Tall Tales from Kansas

outside the hospital DNR forms

This week's palliative care discussion is on the topic of Outside the Hospital DNR forms. This is different from an Advanced Directive, because in addition to outlining your wishes regarding CPR and other medical interventions, it is signed by a physician. Which makes it official. This is necessary in order for Emergency Medical Service providers (EMS) not to attempt resuscitation if they are called.

Sometimes people think if they have an Advanced Directive that outlines their wishes, or tell EMS personnel they don't want to be resuscitated, or they have DNR tattooed on their chest, it will prevent them from having CPR performed. No, no, and no. Below is another example of a form that can be used. It is a bit simpler than the one above.  

The hot pink form in the first photo is a TPOPP form.  It is for Kansas and Missouri.  TPOPP stands for Transportable Physician Orders for Patient Preferences.  It has 4 areas and allows you to outline your wishes about CPR (do it or don't do it), what level of medical intervention you want if you have a pulse and/or are still breathing (1. comfort measures only, 2. do some limited things and going to the hospital is ok but likely no ICU level care, or 3. go ahead and take me to the hospital - even the ICU is ok with me), your wishes regarding medically administered nutrition (including feeding tubes), and finally signatures.  

It is paramount that you talk to your medical provider about a form like this if you want one.  They are generally for people who have a serious illness and know they don't want to be resuscitated if they die. For me, at my stage of life, and knowing that I want the first ticket I am handed it makes sense for me to have one. Remember, I see a lot of stuff and talk about serious illness everyday.  This is not something to be done without a great deal of forethought.  

I will be standing by for your comments and questions.  

Helpful links:  
Here is a place where you can see if your state has a specific form for an outside the hospital DNR form: POLST programs in your state

For more information about the specific parts of a POLST (Physician Orders for Life-Sustaining Treatment) form: Elements of a POLST form

especially when they come with helpful advice about how to refresh them if they start to droop

Morels were front and center at the market this weekend.  And cute boys playing guitar.

Now bear with me for one tiny second while I show you the Duck yolk raviolo with fresh asparagus and morels I had for dinner at Freshwater in KC the other night.  Beautiful to behold and each bite was perfect.  If you are in the area - get there while morels are still in season.  

Now back to regular programming... which this week included more lilacs and friendly people.  

And of course asparagus, as in the dawning of the age of... 

There was also my favorite baclava grandfather and grandson duo.  They were gone for a month over the winter and spring to Turkey and Lebanon.  It's important to catch up with the vendors at the beginning of each season.  

I already mentioned friendly people, flowers, and morels, but I don't think I mentioned an extremely cute puppy yet. 

Hand made signs always get high marks.  As do bouquets of lilacs especially when they come with helpful advice about how to refresh them if they start to droop.  

Now I am off to make lunches for the week.  Baby kale, spinach, dark red kidney beans, cranberries, red onion, broccoli, roasted pumpkin seeds.  Spring farmers market lunches are the best.  

with the sun on your skin but it's not hot

All that stuff I have said in the past about fall being the best for walking?  Wrong.

Clearly spring walks are the best.

When the redbuds are blooming. 

And the new grasses are shockingly green, and it feels good to be out of doors, with the sun on your skin, but it's not hot.  

it is important to try as many bourbon drinks as possible

Do NOT miss a stop in Frankfort Kentucky if ever you find yourself in close proximity. Here are some things you can see, do, enjoy, buy, drink, etc.  We started at the grave of Daniel Boone.  Located at the Frankfort cemetery which is peaceful, beautiful, and has lovely views overlooking the city and river.

If you are lucky, you can stop at The Woolery and they will be open.  The day we were there, they were not.  They were at "Ply Away" a spinning retreat in... wait for it... Kansas City.  But I did appreciate looking in the windows and spying this cool poster for a festival that will be occurring when I am back home.  Oh well.

Frankfort itself is quaint and charming with a great bookstore and all manner of things to exclaim over. 

I had to tear brother away from the Boogie Boutique. 

Cheryl Jean and I met this fine fellow at Kentucky Knows where they have small batch artisan roasted barrel-aged coffee. As in bourbon barrels.  

The Capital Gallery was definitely worth a visit as well.  This is where I found the book of poetry I mentioned day before yesterday.  

When you have concluded your day, go to Bourbon on Main.

Where you should absolutely order a Buffalo Sidecar for sipping and the deviled eggs for noshing.  

If you decide to stay for dinner (like we did), get the Bourbon Tea to go with your burger, or fries, or taco salad, or Brussels sprouts. Or all of the above.  When you are on vacation it is important to try as many bourbon drinks as possible.  

