MDAdvisor Summer 2016 by MDAdvantage Insurance Company of New Jersey

Janet S. Puro, MPH, MBA

AN INTERVIEW WITH CATHLEEN D. BENNETT, COMMISSIONER OF THE NEW JERSEY DEPARTMENT OF HEALTH

Commissioner Cathleen D. Bennett

PROTECTING NEW JERSEY’S CHILDREN FROM LEAD EXPOSURE

Andrew L. Falzon, MD & Sindy M. Paul, MD, MPH

DEATH INVESTIGATION AND CERTIFICATION IN NEW JERSEY

CME

John Zen Jackson, Esq.

IN THE MATTER OF KAREN ANN QUINLAN AFTER 40 YEARS: SOME PERSONAL REMEMBRANCES FROM THE SIDELINES OF HISTORY

VOLUME 9 • ISSUE 3 • SUMMER 2016

Dedicated to the memory of

Friend, colleague and outstanding public servant

MDADVISOR: A JOURNAL FOR THE HEALTHCARE COMMUNITY.

& 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS HONOR YOUR PROFESSION BY HONORING YOUR PEERS. Nominations Now Being Accepted. OUTSTANDING MEDICAL EDUCATOR AWARD OUTSTANDING HEALTHCARE EXECUTIVE AWARD EDWARD J. ILL PHYSICIAN’S AWARD® VERICE M. MASON COMMUNITY SERVICE LEADER AWARD PETER W. RODINO, JR., CITIZEN’S AWARD® OUTSTANDING SCIENTIST AWARD Written nominations will be accepted through August 12, 2016. Nominations are open to all New Jersey physicians, healthcare professionals and community leaders. For additional information about the event, and to view the 2017 Guidelines for Nominations, visit www.EJIawards.org or call us at 609-803-2350.

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MDADVISOR

WHAT’S HAPPENING IN HEALTHCARE?

Tax-Exempt Status for Some NJ Hospitals Remains Undecided A year after a tax court judge ruled that Morristown Memorial Hospital no longer qualified for taxexempt status, 30 hospitals are now facing property tax appeals from their cash-strapped municipalities. There has been little action in either the Senate or Assembly on the latest proposal to address the taxexempt status of the state’s 58 nonprofit hospitals. Lawmakers passed a bipartisan plan last session with support from hospital advocates that would have required nonprofit hospitals that conduct some for-profit clinical activities to pay a community benefit fee. However, Gov. Christie pocket-vetoed the plan in January and, two months later, called for suspending the appeals for two years while a commission studies the problem. Assemblyman Conaway sponsored a bill (A-3635) in April that incorporated many elements of Christie’s proposal; the following month, Sen. Cruz-Perez introduced a Senate version (S-2329).

MDADVISOR

NEWS & ACKNOWLEDGEMENTS

American College of Physicians issues guidelines for updating Maintenance of Certification (MOC) program The requirement for physicians to maintain certification by passing a high-stakes examination every 10 years has been criticized by some physicians who find this requirement onerous and, perhaps, irrelevant. In response to such concerns, a Task Force of the American College of Physicians has issued a report calling for a process that would be more relevant, engaging and efficient, yet provide the public with a useful, valid assessment of physician competence. Major recommendations include: 1. Replacement of the high-stakes examination every 10 years with a series of low-stakes assessments that could be self-administered; 2. Focusing the assessments on relevant cognitive and technical/procedural skills, customized to the physicians’ area(s) of expertise; and 3. Assessment of non-cognitive skills, including communication, teamwork and quality improvement.

A Journal for the Healthcare Community PUBLISHER PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company JANET S. PURO Vice President MDAdvantage Insurance Company THERESA FOY DIGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD PAUL J. HIRSCH, MD, Editor-in-Chief HON. PAUL W. ARMSTRONG, JSC (Ret.) STEVE ADUBATO, PHD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DEBARI, PHD JEREMY S. HIRSCH, MPAP WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, ESQ. ALAN J. LIPPMAN, MD JUDITH M. PERSICHILLI, RN, BSN, MA EMERGING MEDICAL LEADERS ADVISORY COMMITTEE NATALYA ANDRIYANYCHEVA RYAN MILLER RONAK MISTRY RACHEL MORALES, MD

RICHARD STEINWANDTNER MELISSA VILLARS, MD NICOLE VIOLA

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE.

Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company and any affiliated companies (all as “MDAdvantage®”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage®, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage®. If MDAdvantage® ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage Insurance Company. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2016 by MDAdvantage®. POSTMASTER: Send address changes to MDAdvantage, 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104. For advertising opportunities, please contact MDAdvantage at 888-355-5551.

MDADVISOR | SUMMER 2016

SUMMER 2016 – CONTENTS

Photo: Senator Raymond H. Bateman

1 4

LETTER FROM MDADVANTAGE® CHAIRMAN & CEO PATRICIA A. COSTANTE

CME

DEATH INVESTIGATION AND CERTIFICATION IN NEW JERSEY | By Andrew L. Falzon, MD, & Sindy M. Paul, MD, MPH

IN THE MATTER OF KAREN ANN QUINLAN AFTER 40 YEARS: SOME PERSONAL REMEMBRANCES FROM THE SIDELINES OF HISTORY | By John Zen Jackson, Esq.

A DEDICATION TO SENATOR RAYMOND H. BATEMAN | By Paul J. Hirsch, MD

AN INTERVIEW WITH CATHLEEN D. BENNETT COMMISSIONER OF THE NEW JERSEY DEPARTMENT OF HEALTH | Interviewed By Janet S. Puro, MPH, MBA

PROTECTING NEW JERSEY’S CHILDREN FROM LEAD EXPOSURE | By Commissioner Cathleen D. Bennett

HIGHLY RELIABLE ROUNDING | By Valerie Allusson, MD

NEW JERSEY LEGISLATIVE UPDATE | By Michael C. Schweder

ENTERING THE UNCERTAINTY OF RESIDENCY | By Melissa Villars, MD, Emerging Medical Leaders Advisory Committee Member ONLINE ARTICLES – VISIT OUR WEBSITE FOR FULL ARTICLES AT: WWW.MDADVANTAGEONLINE.COM/MDADVISOR

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TOP TIPS FOR PHYSICIANS: PROACTIVELY PREPARING YOUR PHYSICIAN PRACTICE FOR BILLING AUDITS | By Gabrielle Lamb

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USING INNOVATIVE SIMULATION TRAINING TO IMPACT THE CARE OF DEMENTIA PATIENTS | By Steve Adubato

MDADVISOR

In order to obtain AMA PRA Category 1 credit™, participants are required to: 1) Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully. 2) The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form. 3) Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete. 4) Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or Fax to: 978-367-8545 5) Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again. 6) Mail the Registration and Evaluation Form on or before the deadline, which is August 1, 2017. Forms received after that date will not be processed. Author: Andrew L. Falzon, MD, DABP, New Jersey Office of the State Medical Examiner & Sindy M. Paul, MD, MPH, FACPM, New Jersey Board of Medical Examiners Joint Providership Accreditation: This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of The State of New York (MSSNY) through the joint providership of Kern Augustine, P.C. and MDAdvantage Insurance Company. KA is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. Kern Augustine, P.C. designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure: Kern Augustine, P.C. relies upon planners, moderators, reviewers, authors and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with the guidelines of MSSNY and the ACCME guidelines, all planners, moderators, reviewers, authors and faculty for CME activities must disclose any relevant financial relationships with commercial interests whose products, devices or services may be discussed in the content of a CME activity, that might be perceived as a real or apparent conflict of interest. Any discussion of investigational or unlabeled uses of a product will be identified. The planners, moderators, reviewers, authors and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. No commercial funding has been accepted for the activity.

MDADVISOR | SUMMER 2016

IN NEW JERSEY

By Andrew L. Falzon, MD, & Sindy M. Paul, MD, MPH

LEARNING OBJECTIVES At the conclusion of this activity, participants will be able to: 1 – Explain the importance of accurate death certification with regard to mortality statistics. 2 – Understand the death investigation system in New Jersey. 3 – Clarify the role and obligations of physicians when asked to complete death certificates. 4 – Understand the New Jersey Electronic Death Registration System (EDRS).

Vital records and, in particular, death records have been around for centuries. In Europe and North America, vital records such as baptisms, marriages and deaths were maintained by local churches. In 1639, the Massachusetts Bay Colony became the first colony in the future United States to have secular authorities maintain these records. By the end of the 19th century, European countries were pursuing centralized systems for recording deaths. The United States developed a standard model death certificate in approximately 1910 to promote uniformity 1 and consistency in record keeping. This paper explains the process of pronouncement of death and death certificate completion and the related New Jersey Board of Medical Examiners (NJBME) regulations. It also describes the New Jersey Medical Examiner system and its role in the death certification process. SIGNIFICANCE OF DEATH CERTIFICATION IN CURRENT MEDICAL PRACTICE Signing a death certificate has to be one of the least favorite aspects of a physician’s responsibilities; however, death certificate completion is an important final act in caring for patients.1 Death certificates serve many functions, and their completion cannot be taken lightly. In addition to being an important part of the grieving process, the death certificate is the only legal proof of death; lack of a

death certificate or even a delay in getting a signed death certificate can impede the deceased’s family from proceeding with burial or cremation. The family will also need a death certificate to settle the estate and to claim relevant benefits or life insurance proceeds. The World Health Organization (WHO) standardizes death certification to allow international comparison. In the United States, the National Center for Health Statistics (NCHS) within the Centers for Disease Control and Prevention (CDC) is responsible for the collection and analysis of mortality data from the approximately 2.6 million deaths in the United States annually. NCHS develops and periodically revises the U.S. Certificate of Death to comply with WHO standards and to promote uniformity among the states. NCHS, through cooperative agreements with states, collects mortality data from the states. To receive NCHS funding, states must collect and provide data to NCHS in a format that is consistent with the U.S. Certificate of 2 Death. Death certificate data are the source for state and national mortality statistics. These statistics are used to determine which medical conditions receive research and development funding, to set public health goals and to measure health status at local, state, national and international levels. Research topics include identifying disease etiology and evaluating diagnostic and therapeutic techniques, thus providing important information that can be used to develop recommendations for evidence-based practice of medicine.3 NCHS publishes summary mortality data in the National Vital Statistics Report publication ‘’Deaths: Final Data,’’ which is available on the NCHS webpage at www.cdc.gov/nchs (use the search bar to find “National Vital Statistics Report”).3 This summary usually reflects national mortality data for the two calendar years prior to the current year.2 From a legal perspective, the content of the death certificate is important for criminal and civil proceedings. In criminal matters, death certificate information is used to help determine whether the deceased was the victim of a homicide or other act(s) of violence.4 In cases in which a victim is injured and subsequently dies, even if death occurs years or decades later, if the terminal event can be linked causally to the injury, this should be reflected

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in the cause and manner of death. For example, if a person is shot in the back, becomes paraplegic, develops stasis ulcers and dies several years later from sepsis, the cause of death should be listed as: “Sepsis due to stasis ulcers, due to paraplegia, due to gunshot wound of the back.” The manner of death should be classified as: “Homicide.” Because only Medical Examiners are authorized to sign death certificates in non-natural deaths, these cases should be reported to the Medical Examiner’s Office in the county where the death occurred. The focus is broader in civil proceedings. The cause of death listed on the death certificate is important for claims for workers’ compensation or motor vehicle accidents, as it determines whether the surviving next of kin are entitled to death benefits. Death certificates also play a role in personal injury actions, including healthcare liability claims. In these matters, the key issue is whether the conduct of the 4 defendant(s) caused or contributed to the decedent’s death. Thus, if an elderly person is involved in a motor vehicle accident, sustains multiple rib fractures and dies of pneumonia two weeks later, the cause of death should be listed as: “Pneumonia complicating multiple rib fractures due to motor vehicle accident.” The manner of death should be classified as: “Accident.” Unfortunately, most physicians do not receive adequate instruction regarding death certificate completion during medical school or postgraduate training. This leads to misconceptions regarding death certification, one of which is that its completion may result in a malpractice suit or other liability. Clinicians cite various reasons for refusing to sign death certificates following the demise of their patients from natural causes. A common reason for not completing a death certificate is that the physician was not present at the time of death and that the exact cause of death is unknown. With regards to death certification, the standard is not a reasonable degree of medical certainty; rather, it is more likely than not (i.e., requiring a 51 percent chance of being correct).5 Most patients who die suddenly and have a history of cardiovascular disease risk factors will die of a cardiac arrhythmia, acute myocardial infarction, cerebrovascular accident, aortic dissection or rupture of an aneurysm. If that is the case, the term “atherosclerotic cardiovascular disease/ASCVD” or “hypertensive cardiovascular dis-

