Wednesday, February 25, 2015

Using video to jumpstart The Conversation: a book review

Reviewed: The Conversation, by Angelo Volandes

Reviewed by: Alex Smith

Using video to help patients with serious illness make decisions about future care seems like a “no brainer.” Think back to your early training. Remember being at the code for that patient with advanced cancer, wondering why he wasn’t DNR? If he could only have “seen” what it was like to be coded, to be in the ICU, to live on machines. The allure of video is obvious. But as with any thing that seems too good to be true, the reality of using videos to jumpstart goals of care conversations is more laden with potential pitfalls than is apparent on the surface.

Thankfully, we have Angelo Volandes. In his book The Conversation, Angelo uses stories of patients he has cared for to build the case for video. He does this slowly, deliberately. He exposes the limitations of language through his own stories of caring for patients, where he wishes the conversation had gone differently. He does this with humility. He exposes his own mistakes with a touch of self-deprecation, as in this conversation with Helen, a Harvard poetry professor hospitalized with an invariably fatal form of brain cancer, who asks Angelo:
“What happens at the end?”

“In the end the intracranial pressure becomes untenable, causing the blood pressure to elevate drastically, the lungs to stop breathing, and the heart to slow until it stops. It’s called Cushing’s Triad.”

A bead of sweat ran down my forehead. Had I really just said “Cushing’s triad?” I was hiding behind medical jargon. What I really needed to say to Helen was that no matter what anyone might do, she would die very soon.
Angelo later takes Helen on a tour of the ICU. In the midst of the tour Angelo is called into a code blue for an ICU patient. The code is witnessed by Helen and her husband.  Disturbed by what she sees, Helen decide to shift to focus on comfort care. Helen is discharged with hospice and dies at home, surrounded by family and her students.

This is the ah-ha moment. To reach more patients, Angelo unites his passion for improving goals of care conversations with his boyhood dream of becoming a film-maker. He starts to use video in the care of patients with serious illness to dramatic effect.  He creates video examples of what it would be like to chose life prolonging care, limited medical care, or comfort care.  Angelo starts to study the use of video.  After viewing the video, patients are more informed, would recommend use of the video to others, and are more likely to chose a comfort oriented approach when compared to a scripted conversation.

Now, I happen to know Angelo well. We were in fellowship at the same time - he in bioethics, me in palliative care – and we did our research training together. I know that the story is more complicated and the journey toward video rockier than depicted in the book.

I remember a research class where Angelo showed a video of a woman with Advanced Dementia. In the video she is lovingly cared for by her family. The voice-over describes the clinical course of advanced dementia. Our course instructor for this session, a Geriatrician, asked the class, “did anyone notice anything unusual about the woman in the video?” We didn’t. “Her mouth was open and her tongue was hanging out of her mouth. Many people with advanced dementia don’t have that appearance. Might the image of the tongue lolling out of the open mouth sway the viewing audience toward a decision that living in such a state is undignified?” We acknowledged that it might.

Angelo has put a tremendous amount of thought and work into addressing concerns such as these. The primary concern with the use of video is that it the video will be biased biased toward a comfort-oriented approach.  In response to these concerns, Angelo has removed testimonials from his videos, and decided to depict CPR on a dummy rather than on a live (or dying) person.

We need this sort of hard work and attention, because Angelo is right: video is a remarkably powerful tool. As one of his patients says, “if a picture is worth a thousand words, a video is worth hundreds of thousands.” Angelo likens his videos to the Kahn academy’s inversion of the schoolroom – empowering students with knowledge and leaving class time for discussions with teachers. And similarly, patients can be “activated” by videos to engage their physicians in thoughtful conversations about goals of care. He is careful to note that videos should supplement, not replace, conversations with healthcare providers.

This is a very important book.  It presents a remarkably compelling case for the use of video in advance care planning.  To be sure, the book is not without flaws. At times Angelo seems to want to teach a lay audience the intricacies of medicine, when a simpler explanation will do. The citations,  including journal names within the text, will likely be distracting for a lay audience. These are the challenges of someone who is used to writing meticulously cited journal articles learning to write a book for public consumption.