It goes without saying, but of course get thee to the Buffalo Trace Distillery as well.  

surrounded by bunnies

Candy tuft, cat mint, vinca, and lavender. Surrounded by bunnies. On a pedestal. For Wednesday. The end.

this collection has intrigued me

Upon the recommendation of Sister, and with the cooperation of my fabulous local library and their inter-library loan program, I was finally able to get America's First Daughter by Stephanie Dray & Laura Kamoie.  

Wow - I was seriously caught up in this one.  So much so in fact, that I listened to about 10 hours in 2 days because it was due.  I like to be respectful about returning things on time.  This novel is about Martha "Patsy" Jefferson, the daughter of Thomas Jefferson and is historical fiction, but loosely based in fact.  Jeez I am ignorant about the history of this country I live in. When I retire I am going to enroll in an American History class for the sheer pleasure of learning for learnings sake. In the meantime, if you have a favorite book from this era that you think I will enjoy - let me know about it!

My niece told me about these as well- Presidential Podcast  - and we listened to 5 on the way to and from Kentucky.  Entertaining, interesting, and informative.

In other book related matters, despite my love of young adult fiction, and the fact that in our youth Dottie and I were huge fans of comic books,  I could not get into the graphic novel (On a Sunbeam) I told you I was going to investigate.  Which doesn't mean I won't give that genre another try. So, if you have tried one you liked - give me the 4-1-1 on it.  

I just finally finished going through these magazines for the 4th or 5th time.  They are so good I always have to go through them that many times before I have gotten my fill.     

For pencil lovers, if you haven't seen this issue of Uppercase, get it.  

Botannica went with me to Kentucky because it too demands multiple looks, and is perfect for Spring time and gardening inspiration.  

And on one last literary note, this little gem was found at "The Gallery" in downtown Frankfort, Kentucky.  A book full of Haiku.  Which for some reason called to me.  

It is lovely to hold, hand made by Larkspur Press. I would not have called myself someone who appreciated Haiku before now. This collection has intrigued me though. 

Oh, and one last thing on the topics of books and reading - I just placed holds on the following books on CD at the library:
1.  A Gentleman in Moscow upon the recommendation of Cheryl Jean Moss.  2. Where the Crawdads Sing as suggested by Gwen Delmore.  3. Because all good things come in three's Conversations with Friends by Sally Rooney, which just happened to catch my eye and sounded interesting.

back among my people

The Lawrence farmers market opened last week, while we were in Kentucky. Which made this past Saturday the official opening for me. Hello asparagus, good morning extremely cute couple partaking of a strolling breakfast, and howdy flowering crab apple tree.  

The time for local fresh produce is upon us.  

The Eastern redbuds (Cercis canadensis) are having a spectacular year, and I could not resist this shot as I walked into the market area. They were blooming all along 64 eastbound towards Kentucky, and are still going strong at home.  

I don't know what to say about this little miss. No words can accurately capture the complete cuteness.  

Hello Mellowfields Farms.  How I have missed your greens.  

There was an impressive display of lilacs that I am sorry you cannot smell through your screen.  

Happily there were plenty to go around. To prevent any fighting. The nice couple above were going for a slightly different look than I was, but I did warn them that I was not above scrapping if it came down to it.  

It was nice to be back among my people.  Getting flowers and dreaming up things to fix with my produce.  Last night I had a salad with the tender lettuce mix, chopped raw asparagus, a few slivers of red onion, hard boiled egg, and walnuts, all tossed with a dijon vinaigrette. Wonderful.  

This chocolate croissant from Baking Traditions hopped in my basket too. It was made by the creator of the kuchen I discovered at the holiday market in December.  The kuchen that I am still dreaming about in April. You understand why I had to try it. 

it's hard to beat this combination of things to look at

St. Charles Missouri was a lovely stop on our way to Kentucky.  Give me old buildings, cobblestones, trees in bloom, enticing windows, statues, walking paths, a river, and finally a spot to stop for dinner and a drink.  

It's hard to beat this combination of things to look at on an evening stroll.  

for a serious sweets lover like myself

The Lawrenceburg Bed & Breakfast was our home base in Kentucky, accommodations so special that you must hear about them. In case you have a trip anywhere in the vicinity. 

The home is beautiful, the furnishings perfect, it is immaculately clean, and the beds just right for restful sleeps.

A front porch, with comfortable seating for bird watching, bourbon sipping, and easy conversation should be a requirement for all vacations.

Quiet spaces for reading, writing, or stitching in solitude are in each of the two large bedrooms upstairs.

This dining room table was where we thoroughly enjoyed starting each day with china, candles, and fresh flowers.  Followed by eggs, waffles, bacon, French toast, quiche, fruit, pastries, coffee, juices, oh my. We felt like royalty.  

