IQ Tests

Identity Theft IQ Test

Understanding Your Score: 40
0-49 points - Congratulations. You have a high "IQ."
Keep up the good work and do not let your guard down now.

Workplace Identity Theft IQ Test

Are the Businesses You Frequent or Work for Exposing
You to an Identity Thief?
I have four points for answering a NO to.

Phishing IQ Test

I was really suprised that I did good on this IQ test, but I got a 9 out of 10 which is a 90%.

Twinkie

online therapy

Online Therapy Paper
What is Online Therapy: Online counseling generally refers to the provision of professional mental health services concerns via internet communication technology (Google, 2010). Is this for you, let us look at some actual online therapist.
LivePerson
If a person chose to visit LivePerson and become a client of theirs they offer counselors that specialize in Relationship Issues, Sex Therapy, Family Therapy, ADD/ADHD, Child Development, Anxiety Stress, Depression, Phobia, Addiction Recovery, Coaching Personal Development (LIVEPERSON, 2010). LivePerson is the world's leading provider of personal online expert counseling to thousands of people worldwide. With experts in over 600 categories, LivePerson provides a user-friendly platform for customers to find professionals for consultations in real time via live chat and email (LIVEPERSON, 2010). . What makes LivePerson unique is that it is reliable, very easy to use and enables you to get instant answer to your most urgent questions (LIVEPERSON, 2010). LivePerson works a lot like any other theraposit. The client is able to have live chat or email sessions. They are able to contact any of the counselors for answers to things that might be causing problems. There are three steps the client must follow to get started. First the client needs to look throught the types of services offered and make a decision on which one they need(LIVEPERSON, 2010) . Next the client must then contace a live counselor for immediate assistance. And finally the last step needed is to start paying for session only when the client is ready. The clients are always welcome to contact someone for assistance or help at any time. (LIVEPERSON, 2010)
The security that LivePerson offers is to maintain anonymity within a safe platform. Their counseling takes place in a private and confidential environment using aliases. By doing this for their clients it offers them a higher level of anonymity than traditional counseling. They further their security by taking all payment through Secure sockets Layer. By using SSL they are providing their clients with the highest level of security (LIVEPERSON, 2010).

eTherapistsOnline.com
eTherapistsonline is a new way to see a therapist. The use of the internet allows them to make therapists available from a large pool if expert licensed clinicians throughout the US (Find a Therapist, 1997 - 2010). eTherapists offers their clients counseling in relationship, sex, depression, anger, marriage counseling, eating disorders, and many others. eTherapists offers their clients a psychiatrist consultation if needed.
It seems easy to get started with them all need to do is click begin. The types of session offered to clients is a private online chat, phone counseling, email sessions. This company has a panel of therapists all under one roof. Their goal is to provide the best network of experienced online clinicians, not the biggest (Finda Therapist, 1997 - 2010). They to use SSL to collect their fees and they also offer complete privacy to their clients. Clients are given passwords and email accounts that only they have access to. By doing this it allows the clients a high security and privacy. It seems that their main goal is to help the client and make them feel secure in the information that they are sharing with their clinician.
Mytherapy.net
Mytherapy.net offers their clients help for depression, stress, relationship issues, mental health issues. They provide service to clients who live in rural areas , are homebound, those who will not go therapy in person and they are convenient, and discreet. If a client chooses Mytherapy.net they are given the opertunity to meet with a licensed counselor and therapist. They are able to provide for their clients and oportunity to choose from over 1000 licensed counselors, eherapists, and psychologists (Mytherapy.net, 2010). Mytherapynet is a unique service, they have a system that is continually updated with new technologies and features. The company Mytherapy.netuses technology that is proprietary (Mytherapy.net, 2010). Meaning that all the departments of the system are all controlled by Mytherapy.
By doing this it allows them to offer the highest form of security to their clients. By keeping all departments of the system withing the system it allows no outside sources a chance to steel or invade their client’s sessions, information or accounts. After looking at a couple of sites it’s easy to see that they all offer different things.
Why would someone choose online therapy? It really depends on the person who is searching for help. If they prefer person to person or face to face than online therapy would not work well for them. However, there are people who do choose online therapy must do their homework before making a decision. They need to think about what it is exactly they are looking for and make sure that the site they choose can help them. After looking at these three sites, it seems that the best one to choose would be Mytherapy.net. Mainly because of the security issues and protection, they offer. If I had to choose one that would be the choice, I make.

References
Works Cited
Finda Therapist, I. (1997 - 2010). Online Counseling at eTherapistsOnline.com. Retrieved August 30, 2010, from Online Counseling-Find a Therapist : http://www.etherapistsonline.com/
Google. (2010, August 21). Define Online Therapy. Retrieved August 30, 2010, from Online Therapy: http://www.google.com/search?q=define%3AOnline+therapy&btnG=Search&hl=en&client=firefox-a&hs=23H&rls=org.mozilla%3Aen-US%3Aofficial&sa=2
LIVEPERSON. (2010, August 27). LIVEPERSON. Retrieved August 30, 2010, from LIVEPERSON.COM: http://www.liveperson.com/lp/onlinecounseling/online-counselors/?sale=10doff&BanID=79859&gclid=CJiB4Zrh4qMCFRJjgwodvVOZ1A
Mytherapy.net. (2010, July). Mytherapy.net. Retrieved August 30, 2010, from Mytherapy.net: https://www.mytherapynet.com/


By: Loving Life

Online IQ tests

I have taken the IQ test scored 45 points this put me at a high IQ score.
The workplace identity Theft IQ Test- 5 points
MailFrontier's Phishing IQ Test-50%


Purple Rain

Test

I did the IQ test and scored a 60 which is average for having Identity theft happen to you. Workplace was only a 3 which must mean that my company is keeping the partners and customer safe. Mail Frontiers IQ test was 8% out 10.


