Josh Barrow is a hospitalist and palliative care physician at Cook County Hospital. He's a clinician educated with research interests in medical education and ethics at the end of life and Josh will be speaking on organ donation among undocumented Hispanic immigrants assessment of knowledge and attitudes. So I'm standing between all of you in the party. Is that where we're at? Great. It's a good spot to be. So I'm Josh Barrow. I'm excited to be back at U of C. I did my residency here and I went on to do the McLean Fellowship. Thank you for inviting me Mark. So I've been at Cook County since finishing my residency and today I'm going to be discussing a study that we performed at our hospital. I want to give a special thank you to Dan Bronner for advice and insight. Brian Lucas for methods support and Carmen Martinez who is the saintly nurse who interviewed all these patients on her own time. So I have no financial conflicts of interest. I do have organs and may at some point desperately need one in the future so that that may be a conflict we'll see. So my interest in this issue actually it started with a case. Maria this is not actually her but she was a 33 year old undocumented Mexican woman who was admitted to our hospital with shortness of breath. She was diagnosed with acute myocarditis and she rapidly deteriorated to the point where she was requiring maximum life support to survive. Her family was told that the only option to save her life was a heart transplant and she was evaluated. However she was deemed not to be a candidate because she was quote unquote undocumented. She was ultimately actually declared brain dead so she was approached by representatives from our organ procurement organization which is the gift of hope in Chicago. When the hospital interpreter translated the representative's request her family turned to the interpreter and looking at that person said how could you ask us for this? You know that she couldn't get one. And this issue has actually been getting pressed recently. This summer in fact undocumented immigrants and advocates protested outside of major medical centers in Chicago and as you can see from the signs and from the headlines they were protesting the fact that undocumented immigrants cannot receive organ donations. Now I want to take a couple steps back and just explain what we're seeing right. So I mean excluding patients from organ transplantation because of their immigration status seems doesn't seem right. And in fact the organ procurement transplant network has a policy that directly addresses this issue and it clearly states that a person's citizenship or residency shall not affect allocation of organs. But you know the reality isn't so clear. The majority of undocumented immigrants are effectively barred from receiving solid organ transplants because of restrictive reimbursement criteria. Right so upwards of 60% of undocumented immigrants in the US work in low-income fields that don't provide private health insurance. At the same time federal law expressly excludes them from any federally funded program. Medicare, Medicaid, this also applies to the Ford Will Care Act. So as a result this group is effectively uninsurable. And as this group is uninsurable to receive a transplant they would need to cover the costs of the procedure and follow-up care independently. Of course solid organ transplantation is expensive and as a result organ transplantation in this group is exceedingly rare. How relevant is this question? Well based on current estimates by the Pew Hispanic Research Center it affects approximately 7.2 million people. Okay so this explains why our patient couldn't receive a heart transplant and now I want you to focus on the second piece of the story. Right because though they aren't eligible to receive organs these uninsurable undocumented people can donate organs and in fact CMS and JCO regulations require that we ask them or at least I should say ask their families for their organs. Right the so-called required request rule. I find that difficult to say. Okay right so what this means is that people are being asked to donate their organs into a pool from which they are expressly excluded. Right and this challenge is a fundamental principle of the organ transplant system fairness. Right so that's the background. That's how I got to these questions. Right I mean do undocumented immigrants know about this? How do they feel about it? Would knowing this change their opinion about donating their organs? And I mean should we be explaining this to people before asking them to donate their organs? So to determine the answers to these questions we performed a study. We used a convenient sample of patients admitted to the general medicine service and we interviewed them on their first hospital day. We enrolled 59 patients. We approached about 133. So we included all patients who were over 18 years old who spoke either English or Spanish and who self-identified as undocumented immigrants or legal residents who had their green cards for less than five years. And just to be clear in Illinois legal residents who have had their green cards for more than five years are in fact eligible for Medicaid. So we excluded patients who self-reported having diseases that would preclude them from being organ donors. Namely cancers, HIV, chronic viral hepatitis and the reasoning being that if you knew that you couldn't really donate an organ anyway your thoughts about donating your organs or at least your responses to our questions might be different. So our participants were predominantly Mexican. All but one were Spanish speaking. 