Tuesday, December 16, 2014

Bumper Sticker Gaming for Geri-Pal Thinkers



Since there seems to be some serious competitions and analysis happening on this blog, I thought I'd put in my two cents so as to gain some broader and serious Geri-Pal thinking about how bumper stickers apply to client care.

Really? Yeah, really.

So, I will not lie to you. I read and analyze bumper stickers as a clinical hobby, of sorts.

 I live in a place that values and cherishes their viewpoints through a bumper sticker phenomenon. Some vehicles are plastered with them. I kind of like that people are into it! I travel a lot so this bumper sticker viewing amuses and inspires me on what could be a solemn day.

Bumper stickers remind me to think carefully. I believe it's truly valuable to watch, listen and think carefully about big and small matters alike. It promotes that life-long-learner concept as well as helps me remember to have a good sense of humor. Bumper stickers are put on cars and other items to share and discuss so it makes sense this gaming experience has to be interactive. I will tell you what I’m thinking and I hope to read what you are thinking …after all, folks in palliative care have very interesting viewpoints.

How to play: 

One Golden Rule: no outright profanity please or beating up someone in the comment section about his or her response. This is game …play nice.

I start with a bumper sticker that I have seen. I think. I analyze. I place down the thought. Now you think. You tell yourself this is insane.......or a bunch of BS. You add your own personal interpretation in the comment section of your head or in the comment section of this blog.

Go ahead, please jam up the comment section with your bumper sticker analysis and wisdom. Go wild! If you want, add your own new "bumper sticker saying" you saw to the mix.

Why take time out of our busy days to play this game? For the pure fun of it! So we can balance life...because lots of times, we hear and talk about some really serious stuff, don't we? And like knowledgeable elders, we need to learn the importance of “just being” and sharing a little bs [baloney sandwich, of course]. ….so let’s start this game rolling!


1. Bumper sticker: Don't worry, be happy. 

My Analysis: Did I take the time to ask what a client is worried about so they can feel relieved, resolved or possibly happier? Wow! The unexpected answers one receives when you do ask this question! Sometimes I find out how there are many worries. I also find out I can help reduce some of these worries by asking the care team’s advice, providing simple tweaks to our care, or adding a meaningful addition to the care team for problem resolution. I need to remind myself to ask, not assume, I know the answer to that client’s question.

Your Turn: What do you think?


2. Bumper sticker: What if we are all wrong? 

My Analysis: Geez! Ouch. Can I painfully and objectively acknowledge that information collected can be limited and lacking at times? Can I support the client and care partners to collectively direct best care once we are all at the decision-making table? Can I be open to re-thinking solutions?

Your Analysis, please. 


3. Bumper sticker: So, how are the children? 

My Analysis: Really, how is the whole “family" doing? Have I asked the care partner(s) what else is on their plate(s) that competes with care? What causes them the most stress and how could I help support them to reduce that stress? What kind of family life are they managing? How broad is the “care support” for them?

 Your turn. 


4. Bumper sticker: What if doing the Hokey Pokey is really what it's all about? 

My Tip: Get up and dance! It's just another way to figuring it all out.

My Analysis: If this really is what it's all about, do I provide more listening, honoring and advocating for the goals shared by the client and care team?

What about you? 


5. Bumper sticker: Duh! 

My Analysis: Years have gone by and I still have no idea what this truly means.... I don't think I believe in it. (Could you possibly help me on this one? Should we call a friend?)


Two extra points!  Add your bumper sticker addition and analysis in the comment section. 

Game over.

By: Kim Evanoski (@CareManage4All)



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Monday, December 15, 2014

Gifts for Seniors: Holidays 2014

As stores and the internet light up with gift ideas in time for Christmas, you may have a senior or two on your list. Last year we put together a long list of potential gifts for older adults, which can he found here.


Please enjoy this updated list that I hope can help you give thoughtfully and generously.

For the senior who enjoys walking:

Fitbits, Jawbone and other devices to help seniors live a quantified life, share it, and remain motivated. Says a GeriPal: “Family members can set things up on the computer so friends and family can stay connected and challenge each other to walk do many steps.” (Rebecca Sudore)

For the senior who loves to read, but maybe can’t as much these days because of low vision or other impairments:

For the senior who loves photos:

Says a Geripal: “These days it's super easy to upload pictures on a sight like Shutterfly (which often has coupons for 20% off), and you can create a hard or soft cover book of photos, and even mail it directly to people if they live far away. You can add captions and fancy designs, or there are templates which will "autofill" the pictures for you.” (Meera Sheffrin)

For the senior who loves selfies:

This stick is really for anyone at any age, but it and similar competitors turn selfies into much better photos. I’m thinking of those seniors who are posting to Facebook, or travelling to the Great Wall of China or Greece next year and need great photos with this selfie stick!