Charro

Week 5-Indentity Theft and Phishing IQ Tests

Identity Theft IQ Test: I thought that I was doing everything possible to prevent myself from identity theft but I was wrong. I scored a 55 which means my odds of being victimized are about average. I was once a victim of identity theft and I learned tips on how to prevent it from happening again but I guess I did not learn all the tips.

Workplace Identity Theft IQ Test: With the workplace, test I found out my job does a good job at making sure that no one is able to access any personal information from other employees. Any personal information is locked away with only managers having the key to access it.

MailFrontier’s Phishing IQ Test: I found that this test was any eye opening experience for me. I did not do as well as I wanted to do. I got a 6 out of 10 right. I guess I was not really looking carefully at the emails. I know now to pay more attention to what is being sent and how things are being written. Such as spelling and grammar.

*Classy Sassy*

Identity Theft IQ test

Congratulations. You have a high "IQ."
Keep up the good work and don't let your guard down now.

~CHEFCUPPYCAKE~

Workplace Identity Theft

On this quiz I used my last place of employment and I am seeing that my last employer was pretty secure, out of all of the questions I only answered NO to two questions. So this employer was secure with identity stuff.
~CHEFCUPPYCAKE~

EMAIL FRAUD

1. Microsoft Email Link
Fraud ... INCORRECT
(The correct answer was Legitimate)

2. PayPal Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

3. eBay Email Link
Fraud ... CORRECT

4. US Bank Email Link
Fraud ... CORRECT

5. PayPal Email Link
Legitimate ... CORRECT

6. Earthlink Email Link
Fraud ... CORRECT

7. Citibank Email Link
Fraud ... CORRECT

8. eBay Email Link
Fraud ... CORRECT

9. Paypal Email Link
Legitimate ... CORRECT

10. Visa Email Link
Fraud ... CORRECT

You got 8 out of 10 correct, or 80 %

~CHEFCUPPYCAKE~

A dying patient is not a battlefield

Theresa Brown has a compelling story titled "A Dying Patient is Not a Battlefield" at CNN.  She writes "there's another story to be told in these cases, and it's usually the nurse who's the observer of that narrative: the suffering caused by these well-intentioned treatments."

"Watching this patient suffer, not from his disease but because of what we did to him in the name of helping him, was agonizing. He'd wanted to 'keep going,' to 'keep on fighting,' but what did he really mean? . . .  My patient's decision to 'keep fighting' seemed to be based on a misperception of what medicine could accomplish and of what the personal costs of our treatments would be."

Identity Theft and Phishing IQ Tests Week5

I took the workplace Identity Theft Quiz first and I reliazed workplaces do not inforce the workers Identity in a manner that should be professional. now I am not saying all work places our like that just the work enviroments that I have been in. So that is something that needs to be more inforced then other things. When I took the Identity Theft IQ Test I got 60% and my odds of being victimized are about average. So I really need to be careful with the daily choices I make when it comes to Identity Theft. The MailFrontiers's Phishing IQ Test I got a 70% which was not too bad it was 7 right out of 10. I noticed taking this test I really looked over the websites to make sure I was not going into the fraud mode. This is a good experience to know what can be out there and what you think is ok can really be fraud.
Wonderland

Identity Theft and Phishing IQ Tests

First I took the mailfrontier.com test. My score was 70 points (70% right). I think that is a pretty good score. I was incorrect on questions 1, 4, and 7. Next I took the Identity theft IQ test. I got 70 points (50-99 is considered average) the bad thing is I knew about most the mistakes I make about not protecting my identity, but I still do it anyway! Finally, I took The Workplace Identity Theft Quiz. None of the quiz questions were applicable to me because I am currently unemployed. I can honestly say that the tests helped me realize how venerable I am. I will be more observant in the future. -tweedle dumb-

Identiy/ Workplace/Physhing IQ Tests

After taking both IQ Test I came to realize that my liable for identity theft. I have learned to make sure not to trust anyone who calls me or give out my personal information without double checking twice the authenticity of the call or person needing my information on the other side.
The first IQ Test was the Identity Theft. I scored a low 7 points out of more than 15 questions. I need to be more careful with my personal information.
The second test I took was the workplace IQ Test on that one I scored 90 points on that one. Not too bad but I still need to make sure and review the fraud tips that were offered at the end of the test. One suggestion that the web site offered was to review the credit reports every 6 months for any bad transaction being made in my credit. I hardly ever look at it, but after last night I made sure to ask for a copy of the credit report.
The last IQ test was the phishing test. I did better than I thought. I scored an 80%.
Thank You for taking the SonicWALL Phishing IQ Test
# Subject Your Answer Correct Answer Test Result Explain Answer
1.
Paypal Phishing Phishing Why?