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ease/HCVD” covers the most likely scenarios. It is also permissible to preface these causes of death with the word “probable.” Unfortunately, clinicians often feel uneasy about the death of a patient who was well during his or her most recent clinic visit. However, it is wellrecognized that cardiovascular disease can result in sudden death that cannot always be predicted. If an elderly patient dies shortly after sustaining a pathological fracture, death is deemed to be due to natural causes, and this information can be added as contributory to death; the case does not need to be reported to the Medical Examiner. The death certificate is an opinion that is based on the information available at the time that it is completed. If necessary, a death certificate can be amended if and when additional information becomes available. Lawsuits against death certifiers are rare, and the certifier’s opinion 2 is usually upheld. PRONOUNCEMENT OF DEATH Pronouncement of death is the determination of cessation of life based on a physical assessment, which is traditionally considered to have occurred when cardiac and respiratory vital signs have ceased and the pupils are nonreactive. All pronouncements of death should be made in accordance with the NJBME’s regulations, which are set forth at N.J.A.C 13:35-6.2. According to these regulations, the Medical Examiner on duty shall require a proper determination of death prior to assuming responsibility for the death investigation. In most cases, this means that, barring any special circumstances, pronouncement of death is required before the Medical Examiner’s Office personnel can respond to a scene. Typically, pronouncement or assessment of death is conducted by responding paramedics or a professional Registered Nurse (RN) who shall check the patient for vital signs, including any cardiac activity. The paramedic/RN will then contact the medical command physician and relay all findings, which may include a telemetered electrocardiogram. It is important to remember that when responding to a presumed death, Emergency Medical Services (EMS) vehicles shall not be deemed unavailable for response to an emergency call for the sole purpose of performing a pronouncement of death as set forth in N.J.A.C. 8:41-3.9.

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Deaths that occur within a healthcare facility are handled differently from those that occur outside a health facility or at home. When death occurs within a healthcare facility, the attending physician or designated covering physician should proceed without inordinate delay to the location of the presumed death and should make the proper determination and pronouncement of death. With the expansion of organ and tissue transplant programs and widespread use of mechanical ventilation, the determination of brain death has become the principal prerequisite for organ donation. Such certification should be made by a licensed physician who is professionally qualified by specialty or expertise, in accordance with New Jersey law (P.L. 2013, Chapter 185) and NJBME regulations (N.J.A.C. 13:35-6A.4 Standards for Declaration of Brain Death). Details of nationally recognized practice guidelines for determination of brain death have been adopted by the American Academy of Neurology and can be found at: www.neurology.org/content/74/23/1911.full.pdf+html. DEATH CERTIFICATE COMPLETION As discussed earlier, death certificates are a valuable source for state-based and national mortality statistics. Making death certificate information uniform, accurate and complete is crucial when comparing statistics from different sources. Physicians are expected to use medical training, available medical history, symptoms, diagnostic tests and hospital autopsy results (if available) to determine cause of death. The medical part of the certificate includes the following: • Date and time of pronouncement (certifier may choose to list as “unknown” if the deceased is pronounced by someone else or information is unavailable) • Date and time of death • Cause of death, including the best medical judgment as to the cause of death and any contributing factors, manner of death (“Natural” in the case of physicians in clinical practice, all others referred to the Medical Examiner), tobacco use and female’s pregnancy status • Electronic signature of death certificate

DEATH CERTIFICATE TERMINOLOGY The following are terms encountered when completing death certificates: • Cause of death: the disease, injury or combination of conditions that leads to the death of an individual • Manner of death: refers to how death occurred; options available include natural, accident, suicide, homicide or undetermined • Certifier of death: physician, Medical Examiner or Advanced Practice Nurse completing the cause of death information and signing the certificate • Underlying cause of death: the disease or condition that started the sequence of events leading to death • Immediate cause of death: the terminal condition resulting from the underlying condition and immediately resulting in death • Other significant condition: a condition that contributes to death but is not directly related to the underlying cause of death

When properly completed, the cause of death statement will communicate the same crucial information provided by a case history. As an example, when atherosclerotic coronary artery disease is the underlying cause of death, and cardiac tamponade is the immediate cause of death, the cause of death statement may read: “Cardiac tamponade due to ruptured myocardial infarct, due to atherosclerotic coronary artery disease. Other significant condition: Hypertension with cardiomegaly.” The statement clearly outlines the sequence of events. In the case of death due to upper gastrointestinal hemorrhage, if the cause of death is listed as “Rupture of esophageal varices due to cirrhosis of the liver,” the underlying condition (namely, what caused the cirrhosis) remains unknown. If the etiology is known, it should be specified, such as “chronic ethanol abuse” or “hepatitis C infection.” In the event it is unknown, this should be documented by stating “of unknown etiology.” Therefore, non-specific processes, such as pulmonary thromboembolism, pneumonia or cirrhosis, may be listed as the cause of death, but any underlying condition must be specified. Terminal events such as cardiopulmonary arrest, respiratory failure and electro-

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Physicians are

mechanical dissociation are considered final common pathways and should not be listed on the death certificate. Detailed guidelines regarding medical certification of death can be found in the CDC publication Physician’s Handbook on Medical Certification of Death, which is available at: www.cdc.gov/nchs/data/misc/hb_cod.pdf. NEW JERSEY ELECTRONIC DEATH REGISTRATION SYSTEM The New Jersey Electronic Death Registration System (NJ-EDRS) was established in compliance with N.J.S.A. 26:8-24.1. All participants in the death registration process, including physicians, must use NJ-EDRS to provide the information that is required of them by statute or regulation. This secure, web-based system provides an efficient method for electronically registering deaths. NJ-EDRS allows medical professionals and funeral homes to create, update and certify death certificates. It is accessible 24 hours per day, 7 days per week through an Internet connection at www.edrs.nj.gov. A listing of CDC-designated acceptable causes of death is available on this site by following the pathway: help/ additional resources/ CDC Listing of Acceptable Causes of Death. A training guide for NJ-EDRS is available at https://web.njsfda.org/public/Portals/0/EDRS/EDRS_Medical_Training_Guide.pdf. A 24-hour NJ-EDRS helpdesk is available by phone (1-866-668-3788) or electronically via email (helpdesk@dohstate.nj.us). Physicians licensed in any state can complete a death certificate using the NJ-EDRS by registering with NJ-EDRS and selecting the state in which they are licensed. NEW JERSEY BOARD OF MEDICAL EXAMINER REGULATIONS Questions frequently arise regarding physician responsibility to pronounce death and to complete the death certificate. The most frequent complaints regarding this topic that are received by the NJBME are from funeral homes and funeral directors because a physician has not completed a death certificate, and the funeral cannot proceed. To clarify these responsibilities and the time frame in which they must be completed, the NJBME has regulatory requirements regarding the pronouncement of death and death certificate completion by physicians. These regulations (N.J.A.C. 13:35-6.2) apply to every physician licensed by the

MDADVISOR | SUMMER 2016

required to complete the death certificate within 24 hours of death.

NJBME and engaged in active practice in New Jersey. According to these regulations, “attending physician” means any physician who attended, supervised or directed medical treatment of the patient as a primary care physician or as a specialist who treated a significant chronic medical illness that could lead to death. This includes issuing or renewing a prescription to the person within the 12-month period preceding the death, whether or not the physician had personally examined the person within that 12-month period. If a physician is covering for another physician who provided treatment, the covering physician bears the same responsibility to exercise his or her best medical judgment when making a pronouncement of death or drawing the conclusions required when completing the death certificate. Physicians are required to complete the death certificate within 24 hours of death. NJBME regulations do not impose an obligation upon any person not licensed by the BME to pronounce death. The following are the NJBME requirements (N.J.A.C. 13:35-6.2) regarding the pronouncement of death and death certificate completion:

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• Upon notification of an apparent death, the attending physician or designated covering physician shall proceed without inordinate delay to the location of the presumed decedent and shall make the proper determination and pronouncement of the death (N.J.A.C. 13:35-6.2.c). • Where the apparent death has occurred outside a licensed hospital and the attending or covering

physician has been notified but is unable to go to the location to make the determination and pronouncement, said physician may specify another physician or may arrange with a professional nurse (RN) or a paramedic in accordance with N.J.A.C.8:41-3.9. This statute requires the relay of findings, including telemetered electrocardiograms, if feasible, to attend the presumed decedent and make the determination and pronouncement. In every such instance, a written record, which may be contained within a police record, shall be prepared describing the circumstance and identifying the physician and any other person designated as above to perform the death pronouncement responsibility. Such report shall be promptly communicated orally to the attending physician for use in preparation of the death certificate. A copy of the report shall be provided to the physician as soon as practicable (N.J.A.C. 13:356.2.d). • When the apparent death has occurred outside a licensed hospital and the attending or covering physician is known but cannot be reached after exercise of reasonable diligence, or no attending physician is known, then any physician, professional nurse or paramedic in accordance with N.J.A.C. 8:41-3.9 may proceed to the scene and make the determination and pronouncement of death. A written record shall be prepared as set forth above. Following pronouncement of death, the information shall be promptly communicated to the physician for preparation of the death certificate and a copy of the report provided as soon as practicable. If no attending physician is known, or if an attending physician is not available to sign within a reasonable period of time, the death shall be immediately reported to the County Medical Examiner (N.J.A.C. 13:35-6.2.e). • In cases of death within the jurisdiction of the County Medical Examiner, the examiner shall without inordinate delay require the proper and established means for the determination and pronouncement of death and shall arrange for the removal of the body and completion of the death

certificate (N.J.A.C. 13:35-6.2.f). • Within a reasonable period of time, not to exceed 24 hours after the pronouncement of death, the attending, covering or resident physician, the attending Advanced Practice Nurse pursuant to Section 10 of P.L.1991, c.377 (C.45:11-49) or the County Medical Examiner shall execute death certification. The factual data set forth in the certificate shall be based, to the greatest extent possible, upon the personal knowledge of the person preparing the certificate. The certifier shall provide an immediate cause of death as well as such contributing causes as he or she can best determine from the medical history obtained from other healthcare professionals, family or friends of the decedent, from observation of the condition of the body when pronounced and the circumstances known concerning the death. If the certifier lacks sufficient information to provide an immediate cause of death, he or she may indicate an underlying potentially fatal medical condition, which, in the professional judgment of the physician, may, or is likely to, have caused death (N.J.A.C. 13:35-6.2.g). • Pursuant to N.J.S.A. 26:8-24.1 and N.J.A.C. 8:2A3.1, an attending or covering physician shall utilize the NJ-EDRS to provide the information required by this section (N.J.A.C. 13:35-6.2.h). DEATH INVESTIGATION AND THE NEW JERSEY STATE MEDICAL EXAMINER ACT Two types of medicolegal death investigation systems exist in the United States: the coroner system and the medical examiner system (with some states having a combination of both). The coroner system is the older of the two and dates back to Feudal England (around the 12th century). In the United States, coroners are typically elected officials. The required qualifications vary greatly from state to state and are often basic, although in some jurisdictions coroners are required to be licensed physicians. The medical examiner (ME) system was first introduced in Massachusetts in 1877, and the first true ME system in its modern form was established in New York City in 1918. Medical Examiners are typically forensic pathologists, and their position is often appointed.6 Because of pressures

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Figure 1. By County. The Northern Regional Medical Examiners’ Office and the Southern Regional Medical Examiners’ Office.

from the legal community, board certification in anatomic and forensic pathology is often required. New Jersey uses a county-based medical examiner system, established by the State Medical Examiner Act of 1967 (N.J.S.A. 52:17B-94). The Act established the Office of the State Medical Examiner (OSME) within the Division of Criminal Justice; OSME has general supervision over all County Medical Examiner offices. The State Medical Examiner is required to be a fully qualified forensic pathologist, while County Medical Examiners are required to be licensed

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physicians. Any County Medical Examiner who is not a forensic pathologist will administer that office but will not be authorized to perform autopsies. In this situation, the office will contract with forensic pathologists to conduct the postmortem examinations. As seen in Figure 1, the State oversees two offices directly: the Northern Regional Medical Examiners’ Office (which covers Essex, Hudson, Passaic and Somerset counties) and the Southern Regional Medical Examiners’ Office (which covers Cape May, Cumberland and Atlantic