For the senior who would appreciate more visitors or activity:

There is no time like the holidays to arrange more social interaction for the post-holiday season. Connecting people to people and getting them to be more active is practically a magic pill for health and wellbeing, so it’s a great gift for the holidays.

Way to connect people socially (you’ll have to check on specifics in your area):

Ways to get them to be more active:

For safety at home:

This call button device is actually a push-button activated device without the enrollment fee to a service, and per a GeriPal “a great option for non-English speakers since you can program it to call anyone - even a relative first”. (Dandan Liu)

For those seniors who don’t like to shop or don’t like to cook:

All over amazing meal delivery services are popping up. Find one that delivers to his or her home and get a fantastic gift certificate. These are SF based:

For those who like to cook but hate to shop, there are those services that send you all the right ingredients and instructions and you just do the prep and eating. These deliver anywhere in the US.

For seniors with good style, less than perfect veins:

Compression hosiery, which helps with leg swelling, made an appearance on the Paris runways this year. It is a good gift for people who get uncomfortable swelling and fits in with the stocking theme of the holidays.

For those seniors who you don’t know, but could really use your help:

Sadly, an organization in LA, ProjectCARES, lost their donated gifts for seniors to a fire. Their work reminds me that in all our communities there are organizations who work with seniors in need and could use your donation. Look for a local organization that takes gift donations.

For the senior who has everything:

Give a donation in their behalf! Find a great organization that supports seniors in your area or abroad. A few suggestions:

Hope these are helpful-- please give us feedback!

by: Anna Chodos (@annachodos)
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Thursday, December 4, 2014

Make Advance Care Planning Routine



The following is part of a three-post progressive blog about the Center for Medicare Medicaid Services (CMS) choosing not to pay for the new advance care planning codes in this year's Medicare Physician Fee Schedule.  However, now is the time tell CMS why you support reimbursement for advance care planning services in their call for comments.  Please see also Phil Rodgers post on CMS considering reimbursement for Advance Care planning at Pallimed, and Gregg VandeKieft’s update on the state of ACP advocacy at the AAHPM blog.

What will it take for advance care planning to become routine for patients with serious illness?

It is time for US policy makers to put away the negative connotations of the "Death Panel" days and have a mature discussion about serious illness.  No matter what your political persuasion, it is time for us to act to improve the quality of care given to all patients by promoting health advance care planning.  With excellent communication and advance care planning, we can empower patients and families to ask for and receive the care that best fits their values and clinical situations.

From an optimistic viewpoint on advance care planning:

  1. There is now clear guidance to policy makers
    • The Institute of Medicine (IOM) report, Dying In America, sends a clear message to policy makers by highlighting clinician-patient communication and advance care planning as one of the key areas of focus and recommendations.  The IOM report recommends that standards for clinician-patient communication and advance care planning be developed that are measurable, actionable, and evidence-based.  The report states that "payers and health care delivery organizations should adopt these standard and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality"
  2. There is an evidence base for communication and advance care planning
    • The journal JAMA Internal Medicine recently published an excellent article from the American College of Physicians High Value Care Task Force, Communication about Serious Illness Care Goals: A Review and Synthesis of Best Practices. Drs. Bernacki and Block report that communication about serious illness care preferences improved clinical outcomes without increasing anxiety, depression, or loss of hope, but did reduce surrogate distress. The practical guidance for clinicians section is a MUST READ.
  3. There are resources for patients and families
  4. There are resoucrces Health Care providers can use to learn to do this well
    • VitalTalk is a great place where clinicians can develop the skills of challenging conversations.  Check out the VitalTalk clinicians section where you can view quick guides on key skills and then try the Watch, Read, Reflect sub-section to improve your skills.

It is time for advance care planning to be a standard of care.  Completion rates nation-wide should be as good as LaCrosse, Wisconsin. Excellent, on-going advance care planning that is adapted to the patient's values and needs over time should be an expectation of quality doctor-patient communication.