2.
Wells Fargo Legitimate Legitimate Why?

3.
IRS Phishing Phishing Why?

4.
Discover Card Legitimate Phishing Why?

5.
Bank of Choice Legitimate Legitimate Why?

6.
Downey Savings Legitimate Phishing Why?

7.
Yahoo Phishing Phishing Why?

8.
UPS Legitimate Legitimate Why?

9.
Paypal Phishing Phishing Why?

10.
IRS Phishing Phishing Why?

You got 8 out of 10 correct.
80%

Cotton Ball

Week 5

Week 5
1. Individual Assignment: Identity Theft and Phishing IQ Tests

• Navigate to www.privacyrights.org.
• Take the following tests:

o Identity Theft IQ Test
• Are You at Risk for Identity Theft? Test Your "Identity Quotient"
___ I receive several offers of pre-approved credit every week. (5 points)
___ I do not shred the pre-approved credit offers I receive (cross-cut shredder preferred) before putting them in the trash. (5 points)
_10__ I carry my Social Security card in my wallet. (10 points)
___ I use a computer and do not have up-to-date anti-virus, anti-spyware, and firewall protection. (10 points)
___ I do not believe someone would break into my house to steal my personal information. (10 points)
___10 I have not ordered a copy of my credit reports for at least 2 years. (20 points)
___ I use an unlocked, open box at work or at my home to drop off my outgoing mail. (10 points)
__10 I do not have a P.O. Box or a locked, secured mailbox. (5 points)
___ I carry my military ID in my wallet at all times. (It may display my SSN.) (10 points)
___ I do not shred my banking and credit information, using a cross-cut “confetti” shredder, when I throw it in the trash. (10 points)
___ I throw away old credit and debit cards without shredding or cutting them up. (5 points)
10___ I use an ATM machine and do not examine it for signs of tampering. (5 points)
___ I provide my Social Security number (SSN) whenever asked, without asking why it is needed and how it will be safeguarded. (10 points)
___ Add 5 points if you provide it orally without checking to see who might be listening nearby.
___ I respond to unsolicited email messages that appear to be from my bank or credit card company. (10 points)
___ I leave my purse or wallet in my car. (10 points)
10___ I have my driver's license number and/or SSN printed on my personal checks. (10 points)
___ I carry my Medicare card in my wallet at all times. (It displays my SSN.) (10 points)
___ I do not believe that people would root around in my trash looking for credit or financial information or for documents containing my SSN. (10 points)
___ I do not verify that all financial (credit card, debit card, checking) statements are accurate monthly. (10 points)
Each one of these questions represents a possible avenue for an identity thief.

MY SCORE 50
Understanding Your Score:
100 + points - Recent surveys* indicate that 8-9 million people are victims of ID theft each year. You are at high risk. We recommend you purchase a cross-cut paper shredder, become more security-aware in document handling, and start to question why people need your personal data.
50-99 points - Your odds of being victimized are about average.
0-49 points - Congratulations. You have a high "IQ."
Keep up the good work and don't let your guard down now.
o
• Workplace Identity Theft Quiz
•

•
• Are the Businesses You Frequent or Work for Exposing
You to an Identity Thief?
• Assign 1 point for each NO answer.
_1__ It conducts a criminal or civil background check before hiring employees who will have access to personal identifying information and screens cleaning services, temp services, and contractors.
___ It provides cross-cut paper shredders at each workstation or cash register area for the disposal of credit card slips, sensitive data or prescription forms.
___ It "wipes" electronic files, destroys computer diskettes and CD-ROMs, and properly removes any data from computers before disposal.
__1_ It uses an alternate number instead of a Social Security numbers (SSNs) for employee, client and customer ID numbers.
_1__ It requires its health insurance providers to use an alternate number rather than the SSN for employee ID numbers on health insurance cards.
_1__ It has trained designated staff about security procedures in sending sensitive personal data by fax, email or telephone.
___ It places photos on employee business cards for better identification and security.
___ It keeps all personal data about employees and customers in locked cabinets.
_1__ It stores sensitive personal data in secure computer systems with access restricted only to qualified persons with a legitimate.
___ It has implemented electronic audit trail procedures to monitor who is accessing what and enforces strict penalties for illegitimate browsing and access.
_1__ It has installed encryption and other data safeguards for workplace mobile computers, such as laptops and PDAs, that contain files with sensitive personal data.
_1__ It has trained employees in how to receive personal identifying information from customers and clients without jeopardizing their security. For example, pharmacists who do not ask you to repeat your SSN aloud in a busy store.
___ It has a policy of never selling or sharing data about employees or customers.
___ It never asks for more data than absolutely necessary. For example, a health club does not need a SSN nor does a vet really need your driver's license number.
___ It does not print full SSNs on paychecks, parking permits, staff badges, time sheets, training program rosters, lists of who got promoted, on monthly account statements, on customer reports, you name it.
___ It notifies customers and/or employees of computer security breaches involving sensitive personal information.
_1__ It has developed a crisis management plan that includes instructions to prevent identity theft if SSNs and/or financial account numbers are obtained illegitimately or in case sensitive employee or customer data is lost, stolen, or acquired electronically.
__1_ It has adopted a comprehensive privacy policy that includes responsible information-handling practices and has appointed an individual and/or department responsible for the privacy policy, one who can be contacted by employees and customers with questions and complaints.


MY SCORE 9

MailFrontier’s Phishing IQ Test

Thank you for taking the MailFrontier Phishing IQ test. Please see your test results and score below. MailFrontier is the ONLY Anti-spam, Anti-Fraud solution that can protect you from phishing emails.
Get our "Ten Tips for Finding a Fish"
Protect your desktop:
Download a free trial of MailFrontier Desktop
Protect your organization from Spam, Virus, Fraud and Phishing:

Download a free trial of MailFrontier Enterprise Gateway


1. Microsoft Email Link
Legitimate ... CORRECT

2. PayPal Email Link
Fraud ... CORRECT

3. eBay Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

4. US Bank Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

5. PayPal Email Link
Legitimate ... CORRECT

6. Earthlink Email Link
Fraud ... CORRECT

7. Citibank Email Link
Fraud ... CORRECT

8. eBay Email Link
Fraud ... CORRECT

9. Paypal Email Link
Legitimate ... CORRECT

10. Visa Email Link
Fraud ... CORRECT
You got 8 out of 10 correct, or 80 %
*Dragonfly Eyes*

Identity IQ Tests

Loving Life

Theft IQ Test) 50-99 points - Your odds of being victimized are about average.( Identity