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counties). Some counties have entered into shared services agreements (Sussex, Warren and Morris; Camden, Gloucester and Salem; Middlesex and Monmouth), while the remaining six counties (Bergen, Burlington, Hunterdon, Mercer, Ocean and Union) have individual County Medical Examiner Offices. The Act, specifically N.J.S.A. 52:17B-86, clearly identifies which cases need to be reported to the Medical Examiner, although this does not necessarily mean that the Medical Examiner’s Office (MEO) must accept/take jurisdiction over the case. Medical Examiner investigations are to be conducted in the following situations:

the treating physician of the patient’s demise, enquiring about any chronic illnesses the patient may have had and whether the physician is able to sign the death certificate. Once the physician agrees to sign the death certificate, the body can be removed by the funeral director and burial arrangements made as necessary. If it is determined that the case falls under the Medical Examiner’s jurisdiction, the body will be transported to the local MEO facility for further examination. Depending on the nature of the case, either an autopsy or an external examination of the body (with or without fluids drawn for toxicology) will be conducted. Accepted cases are further classified into mandatory and discretionary autopsies as follows:

• Violent deaths; homicidal, suicidal or accidental • Deaths not caused by readily recognizable disease, disability or infirmity • Deaths in suspicious or unusual circumstances • Deaths within 24 hours after hospital admission • Deaths of prison inmates • Deaths of inmates of institutions maintained at the expense of the State or county where the inmate was not hospitalized for disease • Deaths from causes that might constitute a threat to public health • Deaths from disease resulting from employment or accident while employed • Sudden or unexpected deaths of infants and children under three years of age • Fetal deaths occurring without medical attendance According to the statute (N.J.S.A. 52:17B-87), a death can be reported to the Medical Examiner by the physician in attendance or his or her designee, any law enforcement officer, a funeral director or any other person present. In most cases, when a death occurs outside the hospital setting, the local police will respond to the scene. Death is usually pronounced by paramedics, and the responding police officer will call the Medical Examiner’s office after conducting an examination of the scene to rule out anything suspicious. A representative of the MEO, typically a Medicolegal Death Investigator (MLDI), will gather any information regarding the decedent’s health, including the name of any treating physician and his or her contact information. The MLDI will, in turn, notify

1) Mandatory Autopsies • All apparent homicides • All deaths occurring under suspicious or unusual circumstances • All deaths that pose a threat to public health • All deaths in legal custody • All cases of infants and children abused or neglected and all cases of suspected sudden infant death syndrome (SIDS) • All cases in which an autopsy is requested by a State Medical Examiner, Attorney General, Judge or County Prosecutor 2) Discretionary Autopsies • All cases of violent death that are apparent suicides or accidents • All deaths where cause is not recognizable • Deaths in state-/county-funded institutions • All deaths related to diseases resulting from employment or from accidents while employed • All deaths from motor vehicle accidents, including drivers, passengers and pedestrians In New Jersey, barring a compelling public necessity (such as a homicide or a threat to public health), the family has the right to object to an autopsy based on religious grounds. In the case of an objection, the potential consequences of not performing an autopsy (e.g., failing to diagnose a hereditary condition that may affect other family members, difficulty prosecuting a case or problems with the

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statutes and regulations deal with pronouncement and certification of death, which all physicians should be familiar with in order to execute their responsibilities according to the law. Guidelines on how to complete a death certificate, including how to formulate the cause of death, can be obtained from CDC publications, which are readily available online. In the event the treating physician is unsure how to complete the death certificate or whether a particular case falls under the jurisdiction of the Medical Examiner, he or she should contact the local MEO to discuss the case, thus avoiding having to amend the death certificate at a later date or mistakenly releasing the case to the funeral home when the case may have necessitated a Medical Examiner investigation and autopsy. Andrew L. Falzon, MD, DABP, is Acting State Medical Examiner for the New Jersey Office of the State Medical Examiner. Sindy M. Paul, MD, MPH, FACPM, is Medical Director for the New Jersey Board of Medical Examiners.

Guidelines on how to complete a death certificate, including how to formulate the cause of death, can be obtained from CDC publications, which are readily available online.

approval of insurance claims and life insurance policies) are clearly explained to the next of kin. The autopsy is then delayed for 48 hours, during which time the objection is either withdrawn or an ex parte motion is filed, with a Judge making a ruling as to the extent of the examination to be performed. CONCLUSION Properly completed death certificates serve many functions; they are crucial for the compilation of national death statistics, and they allow the decedentâ&#x20AC;&#x2122;s family to proceed with burial or cremation in a timely fashion. Unfortunately, many physicians lack adequate instruction about death certificate completion during their training, which often leads to misinformation regarding death certification, including who is responsible for pronouncing or certifying death, what to list as the cause of death and when to refer a case to the Medical Examiner. Furthermore, because of widely varied training and different cultural and ethnic backgrounds among treating physicians, a lack of uniformity in the way death certificates are completed is often observed. Various New Jersey

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Altman, L. K. (2013, July 1). Making the right call, even in death. www.nytimes.com/2013/07/02/health/making-theright-call-even-in-death.html?_r=0.

Hanzlick, R. L., & Collins, K. A. (2016, January 10). Medical certification of death. http://emedicine.medscape.com/ article/1776211-overview.

Centers for Disease Control and Prevention. (2003, April). Physician handbook on medical certification of death. www.cdc.gov/nchs/data/misc/hb_cod.pdf.

Thornton, R. G. (2006, July). Death certificates. Baylor University Medical Center Proceedings, 19(3), 285â&#x20AC;&#x201C;286. [Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC1484541]

Cina, S. J. (2015, November). Death certification: A final service to your patient. Chicago Medicine, 117(12), 6. [Available at www.cmsdocs.org/news-publications/chicagomedicine-magazine/2014-issues/December2014.pdf]

DiMaio, V. J., & DiMaio, D. (2001). Forensic pathology (2nd ed.). Boca Raton, FL: CRC Press.

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Death Investigation and Certification in New Jersey CME EXAMINATION (Deadline August 1, 2017)

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1) In New Jersey, physicians are required to complete a death certificate within what time frame? a) 24 hours b) 48 hours c) 72 hours d) 96 hours 2) In New Jersey, who is required to complete a death certificate? a) The attending physician who attended, supervised or directed medical treatment of the patient as a primary care physician or as a specialist undertaking to treat a significant chronic medical illness, which could lead to death within 12 months of death b) The attending physician who issued or renewed a prescription issued to the person within the 12-month period preceding the death whether or not he or she has personally examined the person within the 12-month period c) A physician covering the physician who provided treatment d) All of the above 3) Pronouncement of death can be made by: a) Any paramedic or professional nurse b) A paramedic or professional nurse in conjunction with a medical command physician c) Only physicians who have been treating the patient for a minimum of one year d) Only physicians who are professionally qualified by specialty or expertise, in accordance with currently accepted medical standards 4) A 78-year-old female collapses while walking to the bathroom in a nursing home. Because of persistent pain of the right hip, she is taken to the ER where she is diagnosed with a fracture of the femur. Marked osteoporosis is also noted. The patient is admitted, and over the course of several days, her health declines; she develops aspiration pneumonia and dies five days after admission. Her past medical history is significant for Alzheimer’s disease. The cause and manner of death are best classified as: a) Complications of fracture of femur. Accident b) Pneumonia complicating Alzheimer’s disease. Other significant condition: Pathological fracture of femur. Natural c) Pneumonia due to fracture of femur. Accident d) Fracture of femur. Other significant condition: Alzheimer’s disease. Natural

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5) For which of the following is an autopsy mandatory? a) Cases that pose a threat to public health b) Deaths occurring under suspicious or unusual circumstances c) Cases of infants and children abused or neglected and all cases of suspected SIDS d) All of the above 6) Death certificate data may have a role in which of the following situations? a) Criminal proceedings b) Setting public health goals c) Measuring health status at local, state, national and international levels d) All of the above 7) The World Health Organization (WHO) standardizes death certification. a) True b) False 8) Which of the following must be reported to the Medical Examiner? a) Violent deaths; homicidal, suicidal or accidental b) Deaths within 24 hours after hospital admission c) Deaths from disease resulting from employment or accident while employed d) All of the above 9) All participants in the death registration process, including physicians, are required to use NJ-EDRS to provide the information that is required of them by statute or regulation. a) True b) False 10) Which of the following is the standard for death certification? a) Absolute certainty b) Reasonable degree of medical certainty c) More likely than not d) None of the above

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Death Investigation and Certification in New Jersey REGISTRATION AND EVALUATION FORM

(Must be completed in order for your CME Quiz to be scored – Deadline for Response: August 1, 2017)

REGISTRATION FORM First Name

Middle Initial

Last Name

City

State

ZIP

Phone

E-mail Address

Specialty

Degree

Address

ANSWER SHEET Circle the correct answer. 1) A B C D

2) A B C D

3) A B C D

4) A B C D

5) A B C D

6) A B C D

7) T F

8) T F

9) T F

10) A B C D

Number of hours spent on this activity _______ (reading article and completing quiz) I attest that I have read the article “Death Investigation and Certification in New Jersey” and am claiming 1.0 AMA PRA Category 1 Credit.™ Signature EVALUATION 1. 2. 3. 4.

The The The The

Date Completed by

content of the article was: authors’ writing style was: graphics included in the article were: stated objectives of this program were:

❑

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Non-Physician

Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Exceeded____ Met____ Not met_____

Was this article free of commercial bias? Yes _________ No _________ If not, why not __________________________________________________________________________ Please share your name and contact information so that we may investigate further. Participant Name __________________________________ Telephone/E-mail: _____________________ 5. Will the knowledge learned today affect your practice? Very Much____ Moderately____ Minimally____ None____

7. Did this CME activity change what you know about: • The importance of accurate death certification with regard to mortality statistics. Yes ❑ No ❑ • The importance of the death investigation system in New Jersey. Yes ❑ No ❑ • The role and obligations of physicians when asked to complete death certificates. Yes ❑ No ❑ • The New Jersey Electronic Death Registration System (NJ-EDRS). Yes ❑ No ❑ 8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:_________________________________________________________________________________

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6. Based on your participation in the CME activity, will you change the way you practice medicine? __Yes Describe ___________________________________________________________________________________ __No Why not ___________________________________________________________________________________ __N/A Were you the wrong audience for this activity? _________________________________________________

IN THE MATTER OF

AFTER 40 YEARS: Some Personal Remembrances from the Sidelines of History By John Zen Jackson, Esq. In September 1975, I was a recent law school graduate starting a one-year term as Law Secretary to Chief Justice Richard J. Hughes of the Supreme Court of New Jersey. This time period of September 1975 through August 1976 is in many ways the pinnacle of my legal career. During the course of this year, the Court decided the Quinlan case,1 recognizing a patient’s right to refuse medical treatment, authorizing the termination of a patient’s life support equipment and supporting the right to die. The decision was front-page news across the country and, indeed, the world. The day the decision was announced, the venerable Walter Cronkite opened the CBS Evening News stating: “The Supreme Court of New Jersey ruled today on an issue that has tormented the

consciences of the legal and medical professions.”2 I was one of three law secretaries (also known as law clerks) for the Chief Justice that court term. We were all new to the job. On our first day of work, Richard Hughes spoke with us and delivered a strong admonition on the confidentiality of our work and other matters in chambers. That seal of confidentiality, to some extent, impacts the content of this article. The Supreme Court of New Jersey, like the highest courts in most states and the Supreme Court of the United States, has discretion whether or not to grant a further appeal and the review of lower court decisions. Once a case had been filed, accepted for review and fully briefed by parties, the practice in the Supreme Court of New Jersey was for

