality and nonchalantly tries to rattle off one question after another without empathy? Can you make a person comfortable during a physical exam? Can a doctor truly make a patient feel her compassion even if the encounter is done virtually? How is this influence utilized to improve treatment outcomes?

This aspect of healing becomes even more important at the end of life. How can you give hope to the hopeless? How can you create an environment of joviality in misery? No amount of training can actually create this ability. It is simply inherent in a physician’s DNA. It is there. It simply has to be expressed, like a promoter unwinding the cell’s gene to unlock its potential.

We have heard of the placebo effect and its negative connotation. It is time to use the placebo effect for a positive outcome. In this day and age, when technology has started to take over most of human function, there is something that gadgets and equipment can never replace. It is the healing power of the human touch. Healing is the by-product of the physician’s heart.

Cytokine Storm

Jennifer R. Tisoncik et al. Microbiiol. Mol. Biol. Rev.2012; doi 10.1128/MMBR.05015-11

During this COVID-19 pandemic, a lot has been mentioned in popular media about a cytokine storm. It is said that most mortalities due to COVID-19 are attributed to this biological phenomenon, where the body’s immune response is overwhelmed by an infectious agent. Though mounting an immune response is the body’s normal reaction when bacteria or viruses enter the system, too much reactivity may result in organ damage and eventually death. Thus, one of the therapeutic measures undertaken to combat the cytokine storm is to slow down its progression.

The first use of the term “cytokine storm” appears to be in an article published in 1993 on graft-versus-host disease after a transplant operation. Its subsequent use in infectious disease began in early 2000, most especially when SARS-CoV 1 became a pandemic. Normally, when the human body encounters a germ, the immune system attacks the invader and tries to neutralize it. Sometimes, the army of defenders behave out of control, transforming in a “stormy” aftermath. Variants of this hyperactive immune reaction occur in an array of conditions, triggered by infection, faulty genes, or autoimmune disorders (where the body thinks its own tissues are enemies).   

The term "cytokine" is derived from a combination of two Greek words - "cyto" meaning cell and "kinos" meaning movement.  Cytokines are cell signaling molecules that aid cell-to-cell communication in immune responses and stimulate the movement of cells towards sites of inflammation, infection and trauma.  Most are produced by T-helper lymphocytes, but other cells can also produce them.

During an innate immune response to a viral infection, pattern recognition receptors (PRRs) recognize different molecular structures that are characteristic to the invading virus. These molecular structures are referred to as pathogen associated molecular patterns (PAMPs).  The binding of PAMPs to PRRs triggers an inflammatory response against the invading virus resulting in the activation of several signaling pathways that trigger gene expression. Once the gene is expressed, cytokines are generated.  

When the cytokines that raise immune activity become too abundant, the immune system may not be able to apply the brakes. Immune cells spread beyond infected body parts and start attacking healthy organs, destroying red and white blood cells, and damaging the liver. Blood vessel walls open up to let immune cells into surrounding tissues, but the vessels get porous. The lungs start to swell with fluid, and blood pressure drops. Blood clots may form throughout the body, further compromising the circulation. This is the reason why we hear a lot of those who perish from COVID-19 report signs such as bleeding, pallor, lowered blood pressure, and of course, breathlessness.  Most patients experiencing a storm will have a fever, and about half will have some sort of nervous system symptoms, such as headache, seizures or even coma.

The solution to a storm is to quiet the destructive immune response. Steroids are often the first choice of treatment, so a lot of these drugs are given. There are also medications that interfere with specific cytokines, and because of their specificity, they may produce less side effects. None of these are guaranteed cures. Factors such as genetics and other medical conditions such as Diabetes Mellitus and heart disease can complicate matters. The biggest trick in a cytokine storm is to recognize it, and treat it early. However, you have to balance the benefits of a drug with the risks. Thus, these treatments are only given in advanced disease states.

SOURCES:

Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. Into the eye of the cytokine storm. Microbiol Mol Biol Rev. 2012;76(1):16-32.

Sherwani S, Khan MWA. Cytokine Response in SARS-CoV-2 Infection in the Elderly. J Inflamm Res. 2020;13:737-747.

Zhang W, Zhao Y, Zhang F, et al. The use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): The Perspectives of clinical immunologists from China. Clin Immunol. 2020;214:108393.