But, we have work to do.  At a recent large national meeting of primary care physicians, an audience poll found that most physicians acknowledged the importance of advance directive.  However, most report they do not routinely address advance care planning.  A key factor was time.

Unspoken in that audience poll is the statement that time is money.  For practitioners in most health systems in the US who are still in a fee-for-service model, the economic pressures are intensifying and advance care planning is not adequately reimbursed. But we can change that!

The 2015 Medicare Physician Fee Schedule (MPFS) for the first time includes Advance Care Planning (ACP) services and there are now two CPT codes for these ACP services: 99497 and 99498. CMS has acknowledged both codes, but did not authorize Medicare to pay for them in 2015 (see Phil Rogers' Pallimed Post for more details on what the MPFS is and what these CPT codes are).

While it is unfortunate that CMS did not agree to start reimbursing the ACP codes for 2015, they did provide a call for comments until December 30. So, stop reading this post and go to the CMS website (here) to tell them why you support reimbursement for ACP services.

 by: Paul Tatum (@doctatum) with Eric Widera (@ewidera)


Note: For more information, please see also Phil Rodgers' post on CMS considering reimbursement for Advance Care planning at Pallimed, and Gregg VandeKieft’s update on the state of ACP advocacy at the AAHPM blog. The following is from Phil’s post on things to consider when writing your comments which can be submitted online here:  
  1. Tell why you think it’s important to pay for ACP services through a specific mechanism. CMS has suggested that it believes Medicare already pays for ACP services through the Evaluation and Management (E/M) and extended service codes. Tell them about the unique value of advance care planning, and how it is ‘separately and identifiably’ necessary in addition to all other services (medical therapy, symptom management, etc.)
  2. Be specific, be yourself, and write about what you know. It’s OK to reference the literature about ACP services and palliative care, the IOM report, the importance of tracking the frequency ACP is performed, the needs of an older and sicker society etc., but it’s more powerful to speak from personal experience. Tell patient stories that illuminate a connection between high quality advance care planning and better care for your patients. Every HPM professional I know has dozens if not hundreds such stories. Now is the time to tell them. 
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Sunday, November 30, 2014

Wanting to survive more than just 30 days


by: Gretchen Schwarze, @GretchenSchwa10

My husband, also a surgeon, was recently discussing donor-nephrectomy with a healthy 65 year-old woman in his transplant clinic.  He told her the 30-day survival for this operation was excellent.  She was shocked he would quote such metrics, “I don’t want to live for just 30 days!”  Yet for years, we in surgery have judged our successes by the number of patients who don’t die within 30 days of surgery.

I know it is easy to find examples of surgeons behaving badly over a postoperative patient whose death seems to threaten his “numbers,” but as a surgeon who has been there I can tell you that it is viscerally painful to watch a patient you operated on succumb to postoperative complications.  Deep notions of error and responsibility are ingrained in our culture and are reinforced in many ways including M&M conferences and NSQIP (National Safety Quality Improvement Program) reports. While I’m all for improving safety and quality, I shudder to think about the consequences of 30-day mortality reporting for our older patients when increasingly our successes and failures are measured (and reported) by who is alive and who is dead.

Here’s an example of why I am worried.  One newer measure of safety in surgery is “failure to rescue.” (FTR)  Studies show complication rates for major operations are actually pretty constant across hospitals with varying levels of quality however; mortality differences between low and high performers come from the ability to “rescue” patients with postoperative complications, i.e. mortality differences derive from whether the patient is able to survive the complication.  

This measure morphed precariously in a (very well done) study that matched the health status of surgical patients with DNR orders to those without and demonstrated a substantially higher postoperative mortality for patients with DNR orders. The authors called this “failure to pursue rescue.” Sheesh, if you want to get a surgeon to do something, tell him that not doing it would constitute failure – this is the language we speak! If anything, the mortality difference demonstrates a success in honoring patient preferences but the characterization of death as the worst possible outcome doesn’t recognize this important difference.

We are told that these measures are risk-adjusted but risk adjustment doesn’t adequately manage the needs of patients who would benefit from palliative operations or patients who are high-risk and would authentically prefer to take their chances in the operating room.  Risk adjustment is probably not the answer, stratification accounting for palliative operations and robust measures of patient engagement would be more aligned with the goals of patients and their families who likely don’t value “just living to 30 days.”