(WorkPLace Identity Theft)

I scored a 4 ( Work Place Identity Theft Quizz)

Assign 1 point for each NO answer.
___ It conducts a criminal or civil background check before hiring employees who will have access to personal identifying information and screens cleaning services, temp services, and contractors.
___ It provides cross-cut paper shredders at each workstation or cash register area for the disposal of credit card slips, sensitive data or prescription forms.
___ It "wipes" electronic files, destroys computer diskettes and CD-ROMs, and properly removes any data from computers before disposal.
___ It uses an alternate number instead of a Social Security numbers (SSNs) for employee, client and customer ID numbers.
___ It requires its health insurance providers to use an alternate number rather than the SSN for employee ID numbers on health insurance cards.

___ It has trained designated staff about security procedures in sending sensitive personal data by fax, email or telephone.
___ It places photos on employee business cards for better identification and security.

___ It keeps all personal data about employees and customers in locked cabinets.
___ It stores sensitive personal data in secure computer systems with access restricted only to qualified persons with a legitimate.
___ It has implemented electronic audit trail procedures to monitor who is accessing what and enforces strict penalties for illegitimate browsing and access.
___ It has installed encryption and other data safeguards for workplace mobile computers, such as laptops and PDAs, that contain files with sensitive personal data.
___ It has trained employees in how to receive personal identifying information from customers and clients without jeopardizing their security. For example, pharmacists who do not ask you to repeat your SSN aloud in a busy store.
___ It has a policy of never selling or sharing data about employees or customers.
___ It never asks for more data than absolutely necessary. For example, a health club does not need a SSN nor does a vet really need your driver's license number.
___ It does not print full SSNs on paychecks, parking permits, staff badges, time sheets, training program rosters, lists of who got promoted, on monthly account statements, on customer reports, you name it.
___ It notifies customers and/or employees of computer security breaches involving sensitive personal information.
___ It has developed a crisis management plan that includes instructions to prevent identity theft if SSNs and/or financial account numbers are obtained illegitimately or in case sensitive employee or customer data is lost, stolen, or acquired electronically.
___ It has adopted a comprehensive privacy policy that includes responsible information-handling practices and has appointed an individual and/or department responsible for the privacy policy,

(MailFrontier's Phishing IQ Test)

Thank You for taking the SonicWALL Phishing IQ Test
# Subject Your Answer Correct Answer Test Result Explain Answer
1.
Paypal Phishing Phishing Why?

2.
Wells Fargo
Legitimate Legitimate Why?

3.
IRS Phishing Phishing Why?

4.
Discover Card
Legitimate Phishing Why?

5.
Bank of Choice Legitimate Legitimate Why?

6.
Downey Savings Phishing Phishing Why?

7.
Yahoo Phishing Phishing Why?

8.
UPS Legitimate Legitimate Why?

9.
Paypal Phishing Phishing Why?

10.
IRS Legitimate Phishing Why?

You got 8 out of 10 correct.
80%

Loving Life

Identity Theft Tests

Medical Futility at the ASBH in San Diego

The ASBH Annual Meeting is coming up in just under two months.  There are several sessions related to medical futility.

Thursday, October 21st from 2:45 to 3:45 p.m.

Paper Session (109): Concerns in the NICU

• Too Expensive to Treat?—Tragedy, Finitude, and the NICU  (Charles C. Camosy, Fordham University, Bronx, NY)


• Who Makes It to the NICU? The Effect of National Health Policies on NICU Population, Communities, and Ethics  (Annie Janvier, MD PhD BSc, University of Montréal, Montréal, QC, Canada)


• Categorizing Deaths in the Dutch NICUs   (A. Eduard Verhagen, MD JD PhD, University Medical Center, Groningen, The Netherlands)

Friday, October 22^nd from 8:00 – 9:00 a.m.

Panel Session (206) Legal Update 2010: Top 10 Legal Developments in Bioethics and Public Health

• Moderator: Kelly Dineen, JD RN, Saint Louis University School of Law, St. Louis, MO


• Thaddeus M. Pope, JD PhD, Widener University School of Law and Health Law Institute, Wilmington, DE  (my remarks will address medical futility developments)


• Erin A. Egan, MD JD, University of Colorado Denver Neiswanger Institute for Bioethics and Health Policy, Aurora, CO


• Amy T. Campbell, JD MBE, Upstate Medical University, Syracuse, NY


• Joanna K. Weinberg, JD LLM, University of California Hastings Law School and University of California–San Francisco, San Francisco, CA

Friday, October 22^nd from 4:00 – 5:00 p.m.

Panel Session (235) Medical Futility: Seeking a Community Standard

• Moderator: Paula J. Goodman-Crews, LCSW, Kaiser Permanente, San Diego, CA


• Lynette Cederquist, MD, University of California, San Diego, La Jolla, CA


• Lawrence Schneiderman, MD, University of California, San Diego, San Diego, CA


• Mark S. Pian, MD, University of California, San Diego School of Medicine,San Diego, CA

Comparing Physician EOL Recommendations with Attorney Recommendations

Connecticut criminal defense attorney Norm Pattis compares physician prognostication with lawyer prognostication. Just as chronically critically ill patients might expect a miracle, some apparently guilty criminal defendants might expect to be the O.J. Simpson.  Sure, there may be a 1 in 100 chance that the defendant will be acquitted.   But there is a 99% chance that he faces 35 years in prison.  Shouldn't the defense attorney strongly push a plea offer for 10 years?  Yes, he should.  But some prisoners want to "go down swinging" and are prepared to do the time even if they lose.  They are happy to have "given it a shot."  Analogously, physicians should push palliative care where there is a 99% chance that additional aggressive interventions can offer nothing but suffering.  Still, some patients will want to suffer through to "take a shot" at that 1%.