Overall however, we should be grateful for Angelo’s hard work in this area. Video, used correctly, does have the power to “revolutionize” end-of-life care, as the subtitle of the book suggests. It needs to be done thoughtfully, and with great care, an appropriately high bar for someone crafting a goals of care video for thousands, perhaps tens of thousands, perhaps millions of people.

Angelo Volandes

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Tuesday, February 24, 2015

#Thickenedliquidchallenge from a patient's point of view: provocative comments and a poll

by: Stan Terman

Michael Ellenbogen has dementia.  He took the #thickenedliquidchallenge.  He never wants to have thickenedliquids again, even if his life depends on it.  Is this ethical?

Click this link if the video doesn't appear below.

Michael Ellenbogen's video addresses the #Thickenedliquidchallenge from a patient’s point of view. 

Mr. Ellenbogen tries orange soda, one of his favorite drinks, with thickener.  He reports, "The taste was terrible.  The drink lost all of it's flavor, all of the enjoyment of my favorite drink was gone."  He goes on to say, "Many people do not understand that there's a lot more to eating than just getting the nutrition into our bodies.  The texture contributes a lot to how much you enjoy it." 

Mr. Ellenbogen states that if he had advanced dementia he would never want to be fed thickened liquids, "even if my physicians thinks that my life my continued living depends on it."

More generally, his experience and request bring up the issue on what people can or cannot request in Living Wills, and whether health care providers will honor their wishes. Patients who reach the stage of advanced dementia may have few choices other than to forgo food and fluid because they may have "No Plug To Pull"; that is, they may not depend on any high-tech, life-sustaining treatment.

In a recent blog, Tia Powell, M.D., asked this question: "Can advance care directives ethically specify that oral feeding be withheld?" (Her essay’s lead title is: "Bioethics is not about technology" and can be found at this link, along with some discussion.

Dr. Powell stated, "A patient cannot decline a basic healthcare measure that is not a medical treatment. People cannot request that they not be bathed, or kept warm, or covered... Oral food and drink belong in this same category of basic human care, rather than in the category of medical intervention. An advance directive cannot appropriately ask that basic nourishment be withheld from a person in end-stage dementia..." Powell then asks: "Can an Advance Directive Be Cruel?" Her answer (in part) is: "An advance directive can clarify values and preferences for future treatments, but cannot ask a person, an actual person, to do something he or she should not be asked to do."

Michael Ellenbogen and I disagree. Michael is living with dementia. I helped him complete his Advance Care Planning (including his Natural Dying—Living Will) in 2012. Michael passionately hopes health care providers will honor his wishes to implement Natural Dying if someday he reaches the stage of Advanced Dementia and no longer can feed himself.

Now Michael also wants to move up the time when "Natural Dying" may be implemented by also refusing thickened food and liquids--if his risk of aspiration pneumonia is high. Definition: "Natural Dying" withdraws the act of assistance by another person, hand-feeding/drinking, but Natural Dying never withholds food and fluid from the patient since food and fluid are always placed in front of the patient, within reach. (Note that Dr. Powell used the word, "withheld" in the title and text of her essay.)

Please take the following poll.  Feel free to elaborate on your answers in the comments.

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Another Pneumonia Vaccine for Seniors: What's the evidence on Prevnar13?

In September 2014, the Centers for Disease Control and Prevention (CDC) issued a new guideline1 recommending the administration of Prevnar13, a type of pneumonia vaccines, to adults 65 years and older.  This is to be given in addition to Pneumovax23, the pneumonia vaccine that adults 65 years and older already receive based on prior guidelines.

Mr. R, my 67-year-old patient who already received Pneumovax23, was not enthusiastic about the idea. “But I already got one! Why do I need another? What is the difference from the one I already got?”

All good questions. Let’s look closely at the guidelines to see if we can answer these questions.

What is the difference between Pneumovax23 and Prevnar13?
Pneumovax23 stands for pneumococcal polysaccharide vaccine (23-valent). First used in 1945, it was an important landmark in medical history. Pneumovax23 was the first pneumonia vaccine, and the first to be made from capsular polysaccharide, which can help induce immunity in host body.  It is called 23-valent because it aims to protect against 23 types of pneumococcal capsules, which translates to 50-80% efficacy2.