The proprietors, Ron and Marlene, are the epitome of what hosts at a B&B should be.  Marlene is the perfect combination of a southern cook and a trained professional chef. Ron, is the head electrician/plumber/remodeler who also happens to be a charming conversationalist. They have both perfected the art of being present if needed, while making you feel completely comfortable in their home.

I have not yet mentioned that each night, in a shared space upstairs, Marlene laid out freshly made dessert. Things like iced lemon pound cake, bourbon pecan blondies, peach crumble with a caramel drizzle, and chocolate truffle brownies. Which for a serious sweets lover like myself is a treat beyond compare. 

if I tumble off this wall and you think I am dead but aren't sure

April 16th was National Healthcare Decisions Day, so it seems right and proper for me to remind you of the importance of having an advanced directive (AD). An AD outlines what your wishes would be if you were seriously ill and could not let healthcare providers know about your preferences for care.   

If you are 100% confident that your loved ones know exactly what you would want, and will be sure your wishes (not their wishes) are carried out, go to bed tonight and rest easy. If you are not, best to complete an AD. On a regular basis I encounter families who say “I know she wouldn’t want this but I just can’t give up on her” or “... "I have to give him every chance to get better”... and decisions are made. If in either of these cases just described, there is an AD in place that outlines what you want, we are obligated to follow that.  No matter what your family or designated decision maker says.

Here’s the deal though. Make it clear what you want. Outline your minimally acceptable quality of life. Things like this:
I must be able to recognize my loved ones and communicate with them.
I must be able to feed myself.
It is not uncommon to see "I must be able to wipe my own butt".

Spell out what level of disability you are, and are not, ok with.
Specify if you would be ok with a feeding tube and a tracheostomy. Google those things to see what they look like to be sure. If you have to have them permanently is that ok with you?
If you have to be cared for in a nursing home are you ok with that or must you be able to completely care for yourself to consider life worth living?
How long are you willing to remain on a breathing machine/ventilator before you want to focus on comfort as your top priority? FYI - if it’s longer than 10 -14 days you are going to need a tracheostomy.
If your kidneys are shutting down are you willing to be on dialysis? What if it’s going to be permanent? Are you ok with going 3 days a week for 4 hours to do that? Again, google that to see what it entails.

You don’t need a fancy document for this. Write it out and go over it with your physician/NP/PA. Ask them to place it in your medical record. Take a copy with you the next time you go to the hospital so they can scan it into your electronic medical record. You can go to mydirectives.com and do all of this online and then send it to your doctor and your family members. That is how I did mine. They remind you every 6 months to review it and be sure your wishes haven’t changed.

Finally, talk about this stuff with your family. If there are specific things you think they need to know to know, tell them. Remind them about it regularly. For example, last week when I was working on top of a 6 foot rock wall out back I quizzed Chris with specific scenarios... “if I tumble off this wall and you think I am dead but aren’t sure, and I look comfortable what should you do?” To which he replied “wait at least 15 minutes to be sure you are actually dead and then call the ambulance”. Which is exactly the right answer!

Next week I am going to tell you about another document to think about having in your home, if you, like me, understand that your family might need some help from emergency medical services, but you do NOT want attempts made at resuscitation. Did you know they are obligated to attempt to revive you if someone calls them? UNLESS you have a specific form that is signed by a physician.

knowing full well that I need them

On the drive to Kentucky this past week, our first stop was in Fulton Missouri. Where, on a tree lined street, in a charming area, we stopped at 1canoe2 paperie.

You will find many practical, colorful, whimsical items that will make you smile.

In the immediate vicinity there were several sitings that warranted further investigation, but alas there was no time to indulge. On this trip. 

I have begun a list of other reasons to head back to Fulton in the future. It seems quite reasonable that an annual trip to restock my card drawer will be needed. At a minimum. Plus, I purposefully did not buy those Bavarian Gnome crayons. Knowing full well that I need them. For something.  

while we ate pimento cheese on cucumber slices

Kentucky stories to follow in the days ahead.  For now let me say that the people we met have been friendly, the accommodations sumptuous, the food outstanding, the bourbon smooth, and of course there was watching Tiger win the masters today.... with brother, Chris, and Cheryl Jean, while we ate pimento cheese on cucumber slices and discussed all the subtle nuances of the game. 

In other words, a perfect time has been had by all.

the feeling that you have somehow played a role in the development of such beauty

Now that we have concluded show and tell on the magnolia trees and the forsythia bushes, lets move along to the cherry trees shall we?

These are not the showy specimens that can be found in some parts at this time of year, but I'll take 'em.  Because they are right here, where I can appreciate them in person.

All the photos above were from a park in downtown Lawrence. But below, well that's a special tree.

Because it lives in our front yard.

And I happen to be partial to it.  

You who garden understand this concept.