The National Quality Forum (NQF) is proposing 30-day risk adjusted mortality following CABG (heart bypass surgery) as a quality metric. This measure is up for appeal until December 12.   While the Society of Thoracic Surgeons has used this metric for years for their internal database, formalization of this metric for public reporting threatens to exacerbate its unintended consequences.  

I recently ran a “town hall meeting” at the American College of Surgeons annual Clinical Congress about this issue which involved some pretty treacherous terrain: surgeons were clear that mortality measures are increasingly influencing both their pre and postoperative surgical decisions.  


The 30-day metric is a game-able metric that harms patients and families and the surgeon patient relationship.  It also fails to capture important safety information such as the patient who has a straight-forward postoperative course is scored equivalently to one who has a prolonged ICU stay and is transferred to palliative care on postoperative day 31.  I hope the National Quality Forum will reconsider their decision and focus on measures that are more aligned with patient-reported goals.
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Friday, November 28, 2014

Finding dental care for people confined to home


Have you ever had a patient at home who was in need of dental care? Perhaps they were receiving hospice services or maybe they were just discharged from the hospital not on hospice, but still too frail to get to the dentist. Of course the focus is often on the medical issues, yet the most significant issue was broken rotted teeth, which made oral intake nearly impossible without pain. Clearly, the answer here is not opioids for pain control, but rather to take care of the root problem: access to dental care.

Clearly dentists and their staff are not part of a hospice or palliative care IDT, but when you need them, boy do you need them. If the short case I outlined is not clear enough for you, I would really encourage you to read “Love” by Jean-Noel Vergnes, DDS, PhD recently published in the Annals of Internal Medicine (paywall). Written by a dentist in France caring for his wife who had a stroke and was desperately in need of dental care he himself could not provide, it illustrates the anguish of not being able to provide care you know someone needs.
“And little by little, it got difficult to clean her teeth with a toothbrush, too; she made little animal noises all the time, as if we were hurting her. So, it’s true that I didn’t take that much care of her mouth.”
Yet in the end there is a deep satisfaction when a dentist is found who will come to the home and provide the much needed care for his wife.
“Knowing that such a possibility existed made me change my mind. Actually, I’d always had this little voice in my head telling me that I wasn’t doing what was best for her, that I might be convincing myself that it was useless just because I didn’t have the strength to get on with it.”
Reading this story makes me reflect on the access to home visit dentists in my metro service area. When we need a dentist, the team works frantically to find someone willing to come out. So what are the barriers for a dentist? Is it malpractice insurance out of the office? Lack of access to the ever more complicated tools while in someone’s home? Lack of adequate reimbursement? Lack of time? I know many dentists do charitable activities in urban and foreign locations (usually for children), so I know the barrier is not likely to be a cold, uncaring heart. How can we as palliative care providers strengthen this relationship with dentists so the care is not needlessly delayed? The answers are likely complex and different in every community, and I know the answer is not the DentiDrill Home Dentistry Kit. Yet, I’m hopeful by asking this question of our great communities we might find a better answer together. Then maybe more people can have memories like this:
“She gave me a wonderful, broad smile. She was beautiful, so very beautiful. Ah, how can I put it? I knew that smile would be her last. I smiled back at her, savoring the moment . . . a moment that I couldn’t even try to describe. And that smile was, indeed, her last. I’ll remember it every day that I have left to live.”
by: Christian Sinclair, MD, FAAHPM  - When he is not writing payback posts for GeriPal, you can find him over on Pallimed. (Post 1 of 4 in the World Series of Blogs payback)
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Saturday, November 22, 2014

6 tech innovations that will make you say "nifty!"

Generally at GeriPal we focus on low tech, high touch interventions.  Like talking to people.

But this week we had an inspiring visit this week from  David Atashroo, MD, from Stanford.  The title of his talk was "Innovation in Aging."  And some of the stuff he shared is really exciting, and worth sharing.  These are innovative technologies that can be used to help aging seniors.  Many of these are in the early stages of development or are at the startup level.

1.  Check out this wheelchair.  Who says wheelchairs have to be, well, ugly?  This thing looks cool!  Made by Whill.



2.  Now check out this car.  You can roll your cool wheelchair right into it.  And it's electric.  Brilliant!  Made by Kenguru.


3. Check out this spoon.  You know how noise canceling headphones block out background noise?  Well, this spoon, made for patients with essential tremor, cancels out the tremor, so the spoon stays steady.  Made by LiftLabs.