Prevnar13 stands for pneumococcal conjugate vaccine (13-valent). It is made from bacterial cell membrane sugars conjugated with a diphtheria toxin protein called CRM197 to induce a stronger immune response. It is traditionally given to children and adults over 19 years old with certain medical conditions (lack of spleen, compromised immune system, etc.)  It is called 13-valent because it aims to protect against 13 types of pneumococcal capsules, 12 of which were exactly the same as the ones covered by Pneumovax23. The only serotype covered by Prevnar13, but not by Pneumovax23, is serotype 6A.

Why would we want to add Prevnar13 to Pneumovax23, which adults 65 and older were already getting?
It turns out that a percentage of severe illness in older adults is caused by the types of pneumococcal bacteria that Prevnar13 can protect against. For example, 20-25% of a disease entity called invasive pneumococcal disease (such as meningitis, bacteremia) is caused by bacterial serotypes that Prevnar13 covers1. It should be noted that even though Pneumovax23 covers these similar serotypes, it is stipulated that Prevnar13 will be more effective, because its conjugated protein should induce a stronger immune response than Pneumovax23.

Since many adults 65 years and older may have already received Pneumovax23 based on prior guidelines, it cannot be undone or replaced by Prevnar13. The only policy option for these adults would be to add Prevnar13 to the pre-existing vaccine schedule. And we might as well – Prevnar13 should be compared to the status quo, a kind of non-inferiority trial. If it is not better than what we were doing, then why do it?

What kind of evidence was used to back up the new guidelines?
The guidelines stemmed mostly from a large trial conducted by Pfizer, the manufacturer of Prevnar 13. Called the CAPiTA trial3, this study was the first to measure important patient-centered outcomes related to pneumonia vaccines, such as the incidence of pneumonia or invasive pneumococcal diseases among older adults. All prior studies only measured titers, the amount of immune response generated by vaccines, but it is unclear what measured titers mean in real life, how it translates to the number of pneumonia cases prevented, the number of pneumonia-related deaths averted, etc.

The CAPiTA trial looked at 84,496 adults 65 and older who had not received any pneumonia vaccines of any kind (neither Pneumovax23 or Prevnar13). It then randomized these patients to either getting Prevnar13 or placebo. The study reported the overall efficacy of Prevnar13 against the bacterial serotypes it was designed to cover (if patients were infected with bacterial serotypes not covered by Prevnar13, these cases of failure were not counted towards the efficacy calculation). According to the CAPiTA trial, the overall efficacy of Prevnar13 was 45.6% against overall pneumonia, 45.0% against non-bacteremic pneumonia and 75.0% against invasive pneumococcal disease.

On the surface, these results appear significant. But, comparing Prevnar13 against getting no vaccine is not a fair fight. A better comparison would evaluate 2 groups of patients: those who only received Pneumovax23 (status quo) vs those who received both Pneumovax23 and Prevnar13. The CDC included a cost-effectiveness analysis4 of adding Prevnar13 compared to status quo, but no actual research study was conducted to see how the analysis holds up in the real world. In addition, the results of the CAPiTA trial were only reported as part of a research abstract – these results have not been published in any peer-review medical journals, and the validity of the trial cannot be evaluated.

Illustration showing sequential administration and recommended intervals for pneumonia vaccines in adults aged 65 and older (Source: CDC)
What is the best sequence of administration of the two vaccines?
Another study included in the guideline attempted to determine the sequence of pneumonia vaccine administration: should we give Prevnar13 or Pneumovax23 first? The study5 randomized 720 adults between the age of 60 to 64 years old (excluding the population for which the recommendations are made) into 2 groups: the group receiving Prevnar13 followed by Pneumovax23 vs the group receiving Pneumovax23 followed by Prevnar13 (the reverse). The study found that giving Prevnar13 first followed by Pneumovax23 is the best way to go – it produces a higher titer than the other way around. However, the study found that adding Prevnar13 after Pneumovax23 produced lower titers than giving Pneumovax23 alone (status quo). The mechanism is unclear, but it seems that giving Pneumovax23 followed by Prevnar13 resulted in a dampened immune response. Based on this finding, it is unclear why the CDC would recommend adding Prevnar13 in adults 65 and older who have already received Pneumovax23 based on prior guidelines, which is likely the majority of adults 65 and older currently living in the US.