97% of Irish Never Heard of Or Know Nothing of Advance Directives

In a national survey published in the Journal of Medical Ethics, Joan McCarthy and colleagues found that only 3% of respondents report an understanding of the term "advance directive."  The study concludes:  that it "paints a picture of a general public that is not very comfortable with or informed about the processes of dying and death. Great sensitivity is required of health professionals who must negotiate the timing and the context of breaking of bad news with patients and families. Educational interventions, public and organisational policies and legislation need to address the uncertainty that surrounds the role of professionals and families in making decisions for dying patients."

Graham Miles - Recovery from Locked-In Syndrome

Diagnosed with ' locked-in syndrome' and paralysed from head to toe, stroke victim Graham Miles was told that he would never recover.  Doctors said he would be a prisoner in his own body for the rest of his life.  Locked-in sufferers are completely paralysed but remain conscious and are able to think and reason as normal.  They can usually move their eyes and can sometimes communicate by blinking.  (See, e.g., Diving Bell and the Butterfly)  There is only limited treatment available including using electrodes to stimulate muscle reflexes which can sometimes bring some minimal feeling back.  But research over the last 20 years has revealed the brain's capacity to regenerate in a way that was once thought impossible.  Miles is apparently an example of this.  he left the medics 'utterly bewildered' by taking his first faltering steps. (Daily Mail)    

Delaware End-of-Life Coalition - Upcoming Events

News & Upcoming Events Quick Links Our Website All Events More About Veterans Dear Thaddeus, This is an especially exciting year for the Delaware End-of-Life Coalition as we celebrate our 10th Anniversary. We honor our progress with these special events!   Memories Breath Life into Hospice-Bound Veterans  Sep. 28, 2010  Wesley College   Slaybaugh Hall,  Dover, DE   4:30 - 6:00 PM Maria Ash, MSN, CRNP, Coordinator of Palliative Care and Geriatric Evaluation and Management Programs for the VA Medical Center in Wilmington, will talk about how to address special needs of veterans at end-of-life.The program will conclude with a very moving PowerPoint presentation developed by a local Vietnam Veteran titled In Memoriam REGISTER for "Memories" 10th Anniversary Excellence Award Dinner Hospice and Palliative Care Dr. David Casarett   Nov. 3, 2010  Christiana Hilton, Newark, DE  Reception:5:30 pm  Dinner: 6:30 pm   REGISTER FOR DINNER   Nominations Due Oct. 1st  Download nomination form MORE: What would you do if you had only a few days to live? Or a few weeks or months? What if a loved one were in this situation---how could you help that person decide how to spend the time that remained?" Join us as our guest speaker, Dr. David Casarett, NHPCO's Consultant Medical Director and author of Last Acts: Discovering Possibility and Opportunity at the End of Life, discusses answers to these provocative questions and helps us all to make sense of our own last days. 1st 100 registrants will receive Dr. Casarett's Book: Last Acts FREE! Living With Loss, 2nd annual Grief Arts Festival     Nov. 7, 2010   1:00 - 4:30 pm   Newark Senior Center   Newark, DE   REGISTER HERE MORE: Join us for an afternoon of hopeful music with John Flynn in concert, art activities for expressing grief, a grief art display, visit with local grief authors and more! 12th Annual Survivor of Suicide Loss Day (Two Delaware Locations) Nov. 20, 2010 (1) Exceptional Care for Children   Newark, DE    9:00am    Register for Newark location (2) DE Hospice Center Milford, DE 10:00 am Register for Milford location MORE: Listen to a panel of fellow survivors of suicide loss tell their stories.  Hear their struggle to answer the question "why?." YOUR SUPPORT NEEDED Your active involvement in our activities is sincerely appreciated! Please consider participating in and sponsoring one or more events.  Just speak with your corporate marketing representative and explain the DEOLC mission of educating professionals and the Delaware Community on end-of-life issues. Sponsorship forms can be downloaded here: Sponsorship Form.  Sponsorship of two events provides the most PR for your organization and the lowest cost - an important factor in today's economy.  NEW EXECUTIVE DIRECTOROne of our accomplishments this year is the addition of an Executive Director, Dr. Patti Tillotson.  Patti has served on the DEOLC Board, serves as Chair of the Grief Awareness Consortium and on the Board of the Mental Health Association in Delaware. Her expertise will be a valuable asset to DEOLC's mission. If you have any questions, contact Patti Tillotson at 302-383-3300. We look forward to seeing you this fall! Warmly, Madeline E Lambrecht, EdD, RN, FT DEOLC President

Delaware End-of-Life Coalition | P.O Box 5705 | Marshallton Branch | Wilmington | DE | 19808

Chronic Critical Illness: Best Practices, Call for Research

In the latest issue of the American Journal of Respiratory and Critical Care Medicine, Judith Nelson and colleagues provide a very nice overview of chronic critical illness.  From the abstract: “Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing.”

Nelson et al. proceed to describe chronic critical illness as far more than just “prolonged ventilator dependence” but as a “syndrome” including features from brain dysfunction to skin breakdown.  Nearly 90% of chronically critically ill patients do not survive one year and most of those lack sufficient cognitive function.  Should we attempt to save these patients or let them die?  Nelson et al. conclude that the state of the evidence “does not yet support a definite response.”