4. This is a dog avatar that for people with dementia.  It talks with them and reminds them to do things.  It's also fun.  Mad by GeriJoy (nice name).


5. A lot in the news recently about turning back the clock for older adults, particularly those with dementia.  Literally tricking the mind into thinking it's 1940, not 2014, by surrounding them with pictures, news, art, furniture from that time period.  A small step toward recreating that time-period is simply playing music from when someone was young.  But does your average young nursing home staff person know what music to play from the 1940s?  Probably not.  Music and Memory helps design those set list.


6. Another way to take you back is through the use of virtual reality, and no company is hotter in that space right now than Oculus.  Check out this awesome YouTube video called, "My 90 year old grandmother tries the Oculus Rift."





This post is rather risky - I worry about being bombarded with emails from new companies wanting me to write up their products.  Please send those requests to the GeriTech blog - that's the focus of that blog!  Also, I own no stock in these companies and don't plan to buy any.

During his talk, David Atashroo made an appeal to us (UCSF Division of Geriatrics), to become more involved with the start ups.  He pointed out that they need us to design good products.  We know what the problems are - they often have no idea.

Personally, as an academic, I worry about conflicts of interest.  While working with the start ups is not for me, some of us should be talking to these creative geniuses.  Our future depends on it!

by: Alex Smith, @AlexSmithMD

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Thursday, November 20, 2014

Lessons from the Stage: A Lesson About Patient Communication Learned in an Improv Class



My husband and I took a beginner’s improv class not long ago. Two of the most fundamental rules they taught about performing improv with a partner were: (1) never say “no”—it kills the storyline that you should be working with your partner to build. And (2) never say “yes, but...”…. because you might as well have just said “no.”

It plays out something like this: You and your partner get a prompt, such as pretending to be cops. Your partner has an idea for where the scene could go next. Little does your partner know that you have a brilliant idea for where you want to take the scene next. Your partner boldly proclaims, “Alright, partner, I just heard from the sheriff and there’s a murder to investigate.” Still holding to your own idea, you reply, “Yes, but before we get there, we first need to fulfill our assignment as undercover go-go dancers.” Yes, but… you just killed your partner’s storyline instead of building on it.

It sounds so simple. An easy two words to avoid. But once we were aware of it, we noticed that we were doing it every few lines, our own hidden tug-of-war over the storyline. Now, this is not to say that one can’t influence the storyline in improv. The primary building block of influence, however, is a different two words: “Yes, and…”

My husband and I started noticing “yes, but”s all over our lives. “Yes, but let’s do the dishes first.” “Yes, but I think this movie will be even funnier.” “Yes, but doing it this way might work better.” Countless hidden “no”s disguised under the cloak of “yes, but.”

One setting that is certainly not protected from the “yes, but” is the hospital. I was recently working with a resident, watching her interview a patient. The patient was an older gentleman with advanced hepatic disease. He had received a liver transplant many years ago, but subsequently relapsed on alcohol after the death of his wife. He had a history of poor engagement with care, and we were told had been quite stoic and closed-off during this hospitalization.

I watched with awe as the resident I was working with pulled a chair up to the bedside and really tried to get to know this gentleman. As the patient spoke about his 16 years with his wife before she died, of the way she brought meaning to his life, the tough exterior finally began to melt. For a moment, just a moment, water began to build in his eyes. The proud supervisor in me was rooting in my head, yes, let’s see if I we can keep him in this place. “That must have been so hard,” the resident began, “…but I’m glad that you were lucky to have sixteen good years together.” It was the “yes, but.” Coming from a place of good intentions, but a “yes, but” nonetheless.

As quickly as the door had opened, it had closed—the deep sorrow over a life without his wife closed behind it. His face was wiped, and we were back to business as expected. What would have happened, I wondered all afternoon, if the resident’s comment had stopped before the “but”: “That must have been so hard…” Had the patient transiently thrown us off of our storyline? Had my resident been attached to a plan of shifting this conversation towards positivity? Regardless of the cause, rather than building on the opening, we had reclaimed control of the reigns. Yes, but…

I began noticing the subtle messages embedded in so much of our wording in medicine. “I too hope your father will get better, but I’m also worried that he may not.” A phrase that I’ve said so many times from a place of kindness, but is there the subtle message: my worries and practicality are here to put a check on the hope you are so strongly clinging to. Changing the “but” to an “and”: “I too hope your father will get better, and I’m also worried that he may not.” A one-word change, possibly imperceptible, but perhaps with the subtle message: there is room for us to carry both—all the hope you may have, along with our worry.