What is the punch line?
At a closer look, the guidelines appear to be based on a trial of Prevnar13 conducted by its manufacturer with possible conflict of interest, based on unpublished data, studies measuring immune titers with unclear benefits to patients, a mathematical calculation that was not tested in the real world, a study to determine vaccine sequence that excluded the target population (adults 65 years and older), and the possibility that giving Prevnar13 to patients who already received Pneumovax23 might actually be worse than not giving it. Given the lack of clear evidence, physicians should evaluate the new CDC guidelines with caution.

Back to Mr. R: I couldn’t give him a good reason why he should get Prevnar13, so I let him be. So far, no pneumonia yet.

By Dr. June Howell, a geriatric fellow at Icahn School of Medicine at Mount Sinai who blogs at Medium and tweets @junehowellmd.

This post is part of the #GeriCases series, in which we discuss a clinical case in geriatrics and palliative medicine and the attempt to provide patient-centered care with the use of best available evidence. 
Ravishankar Ramaswamy, MD
Section Editor, #GeriCases

1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2014; 63(37);822-825.
2. Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106.
3. Bonten M, Bolkenbaas M, Huijts S, et al. Community Acquired Pneumonia Immunization Trial in Adults (CAPiTA). Abstract no. 0541. Pneumonia 2014;3:95. Available at
4. Stoecker C. Incremental cost-effectiveness of modifying PPSV and PCV recommendations for adults age 50 and over. Presented at the Advisory Committee on Immunization Practices June 25, 2014 meeting, Atlanta, GA; 2014. Available at 
5. Greenberg RN, Gurtman A, Frenck RW, et al. Sequential administration of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine in pneumococcal vaccine–na├»ve adults 60–64 years of age. Vaccine 2014;32:2364–74.
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Sunday, February 15, 2015

CoPs - obstacle, or inspiration?

by Jerry Soucy, RN, CHPN

The title of Amy Getter’s Geripal piece poses a critical question: As we face forces seemingly beyond our control, how can we stay true to the purpose of hospice, and to our patients and families? 

I share Amy’s concern. This is difficult work under ideal circumstances. We frequently face demands that compete for our time and attention. When the demands are in conflict, sources we expect to support us sometimes don’t seem very supportive.

Amy calls the Medicare Conditions of Participation (CoPs) overwhelming. I’ve worked with colleagues who see them in an even more negative light: as irrelevant, not very helpful, or even an obstacle to effective and compassionate care.

The law can seem byzantine for those of us without legal training, but I think it’s worth the effort to understand, internalize, and act on the values expressed in the CoPs. The logic and structure will become more evident as you read, and every hospice clinician will recognize the language, because it’s the foundation of our practice.

I’ve endured countless mediocre inservice and online programs on the topic. I bet Amy has, too. In my experience, negative comments about CoPs at IDG, in orientation, and elsewhere are frequently accompanied by nonverbal language that screams “Bear with me, even though we’d all rather stick needles in each others’ eyeballs.”

I disagree. I also don’t like needles. We should draw upon the CoPs to inform our actions, and share what they say about the spirit and purpose of hospice with the public.

Instead of fearing or scapegoating CoPs, or shunning them as snooze-inducing, overly-complicated, or of questionable worth in the “real world,” let’s consider them in the same way dedicated baseball fans consider that game’s rules: the final arbiter of the most basic question - “What is this all about?” - and the source of every critical element that makes the game possible.

We practice under authority granted by the CoPs, just as we practice within the scope of our state-issued licenses. They are the law, and a basic fact of our professional lives. They are also a great roadmap, providing both clarity and detail. Entire phrases can be lifted to answer anyone who asks, “You work in hospice - what’s it about?” 

Officially, they’re 42 CFR Part 418 - Hospice Care. Here’s a quick exercise: Grab a copy (pdf), and find § 418.52 Patient’s rights. Start your reading there, or skip ahead to (c) Standard: Rights of the patient. “The patient has a right to the following:  (1) Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness;  (2) Be involved in developing his or her hospice plan of care; (3) Refuse care or treatment; (4) Choose his or her attending physician; 

Rights 5 to 8 address confidentiality, being fully informed about what will and will not be provided under the benefit, and the right to be, “free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property.” 