93% were uninsured. They had low educational achievement so 87% had high school education or less. They had strong support systems so 87% had family in the US and 87% had children and interestingly 63% had family members that were US citizens which might suggest some degree of acculturation within US society. Okay so what did we do? All right so the interview consisted of 32 questions, took about 10 minutes to complete and it was performed at the bedside in a face-to-face fashion. There were three parts to the interview. There was an assessment of knowledge, attitudes and beliefs about organ donation. We then performed an intervention and then finally we collected various demographic information. So the intervention, this is what I want to focus on for the remainder of the talk. Here's what we did. So we asked people if they had health insurance. We then told each participant that people without health insurance can only get an organ transplant if they pay for it themselves. We asked them if they knew this. We then asked them to guess in dollars the cost of heart transplant, liver transplant and a kidney transplant. We then gave them the actual costs of the procedure and then reassessed whether they would be willing to donate their organs when they died. Of note we had asked the same question about willingness to donate earlier in the interview at the very beginning. So we were able to document whether there was a change or not. So regarding the cost estimates, so most of our participants, 68% knew that they would have to pay for an organ themselves. But they dramatically underestimated the cost of the organ transplantation. I mean look at the median estimated costs by our participants and then compare those to the actual costs. I mean they're off by hundreds of thousands of dollars. Even people in the 75th percentile aren't really close. And just so you're aware these costs were they incorporate 30 days of kind of pretransplant workup, the procedure and attendant hospitalization and then 100 days of, excuse me, 180 days of post transplant outpatient care and medication. And then inside the box we see people that changed their minds. So you'll see that 43 people that far right column stated that they would be willing to donate their organs before the intervention. Three changed their minds after the intervention. 16 people who had stated that they would not be willing to donate their organs before the intervention actually changed their minds after the intervention so they would donate their organs. So I mean you probably don't need statistical tests to tell you this but we perform the McNamara's test which assesses for a change within a group after an intervention and the P value at the bottom of the slide there is 0.48. Clearly not significant. So now to be frank our study has limitations right. The sample size is small. The possibility of social desirability bias is clearly present. The reported willingness as previous speakers have said does not correlate well with behaviors but you know we believe that it really that is provocative. I mean the present situation in which a group of people can donate resources to a pool but do not have access to the benefits of that community communal pool is inherently unfair. Now that said the solution to this is a political one right and one piece of this puzzle has been addressed in a fashion and let's see how that plays out. I hope you know but through health care reform and we can be hopeful if not optimistic that the second piece may be addressed in the near future with discussions around immigration reform okay but our study raises a corollary issue in this situation which is access to information right and there are real significant barriers to organ transplantation with this within this community and the participants in our study lacked key information about these barriers. I mean it's information that is relevant and it's information that they want and this is a problem with a much more straightforward solution. A solution that I believe is within our purview as clinicians and advocates. Much of the discussion around organ donation centers appropriately around scarcity and increasing access. However you know a robust organ donation program requires that in pursuit of our goals of saving and improving lives we demonstrate respect for persons as Dr. Sanders I think is exploring. Respect for persons requires fairness and it requires informed consent and our study suggests that for the undocumented immigrant community these foundational principles are not being met. Thanks. I found Dr. Sanders' discussion or in use of you know the word coercion I found that interesting. It's something you know the number that is where you have you feel like you it's such a you know such a great deal that you need to do it. I'm not a hundred percent sure I don't know I find that interesting but I and I this question of asking an undocumented immigrant for their say for their kidney would they feel coerced part of that depends on how the question is asked right so I and what type of information the person is given how the question is asked so sometimes you'll hear these concepts of going three deep asking three different ways the question three different ways. I don't know that for that you know the case that I spoke about asking that family three different ways whether they really didn't want to donate the organ to me seems putative it seems there's something wrong there right and so I don't know that is coercion but it's certainly I don't think it's appropriate would be kind of the the weakest word I would use. Please please join me in thanking Josh and and all the speakers for this session.