Nelson et al. observe that "DRGs covering these patients are among the most heavily weighted, supporting relatively high reimbursement to acute care hospitals."  Nevertheless, the authors note, "high costs for long-stay outliers are a burden for these hospitals creating an incentive for transferring chronically critically ill patients . . . ."  This is a point that is often overlooked by those commenting on hospital incentives for providing or refusing ICU care.  It is rarely useful to ask whether the patient was insured or not insured.  At least as far as Medicare goes, the answer is not "yes" or "no," but "how much."

Sooner or Later Restoring Sanity to Your End of Life Care

Damiano de Sano Iocovozzi, author of Sooner or Later, has a new video this week with an advance care planning message for those past a medical cure, or a remission and who need to take control of the rest of their lives.

Physicians' Own Religiosity Impacts EOL Treatment

Survey results published yesterday by Clive Seale in the Journal of Medical Ethics show that physicians who are atheist or agnostic are twice as likely to take decisions that might shorten the life of somebody who is terminally ill as doctors who are deeply religious.  Physicians with strong religious convictions are less likely even to discuss such decisions with the patient.  (also reported in the Guardian and widely elsewhere)

Palliative Care on the Diane Rehm Show

Diane Rehm had a great show on palliative care with first-rate guests on Tuesday.  Palliative care can be a powerful therapy for the pain and stress of serious illness. A new study shows it not only improves the quality of life, it actually extends it.

Guests

Dr. Diane Meier 

Director, Center to Advance Palliative Care at The Mount Sinai School of Medicine in new York City.

Dr. Atul Gawande 

Author, staff writer for New Yorker, surgeon at Brigham and Women’s Hospital and Associate Professor at Harvard Medical School and Harvard School of Public Health

Dr. Jennifer Temel 

assistant professor of medicine at Harvard Medical School, an attending physician in thoracic oncology at Massachusetts General Hospital and lead author of the study of palliative care on terminal lung cancer patients.

Christina Tafe 

palliative care nurse practitioner at the Lombardi Comprehensive Cancer Center at Georgetown University Hospital.

Futility of Ventilation for Children with Severe Neurological Impairment

In the May 2010 issue of Developmental Medicine & Child Neurology, Van Gestel and colleagues in the Netherlands look at ICU admissions of children with severe neurological impairment admitted for respiratory failure.  They found that just 1% had an uneventful 1-year survival (weaning, extubation, discharge, and no readmission to ICU).  Still, they conclude:  "Repeated, prolonged, and complicated admission to the ICU was often required.  However, outcome was not uniformly dismal, which underscores the urgent need for further research for the rational guidance of clinical decision-making in this population."

Trinitas Hospital Should Issue Full Media Statement on Futility Policy

In 2005, when Baylor Hospital was widely criticized (in Slate, the New York Times, and elsewhere) for unilaterally removing life support from Tirhas Habtegiris, the hospital issued a thorough statement explaining its reasons and process.   Baylor has apparently taken these pages off its website, but it was a great means not only to defend its reputation but also to educate the community about how the TADA really works.





It would be great if Trinitas Hospital did the same thing.  All the key medical facts have already been publicly litigated, so confidentiality should not be a bar.  It would educate the community and advance the very debate that the hospital wanted the courts to engage.  





Some key facts did not emerge during the litigation.  Indeed, the "thin record" was one reason the court dismissed the appeal.  Does the hospital have a futility policy?  What efforts were made at mediation with the family?  Who sits on the ethics/prognosis committee?  How did the case reach the committee?  How did the committee reach its decision?  How was the decision communicated to the family?  Why was the point about the dialysis port not being removed but only cleaned not raised in the trial court?

CEO of Trinitas Hospital on the Betancourt Case

Gary Horan, the President and CEO of Trinitas Hospital, has a column today that defends the hospital's position both against some overstatements in recent op-eds and in the merits of the case itself.  I have a comment to develop later (after Torts class).  But I agree with this clear characterization of the appeal:

“In pressing this appeal, we hoped that the court would address a question faced by nearly every hospital:   Should physicians be ordered by a family or court to impose treatment upon their patient when they feel such treatment is outside the standard of care, and even inhumane? . . .   If the courts had ruled in our favor, the outcome might have empowered physicians nationwide to have a say in treatment that they deem inappropriate.”

Palliative Care: Recent Success, Tomorrow's Challenges

In a column in yesterday's New York Times titled "Frank Talk about Care at Life's End," Jane Brody ties together some encouraging developments in palliative care in the past week:

• New York's new "Palliative Care Information Act"


• The NEJM study that cancer patients who received palliative care had a better quality of life and lived longer

But Brody also observes that more still needs to be done:

• Help physicians and nurses acquire the expertise they need to hold meaningful end-of-life discussions with their patients


• Improve the poor ability of physicians to determine a patient’s remaining life expectancy

Betancourt v. Trinitas - Publication of the Trial Court Opinion, Questioning Mootness

I was just about to request that the trial court opinion left standing by the Appellate Division's recent ruling, be published in the N.J. Super. (and thus also the A.2d) reporter.  Under New Jersey Court Rule 1:36-2(c), "Any person may request publication of an opinion by letter to the Committee on Opinion."  Under Rule 1:36-2(d), an opinion shall be published where, among other things, the decision determines a new and important question of law, or is of continuing public interest and importance. 

At first, I thought that the Appellate Division directly addressed and affirmed the satisfaction of these publication standards.  But then again, if the case is, as the court explains, so very "unique," then perhaps the publication standards are not satisfied after all.  How could Judge Malone’s analysis here be useful, if there is no analogous case?  But is the court right?