I don’t think any hospice clinician disagrees. There’s plenty more good stuff where that came from.

Amy's practice is informed by the patients who have shown her, “time and again to STOP, leave my agenda behind, LISTEN to their hopes and desires…” She’s given us a prayer to recite quietly each time we enter a home. 

Her insight joins this reminder: we are engaged in an approach to caring that has been proven to improve the quality of life of patients and their families, allows a patient to remain at home for as long and as comfortably as possible, and with dignity.

I got that from page 32088 of the Federal Register / Vol. 73, No. 109 / Thursday, June 5, 2008 (pdf). I played with the structure of the statement, but didn’t change any words.

You never know where a helpful phrase might pop up.

Photo: image of the Federal Register from the public domain
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Saturday, February 14, 2015

Breathing Heartfelt Care

by: Kim Evanoski, CMC MPA LMSW

Sometimes on the walking trail I get to thinking about my week. The quiet solitude gives me important time for taking those long deep breathes to reflect and come to terms with life's events.

There are particular weeks in working in palliative care that I need time to think through how to facilitate a tough conversation that a care partner, being patient or family member, is ready to talk further on. As a practitioner I think part of my job is to prepare myself for assisting families in what I term as "heartfelt care". Heartfelt care is an activity like sitting around the table while sharing information that garners thoughtful thinking, goal setting and sometimes finite decisions towards understanding how we envision one's living, dying or death. Heartfelt care uses energy, needs focus and thoughtful breathing.

Over the years I have studied my own breathing and have asked my students to pay particular attention to how it affects their interactions with clients. I use breathing for the benefit of my professional self-care and for the benefit of providing heartfelt care to my families. Breathing is a powerful tool to share and to learn to facilitate when strong emotional feelings are present in the room. Do you ever notice your breathing when you are with patients? How do you breathe when giving heartfelt care? Do you notice your breathing after the meeting time?

I think practitioner's breathing and physical pace often affects the effectiveness of patient care. I think this is especially the case in geriatric care when "tender discussions" sometimes must come. My sense is we would fare better with facilitating heartfelt conversations by maneuvering ourselves to a slower pace with steady breathing; this encourages a sense of safety to talk and shows we have the time to seriously discuss important concerns. And this in turn helps us to continue good patient care because we understand the decisions which were made.

I think it is essential when providing caring patient interactions that we clearly focus and notice our breathing. Providing heartfelt care really starts by self-awareness towards a few key questions: 1. Before you walk in to the room do you take a few deep long breathes to feel centered and focused? 2. When you enter the part of the conversation that a hard decision will need to be made can you feel your breathe steady and provide calm assurances that have un-rushed time to listen? 3. Can you patiently wait for the decision to be announced by sitting and breathing slowly?

When I observe myself providing stillness, patience and steady breathing, care partners seem to know it's safe to explore and problem solve. Sometimes the patient's gratitude and resolution about their life emerges.

My sense from families is that giving time for breathing heartfelt care is as much of, if not more, their want in a palliative care partnership. Elders who have lived life for a long time seem to ask me for resolving conversations rather than technological miracles.

So today, I invite you to take a deep breathe for your own self-care and reflection.

What do you sense and listen to when you are providing heartfelt care?

A Heartfelt Valentine's Day to all in our GeriPal community! (That's you!)

Photo credit: Felicity White
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Thursday, February 12, 2015

Electrical Stimulation Therapy for Pressure Ulcers: Does it Work?

Mr J is a 67 year-old man with a history of multiple sclerosis complicated by paraplegia, bilateral upper and lower extremity contractures, and multiple pressure ulcers.  He had required multiple hospitalizations for his wounds, and I met him after an extended hospitalization necessitating debridement when he was transferred to a skilled nursing facility for ongoing wound care.  Given the extent of his wounds, he was started on electrical stimulation therapy.  I had never heard of this type of treatment, so I wondered, in patients with pressure ulcers, is electrical stimulation therapy more effective than standard wound care?