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“In the 1975–1976 term, the opinions of the Justices were typed on a typewriter, not on a computerized word processor. The draft opinions were photocopied and circulated among the seven members of the Court through the use of messengers. Comments from any of the Justices who had not been involved in the drafting of the opinion would be considered; each case to be assigned to one of release to the parties, the public if a suggestion were accepted by the law clerks (there were a total of and the press. 15 at that time) with the responsibility the author, then the opinion to review and summarize the arguments, as a whole, or a page of the opinion THE FACTS OF THE QUINLAN CASE testimony and documents in the The night of April 15, 1975, or even a sentence or phrase record on appeal, analyze the case Karen Ann Quinlan had been to a would be retyped on the law cited by the lawyers and do local bar in Sussex County with typewriter, and the photocopying additional research, when necessary, friends. Returning home, she coland circulating process to more fully assess and present the lapsed and stopped breathing for would be repeated.” case. What was called a “bench at least two periods of 15 minutes. memo” would be prepared by that Friends summoned police, and the law clerk for the use of the entire rescue squad took her to Newton Court. Later in the course of proceedMemorial Hospital. She was then ings, the law clerks might also work transferred to St. Clare’s Hospital with their Justice on the preparation of in Denville. The interruption in her an opinion, whether it was the main breathing had caused anoxia–an opinion for the Court or a separate insufficient supply of oxygen in her dissenting or concurring opinion. blood causing unconsciousness. In the 1975–1976 term, the opinions Her pupils were unreactive; she was of the Justices were typed on a unresponsive to deep pain, with typewriter, not on a computerized legs rigid and curled up; and she word processor. The draft opinions had decorticate brain activity. She were photocopied and circulated required a respirator for assistance among the seven members of the Court through the use with breathing. There was no improvement in her neuroof messengers. Comments from any of the Justices who logical status over many months, and attempts to wean had not been involved in the drafting of the opinion her from the respirator were unsuccessful. She was not would be considered; if a suggestion were accepted by brain-dead but, rather, was in a persistent vegetative the author, then the opinion as a whole, or a page of the state, having irreversible brain damage with no cognitive opinion or even a sentence or phrase would be retyped or cerebral functioning. on the typewriter, and the photocopying and circulating While the family had initially urged the physicians to process would be repeated. There was no capability to do everything they could, as time went by and the daily send an email with a PDF attachment or even a fax. At reports by the neurologist regarding her prognosis for least in the Chief Justice’s chambers, the smaller changes recovery of useful function became increasingly pessimistic, of a sentence or word were handled by typing that short the family decided that their daughter should be passage, cutting it out as a small strip of paper, pasting it removed from the artificial life support of the respirator in place and then photocopying it. This revision was again and allowed to die. Between July and September, subject to review by the Justices. When a version had the Mr. Quinlan came to the decision to release the hospital approval of the necessary members of the Court, it would from any responsibility for removing Karen Ann from the be sent to the State printing office for finalization and respirator. The neurologist, however, would not agree to

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the respirator’s cessation. This led to litigation filed in the Superior Court of New Jersey on September 12, 1975, with a request that the court issue declaratory and injunctive relief authorizing and compelling the removal of the respirator and restraining any interference. On November 10, 1975, Judge Robert Muir issued 3 the trial-level decision denying any relief to the family. Ordinarily, an appeal from a trial division judge’s decision is reviewed by the intermediate Appellate Division before it goes to the Supreme Court. But a provision of the Rules of Court allows this appeal to be bypassed, and the case can be heard directly by the Supreme Court. Recognizing the significance of the issues in this case, the Court acted quickly. It entered an Order taking the case for review on November 17, 1975. IN THE SUPREME COURT The task of preparing the Quinlan bench memo was assigned to Mary Cheh, also one of the Chief Justice’s law clerks and now a Professor of Constitutional Law and Criminal Procedure at George Washington Law School. Her workup went beyond standard legal materials such as case law and went into medical literature. Her research identified approaches to the problem that went beyond the briefs filed by the various lawyers. In particular, she identified the then-emerging concept of “ethics committees” to provide guidance on these end-of-life situations. The concept was first suggested by a physician who had just written an article in 1975.4 Ironically, it appeared in a legal journal because the pediatrician author felt that medicine’s climate was not receptive to the idea of committees reviewing clinical-ethical issues.5 This concept was eventually endorsed in the Court’s opinion and has become widely accepted. Although the Supreme Court of New Jersey had a number of important cases before it that year, the Quinlan case stood out. Starting with the proceedings in the lower court, a significant amount of media coverage surrounded the case. Richard Hughes chose to have his chambers in Trenton. They were located on the fourth floor of the State House Annex on West State Street. Because the library for the Chief Justice’s chambers where we worked was just down the hall and around the corner from the Supreme Court’s courtroom, it was easy for his clerks to sit in on oral arguments before the Court. Oral

argument in Quinlan occurred on January 26, 1976. The courtroom was crowded with observers and press, but I was able to find a seat toward the back of the room. The principal lawyer for the Quinlan family was Paul W. Armstrong. He had been admitted to the New Jersey bar only in 1973. Five other lawyers were present for the litigants and interested parties to argue this case. They included the Attorney General of New Jersey, William F. Hyland, as well as the Morris County Prosecutor, Donald G. Collester, Jr., who addressed the law enforcement issue of whether termination of life support constituted murder or criminal homicide. Ralph Porzio, attorney for the physicians currently caring for Ms. Quinlan, and Theodore Einhorn, attorney for the hospital where she was being maintained on life support, were also there to argue their clients’ position regarding civil tort liability. In addition, because Judge Muir had removed Ms. Quinlan’s father from his position as her guardian and appointed an independent representative, Daniel Coburn–as the lawyer for the guardian ad litem–also participated in the argument. The Court had also accepted a written amicus curiae submission for the New Jersey Catholic Conference without any oral presentation. Following argument, and in accordance with the Court’s usual practice, the Justices met in conference to discuss the tentative outcome of the case. When the Chief Justice was part of the majority as to the tentative outcome, he was empowered to assign the task of writing the opinion for the Court. For Quinlan, he undertook to write that opinion himself. The opinion was finalized and released on March 31, 1976, less than two months after the argument, which was a relatively swift disposition of an appeal. The back story on this prompt resolution can be found in the biography of Richard Hughes by Seton Hall law professor John B. Wefing. Hughes was scheduled to make a trip to Japan in connection with a cultural exchange established in 1972 in which Japanese judges visited and observed New Jersey courtroom proceedings. Wefing reports Betty Hughes’ comments regarding her concern that the Quinlan family had waited long enough: “Tell the Japanese that they’ll have to wait. That girl is 6 dying. Sit down this afternoon and get going.” It was the Chief Justice’s custom to write out por-

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“ The Supreme Court of New Jersey has enjoyed a stature and reputation for independence and innovation that has made it one of the leading state courts. Many decisions of the New Jersey Supreme Court are studied in law schools across the country. The Quinlan opinion is among them.”

tions of his opinion in longhand. He would then dictate the opinion to a secretary, who would type it up, and then his law clerks would check the citations and have the opportunity to provide suggestions and edits. While Mary Cheh had the burden of the bench memo, the work on the opinion was now shared among the three law clerks. This included such erudite tasks as tracking down English court opinions from the 17th century in the lower-level book stacks of Firestone Library at Princeton University. In an early portion of the opinion, the Chief Justice eloquently framed the issues in the case: The matter is of transcendent importance, involving questions related to the definition and existence of death; the prolongation of life through artificial means developed by medical technology undreamed of in past generations of the practice of the healing arts; the impact of such durationally indeterminate and artificial life prolongation on the rights of the incompetent, her family and society in general; the bearing of constitutional right and the scope of judicial responsibility, as to the appropriate response of an equity court of Justice to the extraordinary prayer for relief of the plaintiff. Involved as well is the right of the plaintiff, Joseph Quinlan, to guardianship of the person of his daughter.7 As the Chief Justice himself later acknowledged, the nature of the case led to one Justice preparing a separate concurring opinion delving even deeper into these issues.8 But while a draft of that separate opinion was prepared, it was never circulated, and the members of the Court eventually agreed to all join in the opinion written by Hughes. OPINIONS, PRECEDENTS AND MILESTONES In the history of New Jersey, only one person has held the positions of Governor and of Chief Justice: Richard J. Hughes. That executive experience informed much of his work as the administrative head of the state

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judiciary. It also served him well to bring all the justices to speak together in a single opinion for the Court in Quinlan. That the opinion was unanimous reinforced the decision’s moral authority. Although Quinlan did not answer all questions for the end-of-life challenges, it was a beginning, and the Court would work its way through additional issues in cases that actually presented those issues. Much of that happened with the Conroy-Jobes-Peter-Farrell group of cases that 9 the Court decided between 1985 and 1987. Although the termination of life support was the central issue in the Quinlan case, the lower court’s decision removing Mr. Quinlan as his daughter’s guardian was also an important component. In addressing that issue, the Chief Justice drew on experience from his long time in public service. One of the precedents cited in Quinlan regarding the role of guardians was In re Rollins,10 an opinion that Richard Hughes had written in 1949 when he was serving as a judge for the Mercer County Court. No one connected to the case was unaware or naive concerning the decision’s ground-breaking nature, its ramifications and the potential reactions to it. The Chief Justice grounded the decision in a personal right of privacy and autonomy. Federal case law involving reproductive rights, including the then relatively recent abortion decision of Roe v. Wade, was cited as authority. But recognizing the controversy and challenges that might follow, the opinion had a one-sentence footnote that was eventually moved into the body of the text: “Nor is such right of privacy forgotten in the New Jersey Constitution.”11 This sentence provided “an adequate state ground” for the decision that would limit, if not prevent, any review by the federal courts. Indeed, the Supreme Court of the United States later denied a petition seeking such review.12 While the Court heard oral argument in Trenton every other week, the Justices met in Newark in the off-week to review draft opinions that had been circulated and to discuss the cases and other court business. For the session on

March 29, 1976, during which Quinlan would be discussed, the Chief Justice had one of his secretaries and one of his law clerks come to Newark to be available at that conference in anticipation of finalizing the opinion. The secretary, Joan Doyle, brought her own Remington typewriter. I was that law clerk. This type of task had never happened before, and it never happened again, at least during my time with the Court. The Justices met privately in the conference room. From time to time, I was summoned and given some marked-up pages. At times, the Chief Justice came out to hand me something to review and check. The pages would be retyped as the members of the Court worked their way through the lengthy opinion. The intensity of the Justices’ review even reached discussions of punctuation, whether a comma or a semicolon should be used in a sentence. By the end of the day, the opinion had been finalized and approved. I had traveled to Newark by train that morning. The Chief Justice offered me a ride home. As I sat in the front seat and conversed with the Chief Justice and his driver, the sense of increasing relaxation was palpable. At least two things had been accomplished: For this family, the

case was now concluded, and a landmark had been placed for a turning point in the murky end-of-life jurisprudence that has existed up to that point. Indeed, 14 years later, when the Supreme Court of the United States recognized a patient’s constitutional right to refuse medical treatment, it referred to Quin13 lan as “the seminal decision” in this area of the law. (Since the Constitution of 1947 reorganized the New Jersey court system and starting with the leadership of Chief Justice Arthur Vanderbilt, the Supreme Court of New Jersey has enjoyed a stature and reputation for independence and innovation that 14 has made it one of the leading state courts. Many decisions of the New Jersey Supreme Court are studied in law schools across the country. The Quinlan opinion is among them.) The next day, however, revealed that the opinion had not been finalized. The Chief Justice had begun the opinion identifying “the central figure in this tragic case” and noted in the second sentence that “[a]t the age of 21, she lies in a debilitated and allegedly moribund state.” Karen Ann Quinlan’s birthday was March 29, and she had just turned 22 as the opinion was finalized in Newark. Holding up release of the opinion in Trenton briefly, we searched it for age references and revised them using the old-fashioned literal “cut and paste” technique. The opinion was then made

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public and released to the attorneys for the parties and to the press who had gathered at the State House Annex on the morning of March 31, 1976, to get a copy of the opinion as soon as it was available. Quinlan created a space in which a dialogue concerning the weighty questions involved in end-of-life decision making and the role of medicine could occur. In a particularly profound passage, the Chief Justice had written: We glean from the record here that physicians distinguish between curing the ill and comforting and easing the dying; that they refuse to treat the curable as if they were dying or ought to die, and that they have sometimes refused to treat the hopeless and dying as if they 15 were curable. Quinlan provided the first milestone in the patient empowerment strategy that is central to the hospice movement. Over the past 40 years, the dialogue and conversation have embraced other end-of-life/right-to-die lawsuits such as the Conroy-Jobes-Peter-Farrell cases in New Jersey and elsewhere, as well as legislative enactments, including the Declaration of Death Act providing a definition of death that includes neurological criteria for brain death, Advanced Directives and Practitioner Orders for Life-Sustaining Treatment (POLST) and even consideration of physician-assisted suicide. Issues involving patient or family demands for continued treatment despite contrary medical advice (sometimes referred to as “medical futility”) are also within this space and a search for consensus. In Betancourt v. Trinitas Hospital, a case presenting this type of concern, the intermediate Appellate Division dismissed an appeal as moot because of the death of the patient during the pendency of the appeal, but it stated: While we dismiss the appeal, we do not see our declination to resolve the issue on this record and in this case to be an end to the debate. The issues presented are profound and universal in application.16 This all began with Quinlan. John Zen Jackson is a member of the law firm of McElroy, Deutsch, Mulvaney & Carpenter, LLP and is certified by the Supreme Court of New Jersey as a civil trial attorney.