The feeling that you have somehow played a role in the development of such beauty, through your care and tending. 

you simply can not stop a tasting at #1

Things going on around these parts, that might loosely be called "Easter-ish", include tulips, white ceramic bunnies, and cute tins.

We are also trying cookies on for size. To be sure they are just right and don't clash with the jelly beans. I might have messed up the frosting in my haste to get this soft, generously frosted, liberally sprinkled, sugar cookie out of the bag. But that did nothing to spoil the taste.    

Which was quite good. But the tasting continues. You simply can not stop a tasting at #1.   

Cuttings are being rooted.  Even though there really is no need.  Those ground covers will spring up anywhere you thrown them.  But still... mini vases on the kitchen window sill make me happy. 

That bunny got tossed on the carrots on the front porch.

Lastly, I present a photo of cookie tasting #2, a large, soft, slightly underdone in the middle (in a GOOD way), cinnamon and sugar coated, snickerdoodle. When my teeth sank into it my whole mouth went weak. Which is to say that we may have a winner, but it seems wrong not to try one more cookie. A tie-breaker if you will. 

when the payoff is all this wonderful yellow

In the wild, or by a fence

carefully pruned, or wild and shaggy

planted singly or in a grouping

nothing screams spring like the forsythia.

I tried to plant one when we moved into Tall Tales Headquarters. That was before I really knew the best spot for one and it did not thrive.  In fact, it died. Too wet I think.  

It may be time to give it another whirl.

No sense in not trying, when the payoff is all this wonderful yellow.  

the magic of Spring

Tonight I present a garden update, with photos taken during the first weekend of serious bed clean up.  Cutting down, picking up, uncovering, trimming. You get the idea.  

Vinca's are blooming and clematis is leaping.

Ground covers are greening up and baptisia is busting through the mulch.

Candytuft is going from green to white while buds are forming on the dianthus.

Oriental poppies are looking healthy and the ever faithful oak leaf hydrangea is leafing out. It got a good hair cut.  

This lavender, was almost dug up, until I peaked right down to the bottom and spied some green.  It will get a trimming, but not until that new growth has more time to come back on the old wood.  

I had to smile when I walked by this plastic pot, that sat out all winter, in the cold and the snow, totally unprotected, and saw this ground cover popping up. The magic of Spring, it never ceases to amaze me.  

simply sublime

Last week the magnolia trees around Lawrence started to bloom.  On a cloudy day, they were sweetly beautiful.

Three days later, with a bit of sun and blue skies, they became more showy.  In a "hey look at me!" kind of way.

I circled them, surveying from all angles

When across the street, I spotted some pink.

As in pink magnolias.

In front of a yellow house with a porch swing.

Simply sublime.  The end. 

ordinariness is my superpower

Regular stuff from this week included a little of this and a little bit of that.

Like an absolutely perfect latte and the staying power of the Japanese iris on the table.

And a morning walk with birds chirping, kids riding their bikes to school, a lost glove on the path, new green grass coming up, the day ahead to savor.

The start of cocktails on the front porch. Discussing our upcoming trip to Kentucky.  

Ordinariness is my superpower. That's what I decided this week.

so he could ask the hard questions about what his death might be like

Most people who read this blog, based on your comments, think palliative care is a good thing.  A resource to help.  An extra layer of support for those with serious illness.  Oftentimes however, we find when we go into patients rooms, we are met with resistance or fear.  We can be thought of us as "the bearers of doom and gloom", the ones who "take away hope" for the patient who "is a fighter and is not giving up".

Tonight I present this very humorous, absolutely spot on, illustration of just exactly what I mean.  Created by Jared Rubenstein, MD.

There are days when we have to work really hard to be helpful.  To try to be sure people are staying comfortable as they are maintaining hope and continuing to fight.  Or when they recognize they want someone to talk to about what they will do if things aren't going the way they want them to.

In the last month I recall vividly the adult son of an octogenarian bristling at the thought that we would be involved in the care of his father who had always been in robust health... and the patient telling us after our meeting, how helpful it had been to talk with us so he could ask the hard questions, about what his death might be like, and what could be done to keep him comfortable whenever he was dying.   

a modern lemon tart

Today I present the classic example of where I say "I am going to try ..." something, and then wait long enough that Chris finally does it.  

A lemon tart that uses olive oil instead of butter in the crust and the filling.

No, we are not opposed to butter.  It just sounded interesting.

I am not sure if I should start with how the crust tastes like a shortbread cookie, and melts in your mouth.  OR with the rich, smooth, tart, lusciousness of the filling.  You decide when you make it.  Oh, oh, oh, it's good.  With or without whipped cream on the side.  

Recipe below from America's Test Kitchen.  One of our very favorite sources of things to "try".