Electrical stimulation therapy is the application of a current across a wound.  The theoretical mechanism of this therapy is to replicate the “current of injury” that occurs normally when there is a break in the skin.  This current of injury has been shown in various models to promote angiogenesis, fibroblast migration promoting granulation, and keratinocyte migration promoting epithelialization.

I searched the terms “electrical stimulation treatment pressure ulcers” on PubMed Clinical Queries looking for a meta-analysis.  I found an article that pooled data from 15 different studies, including both randomized control trials and observational studies, for a sample of 909 electrical stimulation patients and 371 controls.  The main outcome was mean percent wound healing, which was coded or calculated independently by 2 authors. 

The results showed that patients who received electrical stimulation to their pressure ulcers had a mean percent wound healing of 13.5 more than the controls, which translates to 144% increase in wound healing.  This effect was the same when analyzing just the randomized control trials, suggesting that the effect is not driven by a placebo effect.

In summary, it seems that electrical stimulation can improve wound healing compared to standard wound care.  Although statistically significant, it is hard to know if this outcome is clinically significant, as the potentially more important outcome is complete closure of the wound.  Further, the analysis included studies that employed different electrical stimulation modalities, which raises the question about what is the best way to deliver electrical stimulation therapy.  For example, what is the optimal positioning of the electrodes relative to the wound?  What is the optimal current (direct or alternating) setting?  How long should the electrical current be applied and at what frequency?

Back to the Patient: Mr J received several treatments with electrical stimulation with some improvement in his wounds.  However, one wound did not heal and was found to be infected necessitating further surgical debridement so he was readmitted to the hospital. 

Take Home Points:
Electrical stimulation can improve wound healing for patients with pressure ulcers.
There are still more questions to be answered about the best way to deliver electrical stimulation therapy to be most effective.

 Reference: Gardner, S. E., Frantz, R. A., & Schmidt, F. L. Effect of electrical stimulation on chronic wound healing: A meta-analysis. Wound Repair Regen. 1999 Nov-Dec;7(6):495-503.
Picture Courtersy: las - initially

by: Natalie Young, MD, MS, Geriatrics and Palliative Medicine fellow at Icahn School of Medicine at Mount Sinai, New York.

This post is part of the #GeriCases series, in which we discuss a clinical case in geriatrics and palliative medicine and the attempt to provide patient-centered care with the use of best available evidence. 
Ravishankar Ramaswamy, MD
Section Editor, #GeriCases
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Tuesday, February 10, 2015

Timing is everything

by: Jason Johanning, vascular surgeon, University of Nebraska

We as surgeons know that the timing of an intervention is an incredibly important decision. Intervene too early and you expose the patient to potential unneeded risk. Intervene too late and the disease process has already taken its toll.

From a surgical perspective, palliative care consultation on the surgical patient can be looked at in a very similar perspective. Not all patients need a palliative care consult prior to surgery. But for a select few, the consultation provides many salient and real benefits. And this I believe can be a good thing for all parties involved.

Contrast this thought with the postoperative palliative care consult process. In my travels I have heard stories of nurses ordering palliative care consultations without surgeon knowledge or consent. I have heard of patients being taken off ventilators on postoperative day 2 without surgeon knowledge by palliative care and ICU teams. To say that postoperative care in the best of circumstances is challenging for the frail patient in the ICU is correct. But throw into the mix multiple provider and nursing factions not on the same page; and now bring in Palliative care to “sort things out”, and you get the picture of why surgeons may have issue with postoperative palliative care consultations. Especially when the patient is having complications that we knew were going to occur and we discussed with the patient and family (or at least we thought we talked about it and we thought the patient heard us).

But the real benefit of preoperative consultation for the surgeon and the palliative care team are the bonds built prior to an operation and the resulting concepts that are addressed. These concepts are often espoused in the literature but are elusive in addressing in the real world. With a preoperative palliative care consultation on the frail elderly patient, the team (surgeon, palliative care team, anesthesia, ICU) goes into the procedure with eyes wide open, ready to address the expected course of operative and postoperative care with recognition of markedly elevated perioperative risk. Prior to the operation, we have addressed shared decision making with the patient and family as we notify them of their individualized increased risk and realistic benefits. With palliative care consultation preoperatively, we now have surgical buy in as a total team agreeing to push through major but survivable complications (pneumonia, myocardial infarction, pulmonary embolism). We have also primed the anesthesia and ICU services to rescue the patient in these high risk circumstances. Just as important, in the setting of these complex decisions, the ability of the palliative care service to clarify goals of care, power of attorney, DNR/DNI status, and be on the same page as the surgical team throughout the operative process can result in a significant reduction of emotional angst for all parties involved postoperatively.