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In re Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922 (1976).

Filene, P. G. (1998). In the arms of others: A cultural history of the right-to-die in America (p. 93). Lanham, MD: Dee.

137 N.J. Super. 227, 348 A.2d 801 (Ch. Div. 1975).

Teel, K. (1975). The physician’s dilemma. A doctor’s view: What the law should be. Baylor Law Review, 27, 6.

Myers, D., & Lantos, J. (2014). The slow, steady development of pediatric ethics committees, 1975–2013. Pediatrics in Review, 35, e15.

Wefing, J. B. (2009). The life and times of Richard J. Hughes: The politics of civility (p. 255). New York, NY: Rivergate Books.

In re Quinlan, supra, 70 N.J. at 19-20, 355 A.2d at 652.

Wefing, J. B. (2009). 254–255.

In re Conroy, 98 N.J. 321, 486 A.2d 1209 (1985); In re Jobes, 108 N.J. 394, 529 A.2d 434 (1987); In re Peter, 108 N.J. 365, 529 A.2d 419 (1987); In re Farrell, 108 N.J. 335, 529 A.2d 404 (1987).

65 A.2d 667 (N.J. Cty. Ct. 1949).

In re Quinlan, supra, 70 N.J. at 40, 355 A.2d at 663.

Garger v. New Jersey, 429 U.S. 922 (1976).

Cruzan v. Director, Mo. Dep’t of Health, 497 U.S. 261, 270 (1990).

Johnson, N. (2014). Battleground New Jersey: Vanderbilt, Hague, and their fight for justice (pp. 232–233). New Brunswick, NJ: Rutgers University Press; Mulcahy, K. M. (2000). Modeling the garden: How New Jersey built the most progressive State Supreme Court and what California can learn. Santa Clara Law Review, 40, 863–864; Canon, B. C., & Baum, L. (1981). Patterns of adoption of tort law innovations: An application of diffusion theory to judicial doctrines. American Political Science Review, 75, 975, 978; See also: Tractenberg, P. L. (Ed.). (2013). Courting justice: Ten New Jersey cases that shook the nation. New Brunswick, NJ: Rutgers University Press.

In re Quinlan, supra, 70 N.J. at 47, 355 A.2d at 667.

415 N.J. Super. 301, 318-19, 1 A.3d 823, 833 (App. Div. 2010).

A Dedication to Senator Raymond H. Bateman By Paul J. Hirsch, MD

“Iconic State Senator Ray Bateman Dies”

“Ray Bateman, 88, A ‘Giant’ of Public Service” These were just two of the headlines in newspapers around the state recently when Raymond H. Bateman, a member of our Editorial Board and of the MDAdvantage Board of Directors, died. The headlines may concisely describe his public life but could not do justice to the extraordinary man that we knew. Senator Bateman was a great and distinguished public servant, widely admired and respected by those on both sides of the political aisle. He said that he never wanted to “beat” the opposition on any particular issue–he wanted to win them over. He usually did. Ray Bateman was also an exceptional person apart from his life as a public figure. He cared about public policy, but was not a policy wonk. He cared about policy, because policy affects real people and he truly cared about people. People knew it, they felt it and they loved him for it. It was accurately said of him that he had an “enormous capacity for caring.” Known for his unquestioned integrity and lifelong commitment to purposeful public service, Ray Bateman served in the state Assembly and Senate, and then was the Republican nominee for Governor in 1977 (losing to then Governor Brendan Byrne, who became a close friend). Later, Bateman served New Jersey as Chairman of the Sports and Exposition Authority. Senator Bateman had a great passion for higher education and had been an author of the legislation that created the community college system in New Jersey. He knew that these colleges would help to

eliminate barriers to education and create a pathway to full participation in our communities for those who might not otherwise have such a path. He remained a strong and vocal advocate of increased funding for higher education in New Jersey and served until the end of his life as a member of the Board of Trustees of Raritan Valley Community College, including 26 years as Board Chairman. We at MDAdvantage were proud and delighted when Senator Bateman agreed to join our Board of Directors. He was knowledgeable about insurance and the insurance industry, and he proved to be a conscientious and diligent Director. He will be greatly missed. We will also miss his presence and guidance on the Editorial Board of MDAdvisor. He had been a journalist early in his career, and he always loved to write and edit. He wrote a weekly newspaper column until recently and was known for saying exactly what he meant–often to the discomfort of Governors and other powerful public figures. Ray Bateman had a multifaceted career and life, but everyone who knew him understood that what defined him most of all was his love of his family, his children, grandchildren and great-grandchildren. They are his greatest monument. A memorial service was held recently at Raritan Valley, the college that he loved and that loved him in return. Among those present were four former Governors, the Lieutenant Governor, the New Jersey Senate President and many other legislators. In all, more than a thousand people attended to honor a great public servant and a thoughtful, selfless and caring man. We were honored to have had Ray as part of our organization, and of this journal, and are proud to dedicate this issue of MDAdvisor to him and his memory. Paul Hirsch, MD, a friend and admirer of Ray Bateman for more than 40 years, is proud to have served with him on several boards and committees, including our Editorial Board, the MDAdvantage Board of Directors and the Board of Trustees of Raritan Valley Community College.

MDADVISOR

An Interview with

Cathleen D. Bennett COMMISSIONER OF THE NEW JERSEY DEPARTMENT OF HEALTH Interviewed By Janet S. Puro, MPH, MBA The New Jersey Senate confirmed Cathleen D. Bennett as Commissioner of the Department of Health on May 26, 2016. Commissioner Bennett, who served as Acting Commissioner since August 2015, joined the Department of Health as Director of Policy and Strategic Planning in August 2010. Prior to joining the Department, Commissioner Bennett spent 20 years as an executive in the private sector, providing consulting, strategy and management services to federal and state health and human services agencies. Commissioner Bennett recently responded to questions posed by MDAdvisor staff about her experiences as Commissioner, her goals for the New Jersey Department of Health and the challenges that lie ahead for New Jersey healthcare. MDAdvisor: What are your top priorities while serving as Commissioner? Bennett: My top priority is to improve population health and to help our health system move from one that has been focused on episodic care to one that is focused on prevention and wellness. One of the most important steps in this process is making sure we start to knit together what happens from a prevention and wellness perspective within our community-based organizations, our offices of local public health and our faith-based efforts, and then determine how those activities can help support what physicians and hospitals have already been doing. This is an area where New Jersey actually is a bit ahead of other places because we have our regional planning collaboratives, such as the Trenton Health Team, the Greater Newark Healthcare Coalition and the Camden Coalition of Healthcare Providers, that are using innovative methods to serve and benefit the community. Healthcare is evolving, and the system itself needs to evolve along with it. Our focus is going to be on facilitating new types of collaborations. It really is an exciting time. 22

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Encourage I N N O VAT I O N S Prevention and Wellness MDAdvisor: What experiences from your background do you feel are useful in your current position as Commissioner? Bennett: One of the things that I’ve learned while working in the health and human services space is the importance of not only being collaborative and listening to other people but also of being open to new ideas. Although there may be best practices already established, there is always the opportunity to make improvements. Clearly, there is value in using evidence-based best practices, but you also need to encourage innovations that can become the next best practice. Being open to continuous quality improvement and being supportive of innovation are strengths that I feel I bring to my position. MDAdvisor: What has surprised you most about serving as Health Commissioner? Bennett: The very first thing I did as Commissioner was to create an Office of Population Health, and I am surprised and excited to find that the interest in collaborating in this area has been very strong. Both hospitals and providers have been quite open to becoming involved and sharing ideas. I don’t want to say that it’s a surprise, but more that I’m really proud that providers, who are also competitors, are willing to support one another. Since I’ve been here with the Department, I have been in regional planning collaborative meetings where CEOs of competing facilities have come together to improve the health of the population. They didn’t say, “What can we do to drive our numbers?” or “What we can do to improve our bottom line?” I think that’s probably one of the great strengths of the New Jersey healthcare system.

partnership with physicians manage new diseases reduce deaths related to opioids

MDAdvisor: What are the greatest challenges facing New Jersey hospitals and providers? Bennett: One of the top challenges at the moment is municipalities’ challenge of the tax-exempt status of New Jersey’s 60 non-profit hospitals, which is of great concern in the hospital community, as well as for municipalities. We are hopeful that the Governor’s proposed moratorium on any litigation for two years will provide the opportunity to thoughtfully evaluate the best path forward. I think we need to have everyone at the table so we can move toward a solution that works for all. This tax-exempt issue is not one that is going to have a quick resolution; it is going to require time for consideration. Another challenge we are focused on, and it’s one that is not unique to New Jersey, is the need to curb addiction and to reduce deaths related to opioids. That has been a focus of this administration and of Governor Christie. Going back to the concept of population health, this is not an issue that the healthcare delivery system alone can resolve; it requires a broad community-based approach. The third major challenge for the healthcare community is the transitioning payment systems that have come about since the Affordable Care Act. There is a lot of focus on the concept of risk sharing, but we don’t really know what the payment methodologies are going to shake out to be in the end. The fact that so many initiatives are still in demonstration status leads to a bit of uncertainty, which makes it really difficult for physicians who are in private practice and who are aligning with health systems to try to navigate the waters and plan for the future.

MDAdvisor: How does the Department of Health partner with physicians to improve the health of New Jersey residents? Bennett: I have already worked with physicians quite a bit in my brief tenure. I have seen a tremendous level of support and interest in the vaccine preventable disease and the immunization programs, and I don’t think we’d see the successes of these programs without that level of partnership with physicians. We have made significant modifications and improvements in the immunization program over the past three years, based on suggestions that came directly from physicians. Physicians are also critical partners for us as we seek to manage new diseases such as, most recently, the Zika virus. The Department shares the most current information we have and collaborates with physicians in our state to come to an understanding on recommendations to keep New Jersey’s residents as safe as possible. When the Zika virus first moved into outbreak status, we were asking questions that the Centers for Disease Control and Prevention (CDC) didn’t yet have information on. Our physicians here at the Department worked directly with physicians through the New Jersey chapters of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. As more information becomes available, we push out our messages through our public health messaging system and through our website and social media, to make sure that providers are immediately aware of every update that now comes from the CDC. We’ve also seen great collaboration from physicians partnering for Healthy New Jersey, which is tied to our state health improvement plan and Healthy New Jersey 2020. It really comes back to how we address the burden of chronic disease and to population health. What can we do to keep healthy people well? How can we best screen those who are at risk so we can identify the risk and give them information and tools to manage that risk and keep it from coming to fruition? How can we help those who already have a chronic disease reduce the impact that it has on their lives and prevent it from becoming a comorbidity? It is about understanding our data from a population perspective and sharing it with physicians who can take the information, drill it down to their clinical episode-of-care perspective and make sure that they provide not only an immediate care visit but also tools that our residents need to keep them well and healthy. Janet S. Puro, MPH, MBA, is Vice President, Business Development and Corporate Communications, at MDAdvantage Insurance Company. MDADVISOR

Health’s regulations are being updated to require earlier intervention when lower levels of lead are detected in a child–from 10 micrograms per deciliter of blood to between 5 and 9 micrograms, as recommended by the Centers for Disease Control and Prevention. The change will enable public health officials and medical providers to intervene with education, case management, home visits and other steps, as appropriate, to address health hazards caused by lead exposure and to bring children’s blood lead levels down below the level of concern at the earliest possible time.