The court finds that the mootness exception is not satisfied because the "specific set of facts" in this case is unlikely to recur.  Butis this true?  Just like Ruben Betancourt, other patients have been the subject of unilateral treatment refusals apparently motivated by insurance status and/or by the desire to "bury" mistakes.  For example:

• Brianna Rideout (Pa)


• James Davis Bland (Tex)


• Kalilah Roberson-Reese (Tex)


• Tirhas Habtegiris (Tex)

The court mentions a third unique fact:  the factual uncertainty over Betancourt’s neurological condition.  But it seems this is factual uncertainty not important in a case that is literally moot, as the court would not be addressing this case so much as this type of case.  In short, I am not sure that the facts of Betancourt really are quite as unique as the court suggests. 

Moreover, even if there are few futility cases reaching the courts, there are logical reasons for this.  Earlier in its opinion, the court observes that end-of-life treatment cases are a classic example of a dispute capable of repetition yet evading review.  It seems contradictory for the court to later use the lack of such cases as evidence of the uniqueness of this very case.  Review articles in Critical Care Medicine and similar journals well-document the high frequency of end-of-life treatment conflict including futility disputes.  Even if most of these are resolved informally, judicial guidance is still needed to cast a clear “shadow of the law” in which this informal dispute resolution takes place (Pope & Waldman 2007).

Significant survey evidence shows that the dominant current practice is for providers to cave-in to surrogate demands.  Providers are typically too risk averse to stand-up to surrogates and do what the Trinitas providers did.  This is the main reason surrogates are rarely going to court for injunctions (before withdrawal) or for damages (after withdrawal).  The Appellate Division’s decision has left the Chancery Division ruling standing.  Moreover, the A.D. even provided dicta (especially in footnote 9) indicating that it thinks New Jersey law precludes withdrawing life support without consent.  In short, the current world of risk-averse providers caving-in to the demands of empowered surrogates has been reinforced.

New Jersey Advisory Council on End-of-Life Care, Accept the Betancourt Court's Invitation

Near the end of its opinion in Betancourt v. Trinitas Hospital, the Appellate Division observes that "The issues presented are profound and . . . warrant thoughtful study and debate . . . by the Legislature as well as Executive agencies and Commissions . . . ."  For this proposition (for a reason I do not appreciate), the court cites two bills on withholding/withdrawing artificial nutrition and hydration from Georgia and South Carolina.  The Court might have instead cited this bill now pending before the New Jersey Senate Health, Human Services and Senior Citizens Committee.  Hopefully, if this Council gets established, it will take up the Court's invitation.

SENATE, No. 2199

STATE OF NEW JERSEY

214th LEGISLATURE

INTRODUCED JULY 19, 2010

Sponsored by:

Senator  M. TERESA RUIZ

District 29 (Essex and Union)

Senator  LORETTA WEINBERG

District 37 (Bergen)

Co-Sponsored by:

Senators Vitale and Cunningham

SYNOPSIS

     Establishes NJ Advisory Council on End-of-Life Care in DHSS.

CURRENT VERSION OF TEXT

     As introduced.

AN ACT establishing the New Jersey Advisory Council on End-of-Life Care in the Department of Health and Senior Services.

     BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:

     1.  The Legislature finds and declares that:

     a.  The current health care system in New Jersey often fails to meet the special needs of persons who are approaching the end of life by depriving them of the opportunity that they earnestly desire to spend their final months free of pain, in familiar surroundings, together with their friends and families, instead of being tethered to tubes and other medical apparatus in an intensive care unit or other acute care hospital setting;

     b.  At the same time, according to the Dartmouth Atlas of Health Care 2006 study on variations among states in the management of severe chronic illness, Medicare expenditures on many aspects of end-of-life care in New Jersey are among the highest of all states nationwide, and often greater than those in any other state, when measured by such indices as:  days spent in a hospital per decedent during the last six months of life; days spent in an intensive care unit per decedent during the last six months of life; physician visits per decedent during the last six months of life; the percentage of deaths associated with an admission to intensive care; Medicare spending and resource inputs during the last two years of life; and standardized physician labor inputs per 1,000 decedents during the last two years of life;

     c.  Compared to the average American, New Jerseyans in the last six months of life spend 30% more days in the hospital, see physicians 43% more often, and spend 44% more days in the intensive care unit;

     d.  Expanded use of licensed hospice care programs, through more timely enrollment by persons in need of end-of-life care that responds to their needs and concerns, could help to avoid much of the expense for this type of care that is incurred in New Jersey;

     e.  In many cases, earlier referrals of persons with terminal conditions to hospice care could serve to improve their pain management and thereby enhance their quality of life and death, by providing high-quality palliative care while also meeting the counseling and spiritual needs of these patients and their families;

     f.  Persons who are near the end of life have unique needs for respectful and responsive care, and concern for their comfort and dignity should guide all aspects of their care so as to alleviate their physical and mental suffering as much as possible;

     g.  At a minimum, the end-of-life care that a person receives should encompass dignified and respectful treatment at all times and aggressive pain management as appropriate to that person’s needs;

     h.  As noted in the Report of the New Jersey Legislative Commission for the Study of Pain Management Policy, issued more than a decade ago, “the public policy of this State should support a compassionate and humane approach to caring for patients who are terminally ill which seeks to mitigate their physical pain and mental anguish and preserve as much of their peace and dignity as possible”;

     i.  As further observed in that report, “We are all stakeholders in the public interest to be served by the advancement of a kinder and gentler approach to caring for patients as they approach the end of life because we will all take that journey”; and

     j.  It is manifestly in the public interest for this State to establish an advisory body, the membership of which would comprise individuals with suitable qualifications for this purpose, to examine those issues that it deems appropriate for the consideration of its members relative to the quality and cost-effectiveness of, and access to, end-of-life care services for all persons in this State, and to propose recommendations for the consideration of State agencies, policymakers, health care providers, and third party payers.