At the end of the day, we will still need palliative care consultations both pre- and postoperatively on our surgical patients. Be we all need to be aware, timing is everything.

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Monday, February 9, 2015

The True Art of Medicine: Atul Gawande and The Being Mortal Documentary

by: Stephanie E. Rogers, MD @SERogersMD

“The two big unfixables are aging and can't fix those,” notes physician-writer Dr. Atul Gawande, in a new documentary based on his recent book Being Mortal. The Frontline documentary airs Tuesday, February 10 on PBS, and explores Gawande's frustration of not being able to “fix” all of his patients.

The Being Mortal documentary examines how Gawande and other physicians struggle to talk with patients and families about death and dying. He explores his own humble journey with the realization that "medicine fails the people it's supposed to help" at the end of life. It also provides a powerful, intimate look at families struggling with conversations about the realities of aging and death, and the uncomfortable and difficult time even well-trained physicians have at leading these discussions.

One of the most startling aspects of the documentary is watching physicians participate in these conversations with patients and the behind the scenes look at what their thoughts are regarding these discussions. Even with cancer physicians who have these conversations all the time, it is apparent that they too are struggling to be forthright and eloquent. In fact, this is what makes Gawande a skillful storyteller- he exposes his own vulnerabilities both as a physician trying not to be the bearer of bad news and as a patient’s family member during his father’s inevitable death from a spinal cord tumor.

"Hope is not a plan,” Dr. Gawande argues. “We find from our trials that we are literally inflicting therapies on people that shorten their lives and increase their suffering, due to an inability to come to good decisions.” He notes that people may have other priorities besides living longer and that we should not be waiting until the last week of life to have these discussions with our patients.

As a Geriatrics fellow, I have learned that speaking to patients frankly about aging, dying, and their priorities for the time they have left has been the toughest challenge I’ve encountered yet in my decade of medical training. We physicians tend to be overly optimistic and timid about the truth, partly because it is difficult to tell a patient something they don't want to hear. We want to instill confidence in our patients and hope with them for a cure or more time.

I now realize that the most worthy challenge– one likely to last my entire career - is to improve my ability to have these conversations. Our decisive goal as physicians is not only to know the most up-to-date scientific studies or treatments, but to be comfortable and capable of communicating truthfully and empathetically to our patients about the realities of life- that we will all age and we will all die. The true challenge is combining all our medical knowledge and skills with the art of communication, to allow our patients to choose how they want to live—all the way to the end. Being Mortal, the Frontline documentary from writer/producer/director Tom Jennings, airs Tuesday, February 10 on PBS and will stream in full online at

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Thursday, February 5, 2015

Top 25 Studies in Hospice and Palliative Care (#HPMtop25)

A recent article in the Journal of the American Geriatrics Society published a list of 27 “landmark” peer-reviewed foundational articles that have helped to shape the contemporary practice of geriatric medicine. The authors of this article did a quite extensive process to identify these articles that included:
  • First finding candidate articles through a literature review and expert opinion survey of geriatric medicine faculty.
  • Winnowing this list down to 30 and then performing a bibliometric analysis that combined journal impact factor and average monthly citation index. 
  • Lastly, bring a panel together to review articles to assess each manuscript’s clinical relevance.

For each of the final 27 articles, a score was determined by averaging, with equal weight, the opinion survey, bibliometric analysis, and consensus panel review.  We’ve included in the note section below a list and ranking of the Geriatrics Landmark articles, and have included links to their PubMed pages.  While we can probably think of other articles not on this list, the published list does serve as a wonderful resource for anyone in the field of geriatrics.