Needless to say, different clinical scenarios will call for different communication strategies, perhaps at times even the use of a “yes, but.” Deciphering what type of communication a patient or family may need is indeed a large part of the art of medicine. But let’s face it, strategies that allow us to take control of the storyline come far more naturally to most clinicians. Controlling, predicting, planning—they are traits that are selected for through the years and hoops of medical training. I can say from firsthand experience that the same temperament that has been serving me through medical training, made the act of relinquishing control in an improv class feel surprisingly unnatural. Amidst our standardized exams and linear templates, perhaps this is just the skill that we need to be training clinicians for: neither taking control nor quietly watching the show, but enough engaged flexibility to build on the story— a partner in the patient’s storyline. Yes, and…

by: Danielle Chammas, MD (@ChammasDani)
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Thursday, November 13, 2014

Time to act! Urge your senators to confirm Dr. Vivek Murthy for Surgeon General



by: Alex Smith @AlexSmithMD

Vivek Murthy was nominated for Surgeon General of the United States by President Obama in November of 2013.  A bipartisan group of Senators approved his nomination in February 2014 and pushed it forward for a full vote.

A (not so) funny thing happened on the way to the vote.

In his confirmation hearing, Dr. Murthy was asked by Senator Lamar Alexander about his tweet that gun control is a public health issue.

Senator Alexander noted that "Americans have a first amendment right to advocate the second amendment."

Daily Show commentator Jon Stewart responded on his show "Yes, Americans have a first amendment right to advocate the second amendment.  And apparently, you don't have a first amendment right to have a different opinion from that.  Everyone knows the first amendment only applies to saying positive things about the second amendment."


Vivek Murthy responded to Senator Alexander that he would not focus on gun control as surgeon general.  He would focus on obesity.

But it was too late - Murthy had touched the third rail of politics - gun control.  Senator Rand Paul of Kentucky wrote a letter to majority leader Harry Reid saying he would put Dr. Murthy's nomination on hold.  His office bragged that they had "put yet another hold on another qualified nominee."

The NRA attack machine went into full swing, opposing the confirmation. The Surgeon General is an office with no control over gun control legislation.  As editors at the New England Journal of Medicine wrote in support of Vivek Murthy for Surgeon General,

The critical question is this: Should a special-interest organization like the NRA have veto power over the appointment of the nation's top doctor? The very idea is unacceptable.

Unacceptable though it is, the Senate backed off.  Senators from red and purple states, worried about re-election, balked at confirmation.  The vote was put on hold.

Well now those Senators have lost.  And this presents a brief window of opportunity to push through the vote on Dr. Vivek Murthy.  Those senators that lost no longer have a political reason to oppose this nomination in their last month in office.  This is a brief window, folks.

And really, this is not about gun control, or the NRA - all of that is a (ridiculous) distraction.  This should really be about the candidate.   Here are some of Vivek Murthy's qualifications for becoming America's Top Doctor:
  • Harvard undergraduate
  • Yale medical school and MBA
  • Primary care residency at Brigham and Women's Hospital, Boston (where he now works)
  • Founded Doctors for America
  • Founded ePernicus, a social networking and collaboration site for health researchers
  • Co-founded Visions Worldwide, supporting HIV/AIDS education in India
  • Served on the U.S. Presidential Advisory Council on Prevention, Health Promotion, and Integrative and Public Health
  • Support from hundreds of public health organizations, including the Hospice and Palliative Nurses Association, American College of Physicians, Society of General Internal Medicine, American Academy of Family Physicians, the American Cancer Society, and the Gerontological Advance Practice Nurses Association.  
  • (I have contacted both the American Academy of Hospice and Palliative Medicine and the American Geriatrics Society about becoming involved in supporting Dr. Murthy's nomination)
I know Dr. Murthy.  We were in the same small primary care residency at the Brigham and Women's Hospital in Boston.  Vivek was one year below me, in a class of four residents per year.  We spent countless hours together in journal club, our patient-doctor course, and on the wards.  Vivek Murthy is one of the most humble, brilliant, innovative, and caring physicians I have ever met.  Vivek Murthy is a fresh face with new ideas for leadership in healthcare.