     2.  There is established the New Jersey Advisory Council on End-of-Life Care in the Department of Health and Senior Services.

     a.   The advisory council shall include 17 members as follows:

     (1)  the Commissioners of Health and Senior Services and Human Services, or their designees, as ex officio members;

     (2)  two members each from the Senate and the General Assembly, to be appointed by the President of the Senate and the Speaker of the General Assembly, respectively, who in each case shall be members of different political parties; and

     (3)  11 public members who are residents of this State, to be appointed by the Governor with the advice and consent of the Senate, including:  one person who represents licensed hospice care programs in this State; two physicians licensed to practice in this State who have expertise in issues relating to pain management or end-of-life care, one of whom is an oncologist; one person who represents general hospitals in this State; one person who represents nursing homes in this State; one registered professional nurse licensed to practice in this State; one attorney licensed to practice in this State who has expertise in health care law; one person who is employed as a patient advocate by a general hospital in this State; two members of the general public with expertise or interest in the work of the advisory council who are not licensed health care professionals, at least one of whom is a member of a minority racial or ethnic group; and one person representing academia who has expertise in biomedical ethical issues relating to end-of-life care and is not a licensed health care professional.

     b.  The public members of the advisory council shall serve without compensation but be reimbursed for any expenses incurred by them in the performance of their duties.

     c.  Legislative members shall serve during their terms of office.  Vacancies shall be filled in the same manner as the original appointments were made.

     d.  The advisory council shall organize as soon as practicable after the appointment of its members and shall select a chairperson and vice-chairperson from among its members and a secretary who need not be a member of the advisory council.

     e.  The advisory council shall be entitled to call to its assistance and avail itself of the services of the employees of any State, county, or municipal department, board, bureau, commission, or agency as it may require and as may be available to it for its purposes.

     f.  The Department of Health and Senior Services shall provide such staff support as the advisory council requires to perform its duties.

     3.  The purpose of the advisory council shall be to conduct a thorough and comprehensive study of all issues that it deems appropriate for the consideration of its members relative to the quality and cost-effectiveness of, and access to, end-of-life care services for all persons in this State, and to develop and present policy recommendations relating thereto for the consideration of State agencies, policymakers, health care providers, and third party payers.  In developing its recommendations, the advisory council shall have, as its overriding concern, to promote an end-of-life care paradigm in which patients’ wishes are paramount and they are provided with dignified and respectful treatment that seeks to alleviate their physical pain and mental anguish as much as possible.

     4.  The advisory council, no later than 18 months after the date of its organization, shall report to the Governor, and to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), on the results of its activities, and shall include in that report such recommendations for administrative, legislative, and other action as it desires to present pursuant to section 3 of this act.

     5.  This act shall take effect immediately and shall expire upon the issuance of the report by the advisory council pursuant to section 4 of this act. 

STATEMENT

     This bill establishes the New Jersey Advisory Council on End-of-Life Care in the Department of Health and Senior Services.

     The bill provides specifically as follows:

·   The advisory council is to include 17 members as follows:

     -- the Commissioners of Health and Senior Services and Human Services, or their designees, as ex officio members;

     -- two members each from the Senate and the General Assembly to be appointed by the President of the Senate and the Speaker of the General Assembly, respectively, who in each case are to be members of different political parties; and

     -- 11 public members who are residents of this State, to be appointed by the Governor with the advice and consent of the Senate, including:  a representative of licensed hospice care programs in this State; two physicians licensed to practice in this State with expertise in issues relating to pain management or end-of-life care, one of whom is an oncologist; a representative of general hospitals in this State; a representative of nursing homes in this State; a registered professional nurse licensed to practice in this State; an attorney licensed to practice in this State with expertise in health care law; a patient advocate employed by a general hospital in this State; two members of the general public with expertise or interest in the work of the advisory council who are not licensed health care professionals, at least one of whom is a member of a minority racial or ethnic group; and a representative of academia with expertise in biomedical ethical issues relating to end-of-life care, who is not a licensed health care professional.  

·   The public members of the advisory council are to serve without compensation but be reimbursed for any expenses incurred by them in the performance of their duties.

·   The advisory council is to organize as soon as practicable after the appointment of its members and to select a chairperson and vice-chairperson from among its members and a secretary who need not be a member of the advisory council.

·   The Department of Health and Senior Services is to provide such staff support as the advisory council requires to perform its duties.

·   The purpose of the advisory council will be to conduct a thorough and comprehensive study of all issues that it deems appropriate for the consideration of its members relative to the quality and cost-effectiveness of, and access to, end-of-life care services for all persons in this State, and to develop and present policy recommendations relating thereto for the consideration of State agencies, policymakers, health care providers, and third party payers.

·   In developing its recommendations, the advisory council is to have, as its overriding concern, to promote an end-of-life care paradigm in which patients’ wishes are paramount and they are provided with dignified and respectful treatment that seeks to alleviate their physical pain and mental anguish as much as possible.

·   The advisory council is to report to the Governor and the Legislature no later than 18 months after the date of its organization on the results of its activities and to include in that report such recommendations for administrative, legislative, and other action as it desires to present pursuant to the bill.

·   The bill expires upon the issuance of the report by the advisory council.