So I know that I said let's party like it's 1999 But really you guys we are assuring in a new decade And I thought this would be a great way to do a very glam very party look very colorful for you guys Hi YouTube family.  This one is from LA girl It's the fierce and wild palette and I think this one is called untamed It has a bunch of greens purples and a bunch of neutral browns, which I absolutely loved up here and I'm pretty sure that's untamed Yes, it is and then I'm going to be using the profusion metallic So I hope that you guys are going to enjoy this today when you do see me next I will have one eye done as usual for the sake of time constraints So if you want to see how I got this look just stay tuned Okay, you guys we're really really close and we are going to be as I said in the beginning we're working with the LA girl fierce and wild palette and this one is Untamed and the color scheme in here is so pretty you guys.  It's the Anastasia Beverly Hills The tape is from Sephora. I put it about a quarter inch away from the bottom of my lash line Clear to the tail of the eyebrow just below it. So I don't disturb any eyebrow Palmade or anything that I put on my eyebrow and That will all be listed below and then I'm going to take my morphe brush And I'm going to go in here and then this is a little bit different than what I've done before I'm going to take that color and I'm going to load that color From the corner of the eye clear to the corner of the tail and I'm not leaving a space Usually I leave a little bit of space there, but as I come in I'm going to start to gradually leave a space in here So I'm just going to run that color all the way in to the inner corner Right where that eyebrow is not all the way down in this corner of the eye because if you did that then it would look Really muddy in there and we need to keep brightness in there. Okay. I have to go into my color again and I'm going to tap that off and Again, I'm going to just very gently Little stipple motions push your brush a little my brush pressure here is really light And if you notice I'm using I'm holding the brush way out on the ferrule almost to the tip And that helps keep the pressure very light as well Again, I'm just going to continue to start out at the tail and blend towards the inner eyebrow Until I have it where it looks like that other eye So what I'm doing is I'm following just a little bit of the arch of the eyebrow right now Because I don't want it to look like I've got a straight line here where there's no color up towards the arch of the eyebrow I need a little bit of color there, but once you get there you can come in almost in a straight line towards the inner brow and Just continue to build that up. Okay, that feels like it looks really good looks really close to the other color We are just going to take the deepest color on a Luxie 231 brush This is a firm but smaller fluffy brush again going right out here And I'm going to completely cover the whole entire area I might just stay away from that tail just a tiny bit at this point because this color is going to get a little bit deeper and Then I'm going to go towards the crease and I'm not going to come all the way into the eyebrow in here I'm going to come just about just about a quarter inch away from there That's where that color is going to stop. So just continue to fluff that up a little bit again I'm clear out on the end of the feral here. I'm using an extremely light touch. Okay, and again Look at yourself straight on. Can you see that they look the same? You want to be following that transition color, but you want to be a little bit lower and that looks pretty good Okay, moving on to the next brush that will use the same color, which is the darkest color in the palette Basically just a really flat kind of shader brush. It's more densely packed and It's going to pack on the color a little bit more densely So we're going to go into that brown color right there on the corner again, and I'm going to load up my brush Tap it off and now we're going to just push the color right there into the corner of the eye Not going further up yet So that we get a lot of color see on this side We have a lot of that deep color down there and we're doing that again So I'm going to push all that color right there into that corner And then I'm going to go back with that last brush that we had that luxe brush, and I'm just going to very lightly Pull it right out there to the tail again. All right for the next one. We're going to go into that green color It's what's going to be packed on our lid. I'm using a Zwayba brush It says that this is a luxe smoky shader So it's kind of just a flat round shader on there, and I'm just going to really load this brush up I mean, I'm going to put a lot on this brush of that green color right there or that kind of greenish tealish color right there and then I'm going to take some spray from Wet and Wild and I'm going to spray my brush Quite well, so it's almost like so what I'm wanting is to get more defined right there into this area and Keep it down there as much as possible And the reason is is because not that it's a cut crease just because it will look a little bit more crisp It will look a little bit more refined. You can see that on this eye Well, maybe you can't see that on the camera It did travel up a little bit and I think that's because I didn't have my brush quite wet enough But we're just going to pack that on Pack it clear all the way to the inner eye and then all the way out To where you're covering about About three-quarters of the eye So you're actually almost going into that dark color Then you're going to go back in with the shader brush that had the darkest color on it And you're going to just blend those two together and I will go back and forth with those Until I feel like I have those two colors really put together well