By Commissioner Cathleen D. Bennett Childhood lead exposure remains an important public health challenge for New Jersey, as well as for the nation. The State of New Jersey, public health officials and health providers have created a strong foundation to combat lead exposure and are building on this progress to further safeguard our children’s health. Healthcare providers, through lead education and screening efforts, have helped the State and public health officials make strides in reducing the impact of lead on New Jersey’s children. Over the past 20 years, screenings for lead exposure have increased 20-fold, and the number of children found with elevated lead levels has plummeted. In Fiscal Year 2015, 989 children had elevated blood lead levels of 10 micrograms per deciliter or higher compared with nearly 1,500 children in Fiscal Year 1998. Screenings went from 10,213 in Fiscal Year 1998 to 206,221 in Fiscal Year 2015.1 INCREASED REGULATIONS New Jersey is one of 17 states that require universal lead screening of all children at ages one and two. Other states target screening only to children at increased risk for lead exposure. New Jersey’s approach is far more protective. Primary care providers and local health departments are working hard to ensure children are screened; consequently, 95 percent of children have had at least one blood lead test before reaching six years of age.2 To further protect children against exposure to lead hazards, the Department of Health is developing regulatory changes to strengthen New Jersey’s standard for intervening in cases of potential lead exposure. The Department of

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SOURCES OF LEAD EXPOSURE AT HOME AND AT SCHOOL Lead paint in homes remains the largest contributor of elevated lead levels in children. Recognizing that, earlier this year, Governor Christie announced the dedication of an additional $10 million of existing funds from the 2016 budget to support an improved lead remediation and containment program for low- and moderate-income households where lead-based paint (outlawed in 1978) is found. Although most of children’s lead exposure is from lead-based paint in the home, about 30 percent of expo3 sures come from other sources. This year, the problem of aging infrastructure and its contribution to elevated lead levels in children was in the spotlight. In the City of Newark, a number of schools tested positive for increased levels of lead higher than the federal standard of 15 parts per billion in their water. Following this discovery in Newark, more school officials began testing their water, and many also found elevated levels above the federal standard. Alone, elevated lead levels in water do not necessarily lead to an increase in blood lead levels; however, lead in water, together with other environmental exposures, can lead to elevated blood lead levels in children. In response, Governor Chris Christie directed the New Jersey Department of Education (DOE) to address concerns about elevated lead levels in school water systems by strengthening regulations (which already require the provision of safe drinking water) to include a mandate requiring lead hazard water testing in schools. The new mandate will apply to approximately 3,000 facilities beginning in the 2016–2017 school year. The Department of Education will also require schools officials, through regulation, to publicly post all test results. If testing shows

elevated levels of lead, school officials must immediately notify parents and provide them with a description of any steps the school is taking to ensure that safe drinking water will be made available to students. NONTRADITIONAL SOURCES OF LEAD EXPOSURE Public health officials must remember there are other lead sources beyond paint and water, such as imported goods. New Jersey’s diverse population, which is more than 20 percent foreign born, is at higher risk than other New Jersey residents of exposure to lead hazards through nonpaint sources of lead, such as cosmetics, pottery, toys and other foreign products. These goods can be ingested or inhaled by children when traveling outside the United States or when the products are brought home from other countries. Nonpaint sources increasingly have been identified as the cause of lead poisoning, particularly in immigrant communities. In 2009, the New York City Department of Health’s Department and Mental Hygiene investigated a case of lead poisoning that was likely caused by an amulet made in Cambodia with leaded beads worn by a oneyear-old. Wearing amulets is common among Cambodians and other ethnic groups in Southeast Asia, including in Vietnamese, Hmong and Lao populations. Typically, infants and toddlers wear these “protection strings” around their necks, wrists or waists.4 Lead is also a risk in imported jewelry and toys. In 2006, a four-year-old Minnesota boy died from acute lead poisoning after swallowing a metallic charm containing nearly 100 percent lead.5 PUBLIC EDUCATION CAMPAIGNS To increase awareness of all lead hazards, this year the Department will be a launching a public education

campaign about the dangers of lead exposure. We want to ensure that the public understands that the threat of lead still exists and that steps can be taken to safeguard family health. The campaign will include New Jersey Transit rail ads and radio advertising in English and Spanish. The Department would like health providers to join us in raising awareness of the dangers of lead and in educating families about nontraditional sources of lead. Combatting lead exposure is a key priority of the Department, and we look forward to working with healthcare providers to build on previous accomplishments and better protect New Jersey’s children. Cathleen D. Bennett is the Commissioner of the New Jersey Department of Health. 1

Office of the New Jersey Governor. (n.d.). Fighting the legacy of lead paint in New Jersey [Press release]. www.nj.gov/governor/news/news/552016/pdf/20160405b.pdf.

New Jersey Department of Health. (Fiscal year 2014). Childhood lead poisoning in New Jersey Annual Report. www.state. nj.us/health/fhs/documents/childhoodlead2014.pdf.

Abelsohn, A. R., & Sanborn, M. (2010, June). Lead and children. Canadian Family Physician, 56(6), 531–535. [Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2902938]

Centers for Disease Control and Prevention. (2011, January 28). Lead poisoning of a child associated with use of a Cambodian amulet–New York City, 2009. Morbidity and Mortality Weekly Report. www.cdc.gov/mmwr/preview/mmwrhtml/ mm6003a2.htm.

Centers for Disease Control and Prevention. (2006, March 31). Death of a child after ingestion of a metallic charm– Minnesota, 2006. Morbidity and Mortality Weekly Report. www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a4.htm.

MDADVISOR

WE’D LIKE TO SAY

PINNACLE OF EXCELLENCE IN HEALTHCARE SOCIETY $50,000+

HEALTHCARE CHAMPION SOCIETY $10,000 – $14,999 Dr. and Mrs. George F. Heinrich New Jersey Orthopaedic Institute & Vincent K. McInerney, MD, Anthony Festa, MD, & Anthony J. Scillia, MD Jean Anderson Eloy, MD Hackensack University Medical Center – In Honor of Robert Korngold, PhD Rowan University School of Osteopathic Medicine – In Honor of Anita Chopra, MD HEALTHCARE VISIONARY SOCIETY $7,500 – $10,000 Patricia A. Costante Paul J. Hirsch, MD

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to our New Jersey healthcare partners for joining us as

2016 EDWARD J. ILL EXCELLENCE IN MEDICINE SCHOLARSHIP HONOR ROLL MEMBERS in support of the Excellence in Medicine Scholarship Fund.

HEALTHCARE INNOVATOR SOCIETY $5,000 – $7,499

HEALTHCARE SUPPORTER SOCIETY $1,000 – $2,499

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Drs. Edgar & Bessie Sullivan Catherine & Ed Williams Gennaro’s Restaurant & Catering Eileen M. Moynihan, MD Jim Ventantonio – In Honor of Anita Ventantonio Drs. Donald & Renee Chervenak Jeremy Hirsch – In Honor of Jean Anderson Eloy, MD Perr&Knight Giblin, Combs & Schwartz, LLC Alan J. Lippman, MD Drake Law Firm MacNeill O’Neill & Riveles, LLC Marshall Dennehey Warner Coleman & Goggin Orlovsky, Moody, Schaaff & Conlon, LLC Ruprecht Hart Weeks & Ricciardulli, LLP Rosenberg Jacobs & Heller, PC Stahl & DeLaurentis, PC

HEALTHCARE ADVOCATE SOCIETY $2,500 – $4,999 MDAdvantage Insurance Company Employees Dr. & Mrs. Harry M. Carnes Princeton Orthopaedic Associates, P.A. Saiber, LLC Robert P. Wise, FACHE StoneHill Reinsurance Partners PriMed Consulting Investors Bank Foundation MDAdvisor Editorial Board Holy Name Medical Center – In Honor of the Congregation of the Sisters of St. Joseph of Peace Roma Bank Community Foundation Winning Strategies ITS

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“MEDICAL ERRORS ARE THE THIRD LEADING CAUSE OF DEATH IN THE UNITED STATES”

By Valerie Allusson, MD Hospitals are dangerous places. Lucien Leape, a pediatric surgeon professor at Harvard School of Public Health and Chair of the National Patient Safety Foundation, compared the risk of being admitted to an American hospital to the risk of riding motorized hang gliders or parachuting off bridges.1 In fact, medical errors are the third leading cause of death in the United States.2 A 2000 report from the Institute of Medicine noted that 44,000 to 98,000 people die of preventable medical errors each year,3 and these numbers have not improved much since then. The Journal of Patient Safety has reported that “premature deaths associated with preventable harm to patients is estimated at more than 400,000 per year.”4 Interestingly, these appalling statistics are not the consequence of negligence or malicious intent; they arise from an inefficient system that favors a culture of autonomy and poor communication.

MDADVISOR

Don Berwick, Founder of the Institute for Healthcare relevant department stakeholders–nursing, pharmacy, nutrition, rehabilitation medicine, case management, Improvement (IHI), has stated: “Every system is perfectly 5 designed to achieve exactly the results it gets.” Certainly, social work and the medical housestaff–to create a model unless you rethink the system, you will always get the of geographic teams and structured, interdisciplinary same results. A way to rethink the complexity and bedside rounds. “DURING inefficiency of the healthcare system is to look at The goals of Highly Reliable Rounding HIGHLY RELIABLE it with fresh eyes or through someone else’s are threefold: 1) sharing real-time informaROUNDING, EACH eyes: The time spent on the phone by a frustion among all providers with the patient as MEMBER OF THE trated nurse trying to reach a physician, the a partner in the center, 2) performing a TEAM IS EQUALLY miles walked by residents switching from one quality and safety check and 3) engaging IMPORTANT.” floor to another instead of spending time with the patient and the team in discharge planning, patients, the physical therapy ordered at the last assuring a safe transition of care at discharge. minute because no one thought about it earlier, the Foley The Highly Reliable team meets at 10:58 every morning catheter or the central line that should have been discontin(assuring that the round will start at 11:00 a.m. sharp). The ued a while back, the case manager and the patient wondering entire team then spends three to four minutes with each about the treatment plan and about when to expect resident patient using a predetermined script with checkdischarge; the confusion of a vulnerable patient who sees too list. The plan of the day and possible anticipated day many providers giving different assessments and plans. These of discharge are expressed to the patient. After the types of issues have driven Hackensack University Medical rounds, any inputs are discussed respectfully with the Center (UMC) Mountainside to develop a Patient Safety and primary attending physician. Quality initiative called Highly Reliable Rounding (HRR). During HRR, each member of the team is equally The HRR team may be compared to a Swiss Army important. We meet, we listen, we “team play,” we engage knife–each object or team player has a function, which may face-to-face on a daily basis. Ideas and concerns are openly or may not be used, but are all available to contribute to voiced and addressed at our monthly meeting with a the predictability, cohesiveness, communication and focus on quality and safety for the patient. formulation of a quality plan. THE RESULTS THE HRR MODEL In the three-and-a-half months since the start of the Our HHR initiative was developed by combining two project, we have addressed more than 200 medication concepts from the safety and quality literature: highly reliable issues; some were quite significant. We addressed organizations and accountable care units. Highly reliable medication reconciliation discrepancy, renal dose organizations are organizations that operate in very hazardous adjustment, discontinuation of duplicative therapy, and complex systems but manage to have fewer than their unnecessary medication administrations, drug interaction fair share of catastrophic failures, adverse events or even recommendations, safety issues and more. near misses. They are driven by five principles: three princiThe rounds also identified waste and decreased ples of anticipation (preoccupation with failure, sensitivity resource utilization. We discontinued 21 orders of unnecesto operations and reluctance to simplify) and two principles sary stress ulcer prophylaxis in less than two months. These of containment (commitment to resilience and deference to medications are associated with Clostridium difficile 6 expertise). Accountable care units are collaborative infections, pneumonia and interstitial nephritis and are medical floor rounding models that include unit-based rarely indicated outside the intensive care unit (ICU) physician and nurse teams, structured interdisciplinary setting. We discontinued telemetry monitoring on bedside rounds (SIBR), unit-level performance reports, patients who had no indication for it. We addressed unit-level physician and nurse partners with complete venous thromboembolism (VTE) prophylaxis, use of Foley 7 involvement of the patient and family. catheters and pressure ulcers in all patients. The project combining these two concepts was led by We also looked at descriptive, clinical and operational the Department of Medicine leadership who engaged all metrics using a physician performance data management

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platform called Crimson. The center of this program is an online technology platform that collects clinical data on physician performance from hospital data storage sites. The compiled information is then organized in online dashboards. We focused on 30-day readmission rates, adjusted length of stay (LOS) and the case mix index (CMI). Four hundred and thirty patients were impacted by the HRR during three-and-a-half months (from mid-March to the end of June). The patients on observation status were excluded, and not all patients were able to be processed on time, leaving a total number of 325 patients. The CMI of the HRR patients was higher when compared to the CMI of the control group (1.488 versus 1.384). The LOS was lower (4.88 versus 4.97). The adjusted LOS was one-third of a day lower for HRR (3.28 versus 3.60). The 30-day readmission for HRR was 10.50 percent compared to 14.50 percent for the control group (25 percent below system peers with similar cases), and the average cost was 6.23 percent below system peers with an estimated cost savings of $122,880. Other metrics that are being looked at are patient satisfaction and staff satisfaction. Highly Reliable Rounding has also been instrumental in fostering improved interdisciplinary communication, improved utilization of scarce resources (e.g., telemetry), improved patient safety (e.g., medication interactions) and cohesive discharge planning–all at the patient’s bedside. From the housestaff perspective, participating in Highly Reliable Rounding allows participation in Clinical Learning Environment Review (CLER) focus areas such as patient safety, quality improvement and transitions of care. The residents also are afforded the opportunity to be directly observed and evaluated by the faculty and interdisciplinary team in competencies of system-based practice, interpersonal and communication skills and patient care. Highly Reliable Rounding is a work in progress that requires teamwork and constant reevaluation with a goal of fostering good communication among all stakeholders. When discussing “the new science of building great teams,” Professor Alex “Sandy” Pentland, who directs the MIT Connection Science and Human Dynamics and has done a lot of work on patterns of communication, stated that the key elements of communication are energy, engagement and exploration. Exploration is the communication that members engage in outside the team for discovery or creativity. And this, with high engagement and energy, creates the perfect recipe for success.