Top 25 Studies in Hospice and Palliative Care

Thinking about these top 27 articles in geriatrics got us interested in putting together a list of the top 25 articles in palliative care. The timing is good as on February 19th we will be giving a talk to our palliative care fellows on this very subject. We have decided to focus on palliative care studies and trials - as opposed to review articles, consensus statements and opinion pieces - in order to narrow our focus and cater to our academically-oriented fellows.

We're guessing there may be some overlap with the published geriatrics list.  We are also guessing it may include many of the articles that Diane Meier wrote about in her book Palliative Care: Transforming the Care of Serious Illness. However, we are interested to see what articles you all think have shaped the contemporary practice of the hospice and palliative care field.

So here is a plea for your help: What articles have you found most impactful in the fields of hospice and palliative care? What studies do you most commonly think about, mention, and cite during your clinical work?
  • Tweet your landmark articles using the #HPMtop25 hashtag on twitter
  • Write a list of your landmark articles below in the comments 
  • Share your thoughts on our Facebook page
Thank you for your help!

By: Kara Bishoff (@Kara_Bishoff) and Eric Widera (@ewidera)

Note: Here is the list of the articles that were identified as landmark in geriatrics:
  1. Treatment of hypertension in patients 80 years of age or older. Beckett NS et al. NEJM, May 2008 
  2. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease Schneider LS et al. NEJM, Oct 2006. 
  3. The clinical course of advanced dementia Mitchell SL et al. NEJM, Oct 2009 
  4. Rehospitalizations among patients in the Medicare fee-for-service program Jencks SF et al. NEJM, Apr 2009 
  5. A multicomponent intervention to prevent delirium in hospitalized older patients Inouye SK et al. NEJM, Mar 1999
  6. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases—implications for pay for performance Boyd CM et al. JAMA, Aug 2005
  7. A multifactorial intervention to reduce the risk of falling among elderly people living in the community Tinetti ME et al. NEJM, Sept 1994
  8. A randomized trial of care in a hospital medical unit especially designed to improve functional outcomes of acutely ill older patients Landefeld CS et al. NEJM, May 1995 
  9. Emergency hospitalization for adverse drug events in older Americans Budnitz DS et al. NEJM, Nov 2011 
  10. Updating the Beers criteria for potentially inappropriate medication use in older adults—results of a U.S. consensus panel of expertsa Fick DM et al. Arch Int Med, Dec 2003 
  11. Gait speed and survival in older adults Studenski S et al. JAMA, Jan 2011
  12. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure Rich MW et al. NEJM, Nov 1995
  13. Exercise training and nutritional supplementation for physical frailty in very elderly people Fiatarone MA et al. NEJM, Jun 1994
  14. A controlled trial of inpatient and outpatient geriatric evaluation and management Cohen HJ et al. NEJM, Mar 2002
  15. Hazards of hospitalization of the elderly Creditor MC. Ann Int Med. Feb 1993
  16. Trajectories of disability in the last year of life Gill TM et al. NEJM, Apr 2010
  17. The care transitions intervention—results of a randomized controlled trial Coleman EA et al. Arch Int Med, Sept 2006 
  18. Tube feeding in patients with advanced dementia: a review of the evidence Finucane TE et al. JAMA, Oct 1999 
  19. Appropriate use of artificial nutrition and hydration: fundamental principles and recommendations Casarett D et al. NEJM, Dec 2005 
  20. Cancer screening in elderly patients—a framework for individualized decision making. Walter LC & Covinsky KE. JAMA, Jun 2001 
  21. Aging, natural death, and the compression of morbidity Fries JF. NEJM 1980 
  22. Frailty in older adults: evidence for a phenotype Fried LP et al. J Gerontol, Mar 2001
  23. Change in disability after hospitalization or restricted activity in older persons Gill TM et al. JAMA, Nov 2010 
  24. Geriatric care management for low-income seniors—a randomized controlled trial. Counsell SR et al. JAMA, Dec 2007 
  25. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women—a randomized controlled trial. Burgio KL et al. JAMA, Nov 2002 
  26. Long-term effects of cognitive training on everyday functional outcomes in older adults Willis SL et al. JAMA, Dec 2006 
  27. Shared risk factors for falls, incontinence, and functional dependence: unifying the approach to geriatrics syndromes Tinetti ME et al. JAMA, May 1995
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