And this is not really about Republicans and Democrats, either.  Ask yourself this: at this time of healthcare crisis after crisis (think Ebola), can our nation afford to go without leadership from its top doctor, the Surgeon General?  We need thinking at the top that is steady, informed, and sharp, not a leadership vacuum imposed by a single issue special interest group enraged by a tweet.

Please take action.  In just 2 minutes you can email or call your Senator to support Vivek Murthy's confirmation in the Senate.  I did both in about 5 minutes.  Then I asked my wife do it and it took her even less time.  Ask your family and friends to do it.  It's easy - just follow this link.  You can tweet about the issue here.
I can say that as a resident, Vivek Murthy was a strong supporter of geriatrics and palliative care.  In terms of his published views on the internet, he responded to a NEJM perspective by Drs. Thomas Smith and Bruce Hillner on bending the cost curve in cancer.  One of the issues in this area are unnecessary tests for cancer in patients with a short life expectancy, like screening for cancer in those already diagnosed with advanced cancer.  We blogged about this subject in a post called "Dumb Medicine."  In reply to this issue, Dr. Murthy is quoted on Kaiser Health News:
Dr. Vivek Murthy, President of Doctors for America, e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effect of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.
Advocacy to train physicians with communication skills, and concern about millions of missed conversations and the "intervention mindset" - doesn't that sound like something GeriPal readers should support?

This window of opportunity will soon pass.  The current Senate breaks for the Holidays soon.  After that, the new Senate with new leadership takes hold.

The time is now.






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Wednesday, November 12, 2014

Some say Geriatrics is not glamorous, but I say it is.


Tonight I was having a discussion with some close friends.  I’ve got to brag here, I have some very smart, passionate physician friends from residency.    One of the hospitalists asked for our collective advice about a recent difficult clinical encounter: 

“How would you handle a 90 year-old patient in the hospital who refuses to let the nurses change her until we let her go home?  She’s been sitting there in her own urine for 24 hours, and I just don’t know how to help.”

Five months into my geriatrics fellowship, I thought maybe I could handle this one.  I suggested that likely she’s likely very frustrated about her declining health and her ability to care for herself.  She recognizes that her independence and freedoms are slowly being taken away from her.  She’s probably trying to exert control the only way she can. 

The other comments from the group were very different.  “More colace,” one said jokingly (from the friend who thinks that’s all I prescribe).  “Oh that’s ‘failure to thrive,’ she should be conserved,” another weighed in.   “I’d just put her in long-term care, there’s nothing TO do,” said another. 

I realized then how much these five months had already changed me.  My viewpoint had shifted, and I wasn’t seeing things the way my colleagues were anymore.  I still knew the complex physiology and I still got excited about the mystery diagnosis, but now I was managing patients way more challenging than I ever had in residency.  They had multiple medical problems combined with frail cognitive and functional issues, sometimes complicated by loneliness and a loss of dignity.

This was not doctoring I read about in books or learned from writing orders on the wards.  This was an art of balancing the social with the emotional, the physical with the existential.

“I just wanted to brag about my glamorous life,” my hospitalist friend said jokingly about the case she presented me. 

Glamorous.  I looked up the meaning.   One definition was “full of excitement, adventure and unusual activity.”   Well, I’d have to say taking care of older adults IS very glamorous.

I’m still excited every time Mrs. S, a lively 96 year-old lady, tells me how she met her husband.  (Her dementia has progressed, she doesn’t remember she has already told me this many times.)  “It was 1934, and I was on a 3-day train trip from Texas to San Francisco.  There were 250 military men on the train and 8 ladies.  I had my pick of the litter and we had a ball,” she laughs until tears fill her eyes.  We giggle until our stomachs hurt, but after a while, we decide to talk seriously about her blood pressure.  It has been low lately, and the dizziness it causes may be the reason for her recent falls.  Although she may need the medication for her heart failure and to prevent a future heart attack, I have the difficult decision of weighing the risks and benefits of the medication. 

There are no studies to guide my clinical decision-making.   (In fact, there are very few studies that include any 96 year-old patients at all).  There is no review of the literature I can do to determine what the “best” answer is.  Instead, I have the glamorous job really listening to what’s important to her, what gets her up in the morning, and what sacrifices or risks she is willing to take so that she can have the life that she wants. 

My job is so exciting, adventurous, and unusual that I get to individualize the care I provide for every person I see.  Its scary territory when there is no case like another in which to guide my decisions.