“Successful teams, especially successful creative teams, oscillate between exploration for discovery and engagement for integration of ideas.” Pentland’s research also showed that the most valuable form of communication is face to 8 face. E-mail or texting are, in fact, the least valuable. CONCLUSION We live in an ambiguous environment with a workaround culture in which many issues are not completely addressed. Unfortunately, healthcare has become a “whack a mole” system where providers react to situations as they come into a system that is too often fragmented, asynchronous, wasteful and possibly dangerous. Hackensack UMC Mountainside has used Highly Reliable Rounding to rethink the healthcare system and change the results by developing a successful Patient Safety and Quality initiative. Valerie Allusson, MD, SFHM, MMM, is the Chair of the Department of Medicine, Medical Director of the hospitalist program and Associate Program Director at Hackensack UMC Mountainside. 1

Spears, S. (2010). The high-velocity edge. New York, NY: McGraw Hill Education.

Makary, M., & Daniel, M. (2016, May). Medical error: The third leading cause of death in the US. The BMJ. www.bmj.com/ content/353/bmj.i2139.

Institute of Medicine. (2000). To err is human: Building a safer health system, November 1999. www.nap.edu/books/ 0309068371/html.

James, J. T. (2013, September). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–128.

Donahue, C. (2015, April 17). Learning from healthcare’s use of improvement science. http://www.carnegiefoundation.org/ blog/learning-from-healthcares-use-of-improvement-science.

Weick, K., & Sutcliffe, K. (2001). Managing the unexpected: Assuring high performance in an age of complexity. Hoboken, NJ: Wiley.

Stein, J., Murphy, D., Payne, C., Clark, D., Bornstein, W., Tong, D., . . . Shapiro, S. (2013, November 20). A remedy for fragmented hospital care. Harvard Business Review. https:// hbr.org/2013/11/a-remedy-for-fragmented-hospital-care/.

Pentland, A. (2012, April). The new science of building great teams. Harvard Business Review. https://hbr.org/2012/04/ the-new-science-of-building-great-teams/ar/1.

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★★★ ★★★★ ★ ★ ★ ★★★ ★★★★

★

By Michael C. Schweder

EY S R E J NEW

e v i t a l s i g

E T A D UP

Primary election day on Tuesday, June 7, 2016, was the warmup for New Jersey’s November general election, featuring the Presidential candidates Hillary Clinton (Democrat) and Donald Trump (Republican), as well as every U.S. Congressman in New Jersey and multiple local contests. During the primary election, more than 1.25 million voters went to the polls to cast ballots. That number is more than twice the number who voted during the 2012 primary and only slightly less than the 2008 primary when Barack Obama was first elected President. Although a spike in the numbers makes sense on the Democrat side due to the unusually competitive New Jersey primary this year between eventual victor Hillary Clinton and Vermont Senator Bernie Sanders, numbers also spiked on the Republican side for a primary that featured Donald Trump as the uncontested nominee.1 A recent poll shows that Clinton’s lead in the general election over businessman Donald Trump is increasing. Thirty-nine percent of voters said they back Clinton, 33 percent said they back Trump and 10 percent opted for Libertarian candidate Gary Johnson. If Johnson is removed from the mix and the matchup is only Clinton/Trump, Clinton gets 42 percent of the vote while Trump gets 37 percent.2 All 12 New Jersey Congressional office holders are up for reelection. Some political pundits in New Jersey do not foresee the incumbents being challenged in the general election, with the exception of Congressman Garrett in LD5.3 The Democrats have targeted this race to try to break the Republican Congressional stronghold currently in New Jersey; their challenger is Josh Gottheimer, “a former Bill Clinton speechwriter who is unopposed in the primary.”4 Democrat Gottheimer has already raised more than

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$2 million in this costly race, but he needs to continue raising funds to compete with Rep. Garrett’s $2.6 million 4 and counting. GOVERNOR’S RACE Although the race for New Jersey Governor is not on the statewide ballot this year, it seems as if the 2017 race is already under way. Only one candidate has officially declared, Democrat Phil Murphy, a former Goldman Sachs executive and Ambassador to Germany,5 but others are raising money for their potential campaigns. The possible Democrat frontrunners believed to be positioning themselves to enter the race include Jersey City Mayor Steve Fulop, New Jersey Senate President Steve Sweeney, New Jersey State Senator Ray Lesniak and New Jersey Assemblyman John Wisniewski. The potential Republican candidates for New Jersey Governor include New Jersey Lieutenant Governor Kim Guadagno, New Jersey State Assembly Minority Leader Jon Bramnick and Evesham Township Mayor Randy Brown.6 As of early June, some of these candidates had already raised more than $10 million in super political action committees (super PACs), led by Murphy at $4.7 million, Mayor Fulop at $3.5 million and Senate President Sweeney at $1.5 million, according to the New Jersey Election Law Enforcement Commission.5 MEDICAL MALPRACTICE LEGISLATION A-2549: This Assembly bill was recently introduced and referred to the full Assembly Financial Institutions and Insurance Committee by the bill’s prime sponsor, Assemblywoman Nancy Munoz (R-LD21). A-2549 provides “that an insurer shall not increase the premium of any medical malpractice liability insurance policy based on a claim of medical negligence or malpractice against an insured unless the claim, as identified in the bill, results in a medical malpractice claim settlement, judgment, or arbitration award against the insured.”7 A-1799: This Assembly bill was recently introduced and referred to the Assembly Health and Senior Services Committee by the bill’s prime sponsors, Chairman Herb Conaway (D-LD7), Assemblyman Declan O’Scanlon (R-LD13) and Assemblyman Jay Webber (R-LD26). A-1799

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★ ★ ★★ “concerns liability, standard of care, and insurance coverage for medical malpractice actions.”8 A-1818: This bill was introduced and referred to the Assembly Financial Institutions and Insurance Committee by Chairman Herb Conaway (D-LD7). A-1818 “prohibits insurers from increasing premiums or making other adverse underwriting decisions with respect to medical malpractice liability insurance

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the Governor’s desk for him to decide the law’s fate. This bill will put New Jersey in a category by itself, making the state the only one in the United States to “extend the 12 prohibition to all state, county, and municipal properties.” Earlier this year, Governor Christie vetoed a similar bill that attempted to raise the age for legally purchasing cigarettes from 19 to 21 years old.13

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★ S-1734/A-893: G PROHIBITS SMOKIN ND AT PUBLIC PARKS A BEACHES.

AJR-41/SJR-18: F DESIGNATES MAY O IN EACH YEAR AS “SK N CANCER DETECTIO AND PREVENTION MONTH”

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under certain circumstances.” A-3872: Assemblyman Michael Carroll (R-LD25), Assemblywoman Nancy Munoz (R-LD21) and Chairman Herb Conaway (D-LD7) sponsored this bill, which has been referred to the Assembly Judiciary Committee. The bill “requires preliminary finding of liability for professional malpractice by panel of three experts appointed by licensing authority prior to institution of action.”10

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SMOKING BAN AT PUBLIC PARKS AND BEACHES S-1734/A-893: This Senate bill “prohibits smoking at public parks and beaches.” 11 This bill recently passed both houses in New Jersey and is headed to

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SKIN CANCER DETECTION AND PREVENTION AJR-41/SJR-18: This bill, introduced by Senator Robert Singer (R-LD30), “designates May of each year as ‘Skin Cancer Detection and Prevention Month’ and the first Monday in May as ‘Melanoma Monday.’”14 Raising awareness and detection of skin cancers is a worthy effort, especially in New Jersey where 2,000 new cases of melanoma are diagnosed each year.15 In 2013, New Jersey become one of a handful of states to ban anyone under the age of 17 from using indoor tanning beds.16 MEDICATION THERAPY MANAGEMENT A-1443: This bill, sponsored by Assemblywoman Pamela Lampitt (D-LD6) and Assemblyman Joseph Lagana (D-LD38),

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★ ★ ★★ “requires coverage of medication therapy management in Medicaid and NJ Family Care.”17 Medication therapy management (MTM) is a process that “helps weed out duplicate drugs, flags prescriptions that are incompatible, and enables patients to better understand and participate in 18 their own care.” For years, Medicare has paid pharmacists to help ensure that seniors who take multiple medications for chronic diseases are taking these drugs properly; now, lawmakers in Trenton are “looking to expand the use of MTM services to tens of thousands of low-income residents covered by the federal Medicaid program and FamilyCare.”18 Health insurance companies have raised concerns about the added costs and inconsistencies with Medicare requirements. Recently, A-1443 passed out of the Assembly Health Committee, and its companion Senate bill, S-1175, awaits action in the Senate Budget Committee. Michael C. Schweder is the Director of Government Affairs at Cammarano, Layton & Bombardieri Partners, LLC, in Trenton, New Jersey. 1

Alfaro, A. (2016, June 9). Dissecting the high turnout of the NJ primary. PolitickerNJ. www.politickernj.com/2016/06/ dissecting-the-high-turnout-of-the-nj-primary. Alfaro, A. (2016, June 14). Poll: Most voters don’t think Clinton’s nomination is historic. PolitickerNJ. www.politickernj.com/2016/06/poll-most-voters-dont-think-clintonsnomination-is-historic. French, L. (2016, February 11). House Democrats pick top Republican targets. Politico.com. www.politico.com/story /2016/02/house-democrats-republican-targets-219118. Tamari, J. (2016, May 30). Democrats target North Jersey congressman over views on gay issues. Philly.com. http:// articles.philly.com/2016-05-30/news/73429138_1_garrettnational-party-confederate.

Munoz, N. F. (2016, February 4). Assembly, No. 2549; State of New Jersey 217th Legislature. www.njleg.state.nj.us /2016/Bills/A3000/2549_I1.PDF.

Conaway, H., O’Scanlon, D. J., & Webber, J. (Pre-2016 session). Assembly, No. 1799; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A2000/1799_I1.PDF.

Conaway, H. (Pre-2016 session). Assembly, No. 1818; State of New Jersey 217th Legislature. www.njleg.state.nj.us /2016/Bills/A2000/1818_I1.HTM.

Carroll, M. P., Conaway, H., & Munoz, N. F. (2016, June 2). Assembly, No. 3872; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A4000/3872_I1.PDF.

Huttle, V. V., Jimenez, A. M., Moriarty, P. D., Downey, J., Turner, S. K., & Vitale, J. F. (Pre-2016 session). Assembly, No. 893; State of New Jersey 217th Legislature. www.njleg.state.nj.us /2016/Bills/A1000/893_R1.PDF.

Stainton, L. H. (2016, May 25). State leadership creates heat to support smoking ban. NJSpotlight.com. www.njspotlight.com/stories/16/05/25/senate-leadership-creates-heatto-support-smoking-ban.