Now when I originally put this color on I noticed that it was a bit more green and I wanted to have it be a little bit more on the blue side So what I did was I picked up my metallics palette from profusion Which I love so much because it has every metallic shade you could ever really want What I decided to do to kind of line it up and blow it up a little bit or teal it up a little bit is Take some of this color that is right out there and brush really well again And then I'm going to go in and I'm just going to lightly go across it This is the easiest way for you to change a look if you're not liking what you see when you see a look I'm going to take off the tape and you can see the stark line there and Sometimes like right now. I got really sweaty while I was doing it sometimes it does take your makeup off So I'll go in with my damp and beauty blender with what was ever left on there from my My foundation and I'll just pat across there. You can actually see that I already lined my waterline I always like to do that before I do my concealer that way I don't smudge my concealer when I'm pulling down to put that in the waterline. This is from Urban Decay It's a 24-7 slide-on pencil and this is called the deep end and it's very very turquoise And as you can see it kind of just sets that whole look off to Kind of pull it together for the actual turquoise that we're going for and then I'm going to take the Milani pencil And I'm going to go out here, and I'm just going to line Across not all the way in I'm going to stay about a quarter of the way out of there And I'm just going to line up underneath there a little bit And then I'm going to take a morphe smudger brush so the M168 and I'm going to go into this dark color again This is such a tiny little smudger brush. It just barely has any tip on it I'm just going to take it and I'm going to go across And I'm going to smudge that eyeliner with a little bit of The eye shadow that we use to tie the look together to the outside But also the eye shadow on top of the eyeliner helps pack it on and helps it stay on really good All right, so now I'm going to go back into that metallics palette that I had and I'm going to go into a gold color the second color over right here It's actually very gold. It doesn't look as gold on camera But it is an extremely gold color and this is going to be my inner color there on the inner Part of the eye, excuse me, and I'm going to spray my brush again. I want it to be just a little bit More metallic looking than just highlight looking in there for this kind of party festive look that we're doing And I'm going to just go in there and just touch it a little bit to go up towards the top of the eye And down towards the bottom of the eye. All right, and as one last step I'm going to take that medium brush again, and I'm just going to very softly Kind of just diffuse that stark line that we had from the tape. All right So for the sake of time today, I did have my contour already done I'm going to be using the Lumie bronze it This is from L'Oreal and I have the lightest color I'll make sure that I list it But I'm using a real techniques fluffy brush and I'm just going to warm my whole look up with this I like this bronzer for a more You know dressy look or a party look because it has a little bit of luminizer in it And I'm just going to take it up here in my hair a little bit and down a little bit on the forehead And what you want bronzer to do is kind of hit the points Where you would normally have the sun hit and I know that a lot of people don't talk about putting across your nose But I do a little bit so I'm going to start out here on the cheeks just a little bit and again I'm using a super duper light touch with this. Sorry.   Sorry, and that is just fine I'm using my Cody airspun. This is their highlighter. You guys I found this on clearance at Walmart the other day And I got their other two colors, but this is my favorite. It's called snowmuch eyes Anyway, not only is it a pretty highlighter, but it does really good on my mature skin And I'm just going to hit the high points of my cheeks with that And you can see that coming into view very quickly. Look at that so pretty and then the other side Just a beautiful beautiful Highlighter next time I'm going to line my lips with the believe beauty. This is almost rose This is one of their mechanical pencils. I really like these. I think they're they did a really good job on them After I line my lips, I'm going to be going in with the essence So it's the plumping nude glosses from Essence and this color I think it's oh for that big or something like that. This is just going to be my lipstick and my lip gloss today I love that color because it's just a couple shades darker than my own natural color So you get a nude look without it giving you, you know making you too washed out Okay for the sake of time as always I'm going to go off camera I'm going to do my liner and two coats on my lashes of mascara And I will make sure that I link below for you a Tutorial on my mascara and eyeliner and how I do all of that But I'm going to go off camera right now and take care of that. Okay guys, so there is the finished look on it I love this green on here and I love the way that it turned out Let me just pan out just a little bit so you guys can kind of see it a little bit further away So you kind of get the effect of it So when I look down you completely see the turquoise or the bluish green on there And then when you're got your eyes open you can see it into the waterline. So I really love the way this turned out I hope you did too. Please give it a thumbs up if you do like seeing these kind of tutorials Definitely, let's party like it's 1999 or 2019 going into the new decade you guys have a wonderful day I love you all so very much. Take care of yourselves and I'll see you in my very next video. Bye guys