Stainton, L. H. (2016, May 9). Smoke out: New efforts to curb smoking in New Jersey catch fire. NJSpotlight.com. www.njspotlight.com/stories/16/05/08/smoke-out-newefforts-to-curb-smoking-in-new-jersey-catch-fire.

Singer, R. W. (2016, February 4). Senate joint resolution, No. 18; State of New Jersey 217th Legislature. www.njleg. state.nj.us/2016/Bills/SJR/18_I1.PDF.

De Oliveira, D. (2016, June 1). Why NJ residents can’t ignore risk of skin cancer. NJ1015. http://nj1015.com/whynj-residents-cant-ignore-risk-of-melanoma.

Livio, S. K. (2013, April 1). Christie signs bill prohibiting kids under 17 from using tanning salons. NJ.com. www.nj.com/ politics/index.ssf/2013/04/christie_signs_bill_prohibitin.html.

Marcus, S. (2016, June 2). Let the N.J. governor’s race begin: Candidates have already raised millions. NJ.com. www.nj.com/ politics/index.ssf/2016/06/10m_raised_by_on_behalf_of_likely_ gubernatorial_ca.html.

Assembly Health and Senior Services Committee. (2016, June 2). Statement to Assembly, No. 1443, with committee amendments; State of New Jersey. www.njleg.state.nj.us/ 2016/Bills/A1500/1443_S1.PDF.

Catalini, M. (2016, May 21). Election is a year away, yet 2017 governor’s race is on. NorthJersey.com. www.northjersey.com/ news/election-is-a-year-away-yet-2017-n-j-governor-s-race-ison-1.1603122.

Stainton, L. H. (2016, June 3). Helping chronically ill patients manage medications saves lives, money. NJSpotlight.com. www.njspotlight.com/stories/16/06/02/helping-chronically-illpatients-manage-medications-saves-lives-money.

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By Melissa Villars, MD, Emerging Medical Leaders Advisory Committee Member

According to Socrates, “The only true wisdom is in knowing you know nothing.” If that is the case, my fellow rising interns and I must be quite brilliant. The acute awareness of our lack of knowledge seems to be pervasive in the minds of recent medical school graduates. We have passed the exams and experienced the clerkships; we have been gowned and hooded. We have been deemed ready. We are doctors. And yet, despite the last four years dedicated to learning this trade, we face this transition constantly questioning ourselves. Is this the right decision? What is the dosage of this medication? What is the proper regimen for that diagnosis? Is it safe to give this patient ibuprofen? As the celebrations and final hurrahs wind down, I pack my U-Haul with all my worldly possessions, mismatched hand-me-down furniture and an old bike, and the finality begins to hit me. This is going to be the next four years of my life. Am I going to be happy with my program? Am I going to be ok? As I find myself searching for reasons to go back into my house just one more time, I realize that this is my new reality: I’m leaving, heading off to an area I do not know to start something I know very little about. The first day of orientation, I sit in a large conference room making small talk with the strangers I will be calling coresidents for the next few years. The Program Director enters with a large cardboard box, greets us and, one at a time, calls our names. We are handed plastic-wrapped white coats. As I shuffle back to my seat, I glance at what is in my hands: Melissa Villars, MD. Medical Resident. I pause. This is the first time I’ve seen these new letters in writing. A wave of pride

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and pure joy sweeps over me. We collectively rip open the packages like children at Christmas and stand adorned in our long white coats, still creased from the packaging. As I stare gleefully at the letters printed on my coat, a sense of confidence and accomplishment hits me. I am a doctor. The following day, we are in the simulation room. A plastic neonate covered in what I believe is strawberry jam is placed in front of my team, and I start calling out directions. Hook up the monitor, dry and stimulate the baby, assess for independent breathing, start positive pressure ventilation. In the swirl of American Heart Association (AHA) guidelines and algorithms, the next wave hits me: The next time I do this, it will no longer be on a manikin. Medical school has ended. The real patients are next. I will no longer be in the corner observing; I will be running these codes. Suddenly, the rote memorization of epinephrine doses and their conversion for pediatrics, neonates and adults all becomes terrifyingly pertinent. The excitement of finally having direct care of my patients is immediately juxtaposed with the fear of the new responsibility. Am I ready? Do I know enough? Entering the uncertainty of residency, exhilaration will be juxtaposed with exhaustion. Fear next to joy. Confidence followed by insecurity. Sleep deprivation will be a constant. This is what we are starting. This is what the next few years will be. The only thing we can do right now is trust our education, trust the larger governing bodies, trust the mentors and residency directors who say we are ready. We will be fine. Really we will. And so, with a deep breath, I put on my freshly pressed, long white coat; I stand up straight, and I enter through the doors of the hospital. And so it begins. Melissa Villars, MD, is a first-year internal medicine and pediatrics resident at University of North Carolina and a 2016 Edward J. Ill Excellence in Medicine Scholarship Recipient.

Proactively Preparing Your Physician Practice for Billing Audits By Gabrielle Lamb

illing audits have been on the rise in recent years as federal officers and private insurers have stepped up enforcement efforts. New Jersey is ranked as one of the top five states in the country where billing audits are being implemented. Compliance enforcement is here to stay and is likely to increase over time, but if you proactively manage your risk and prepare for the potential of an audit, you ease the worry of such an occurrence in your practice. Billing Errors and Omissions (E&O) insurance policies are available that will respond to and help you through regulatory billing audits and investigations, including Recovery Audit Contractor (RAC) audits and HIPAA privacy, Stark and EMTALA proceedings. Some of the leading medical malpractice insurance carriers offer Billing E&O as a complementary coverage for insureds. However, the limits of liability offered with this complementary coverage may not provide enough protection to fully protect you and your practice, should you be faced with an audit. It is important to know the type and extent of the coverage you have, should your practice ever receive notice of a pending audit. The costs for increasing your coverage and better protecting your practice may be quite affordable and less than you may think. If you have Billing E&O coverage in place, you will also have the expertise and guidance of a shadow auditor to guide you and help you minimize the burden of the audit itself.

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To proactively prepare for a potential audit, consider these important steps: Speak to your broker about the need for Billing E&O coverage in your practice. In today’s world, the potential for an audit is real. It is important to discuss your practice’s potential exposures with your broker so that you can be guided to obtain the right level of coverage. Find out whether you have any coverage under your medical professional liability policy and whether you can purchase increased limits. You may have Billing E&O coverage and not even know it. Your broker will be able to walk you through your current coverage and point out any gaps that you may have. He or she can also assist you in understanding the process of reporting a claim. Understand what is covered under your policy. It is important to understand what is covered and what is not covered under the Billing E&O policy. Most policies do not provide for the repayment of funds that are determined to have been paid in error. However, with Billing E&O coverage, you will have an advocate to assist you to challenge the claims of overpayment and potentially reduce or eradicate repayment requests. These policies often have a broad definition of billing errors proceedings that include government (RAC) and commercial payer audits and investigations. In some cases, billing audits extend to qui tam plaintiffs or voluntary self-disclosure scenarios. Typically, Billing E&O policies provide the following:

• • •

Coverage for attorney and audit costs, as well as fines and penalties incurred in response to actions or proceedings resulting from audit findings Defense costs and civil fines and penalties for billing errors, HIPAA violations and Stark and EMTALA proceedings A shadow auditor to oversee the process and work on your behalf

Comparison shop. Coverage and cost will vary based on need. If you have basic coverage and desire to purchase additional coverage, be sure that there are no gaps in coverage between the two policies. Also, determine how limits, sub-limits, retentions and coverage differ from insurer to insurer and determine which policy best suits your need. Manage your risk so that you are prepared for an audit should one arise. Be proactive by implementing billing policies and procedures and monitoring the quality of your submissions. Routinely perform random internal billing audits to make sure the proper code is used and medical documentation supports the services billed. Provide ongoing training to the billing staff related to coding and billing standards and requirements as they continue to change. Look for denial trends in the submitted billing. Once a denial trend is identified, correct the issue and make changes to your process. By providing accurate coding and billing for services, you will reduce denials, and your practice’s return on investment will be increased. Finally, understand that an auditor cannot infer information from the chart. An auditor can only review and respond to what is documented. If your documentation does not support the level of service that is billed, you may be held responsible for overbilling. Gabrielle Lamb is President of PriMed Consulting, a medical malpractice agency serving physicians in New York and New Jersey.

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USING

INNOVATIVE

Simulation Training TO

IMPACT

THE

CARE

Dementia Patients By Steve Adubato

Steve Adubato, host of Caucus: New Jersey, interviewed Cedar Wang, APN, CHSE, Director of Simulation Education at Holy Name Medical Center in Teaneck, New Jersey, about the innovative dementia simulation training available at Holy Name to healthcare workers who are dealing with the multifaceted needs of the growing population of patients living with dementia.

Adubato: Can you describe the dementia simulation training that you provide at Holy Name Medical Center’s simulation training center? Wang: The training involves a virtual dementia tour that takes our staff, specifically those involved in direct patient care, through a five- to ten-minute simulation scenario in which they experience what it would be like to have dementia. They wear headphones to obscure their auditory sense; they hear voices, and there’s background noise. They wear goggles that obscure their vision, gloves that decrease their tactile sense and inserts in their shoes that make it uncomfortable to walk, as it might be if they had neuropathy. Then they must follow instructions for five very simple tasks. It’s enlightening to them when they realize that they’re afraid. Adubato: Why is this dementia training an important aspect of your simulation program? Wang: Because the simulation provides an opportunity for healthcare providers to experience what many of our patients

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deal with day after day and what family members have to face. We believe that the experience gives providers better insight into the fact that this really is a disease process, and it makes providers a little bit more understanding when patients ask the same question 10 times because they lost their short-term memory due to dementia. Adubato: How close is the simulated scenario to what dementia patients actually experience? And how do you know? Wang: We can’t know everything the patient experiences, but the kinds of feelings that our participants describe are very similar to the feelings of those with dementia who are able to articulate what they experience–feelings like fear or embarrassment because they can’t remember the instructions we just gave them. Not being able to remember is something that people with dementia experience every day–and they are often aware that they can’t remember. Many times, they’ll compensate by trying to do word puzzles or doing other things they do feel competent at. Adubato: Patients with dementia are aware of the memory issues? Wang: Absolutely. Especially in the early stages, they are aware. It’s really not until the late stages that they are no longer aware. Some people will go to the provider themselves and say, “I’m having memory problems.” We hear many older folks complain about memory problems. For some, it is a slow decline, but for others, it is a diagnosis of dementia.

Adubato: How does this simulation training help medical professionals become better at what they do and help those dealing with dementia in their family members? Wang: I think this kind of training raises awareness within their own soul that this is an issue that is not just someone else’s problem. If we are able to give our healthcare providers just a glimpse of what it feels like and to connect with that emotion, we really believe that that glimpse can change attitudes about dealing with patients with dementia. When we took more than 400 of our staff through this experience, we demonstrated that their attitudes about dementia changed. Adubato: So the healthcare providers had an emotional reaction? Wang: Very emotional, especially for those members of our staff who have a close family member who’s currently dealing with dementia. We had many tears shed in our simulation lab by those who feel for their loved ones so much. They realized that they had experienced the effects of dementia for only five or ten minutes, while their loved ones live with the effects constantly. Adubato: What is the alternative to not finding better, more effective, more relevant, more empathetic ways of dealing with dementia and its impact on people? Wang: It certainly leads to ineffective care of the person

with dementia and more burnout of caregivers because of frustration. Adubato: So many of us who have loved ones dealing with dementia, say, “We can’t imagine what they’re going through.” This dementia simulation certainly must help your professionals imagine what it’s like to be living with this disease. How many people are dealing with dementia right now? Wang: According to the World Health Organization, 47.5 million people in the world have the diagnosis of dementia. More importantly, by 2050 that number will triple. We’re watching what they call a silver tsunami of an aging population. Those over the age of 75 to 80 are the largest segment of the population that’s growing in numbers. Adubato: The simulation education work is powerful and helps people to see things in a way that they otherwise couldn’t, even if they were the best clinicians in a certain area technically. Wang: Exactly. I think this training really speaks to the heart. Steve Adubato, PhD, is a four-time Emmy Awardwinning anchor for Thirteen/WNET (PBS) and NJTV (PBS) and has appeared on the TODAY Show, CNN and FOX as a media and communication expert.

“We had many tears shed in our simulation lab by those who feel for their loved ones so much. They realized that they had experienced the effects of dementia for only five or ten minutes, while their loved ones live with the effects constantly.”

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