My patients’ lives are filled with amazing stories and memories.  They have survived decades of experiences, with peaks of joy and valleys of suffering.  They continue to have dreams and wishes.  They still have many tear-filled fits of laughter left.   My job IS glamorous because I get to do my best to get them there.  And I’m loving every minute of it. 


by: Stephanie Rogers @SERogersMD
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Monday, November 10, 2014

Geriatrics and Palliative Medicine: Partners in a Common Mission



Over the past decade, the disciplines of Geriatrics and Palliative Medicine have become intellectual cousins. 

Within Palliative Medicine, the recognition that Palliative Medicine is not just about end of life care has been a paradigm shift.   There is now recognition that core skills of Palliative Medicine, including symptom management, communication, and caregiver support are needed throughout the course of serious illness.  While these needs of seriously ill patients transcend age, it is a demographic fact that older persons will be the bulk of persons with these chronic palliative care needs.  So, the population that has long been of interest to Geriatrics is now of great interest to Palliative Medicine. 

Within Geriatrics, we have become consumed with the recognition that most frail older persons have multiple illnesses.  We realize that treating each illness separately, rather than treating the whole patient leads to considerable harm.   Geriatricians strongly advocate for a focus on whole person health outcomes such quality of life and functional status rather than traditional disease metrics.  Geriatricians have been increasingly concerned that traditional treatments focused on each individual diagnosis leads to dangerous levels of overtreatment that can harm patients. 

On the other hand, care that is grounded in an understanding of the patient’s goals, focused on quality of life, functional, and supportive needs of the patient and caregiver is of great benefit.  Kind of sounds like we are getting pretty close to palliative care, doesn’t it?  So a basic competency of Geriatrics is the ability to attend to the palliative needs of frail patients throughout the full course of serious illness

So, given this overlap between the two fields, shouldn’t the next step for each field be to aggressively define and defend its turf?

Two wonderful perspectives, by Jim Pacala and Diane Meier in the Journal of the American Geriatrics Society, eloquently argue that the answer to this question is an emphatic NO!  These thoughtful perspectives are great reading for those in both fields.

Pacala and Meier implore us to put a laser focus on the needs of seriously ill patients, rather than worry about who has what turf.   Both fields focus on the most vulnerable patients, the 5% of patients who consume 50% of health costs.  Yet for all that money, our health system is utterly failing these vulnerable patients, delivering disjointed, dysfunctional care that does not meet their needs and goals, and often causes harm rather than benefit.   We should of course embrace what is unique about each discipline and value the specialized skills each discipline may bring to the table.  But, Pacala and Meier tell us that we have so much more to gain by collaborating and working together than worrying about turf.

Perhaps the most important feature that unites those in Geriatrics and Palliative Medicine is the passionate belief that we need to change how health care is delivered to seriously ill patients.  With needs so great, we do not need to worry about turf.  There is more than enough work to go around.  By working together, we can offer hope to seriously ill patients and their caregivers who feel that their voices are not being heard. 
by: Ken Covinsky @geri_doc
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Friday, November 7, 2014

Family caregivers give up $522 billion in income per year to care for seniors



by: Alex Smith @AlexSmithMD

You don't get something for nothing.

We've blogged previously about the silent long term care system of informal caregivers in the US.  These are the families and friends who provide the bulk of care for older adults in the US.  The National Caregiving Alliance estimates that nearly 1/3 of US aldults are caregivers.  This caregiving is seemingly "free" - it appears to cost the US Healthcare System nothing.  Often, however, this work comes at great cost to the caregivers, including higher rates of depression and other health effects.  It also means the caregiver is providing care, and not earning an income for themselves or their family.

Today we have more information about the economic costs of informal caregiving in the US.
Amalavoyal V. Chari and colleagues published a national study of the costs of caregiving for elders in the US in the journal Health Services Research (link to an interview with Dr. Chari here).  They focused on how much these caregivers would have earned had they been working instead of providing informal care for older adults.  What they found:
  • They estimate the cost of informal elder care at $522 billion annually.  That is, had these caregivers been working instead of providing care for "free", they would have made $522 billion. 
  • The costs of formal long term care (e.g. nursing home care) are less than half the costs of informal care - $221 billion annually vs. $522 billion annually.
  • The estimated costs of replacing informal caregivers with paid unskilled caregivers is $221 billion, and replacing informal caregivers with skilled caregivers is $642 billion.  Conclusion: the informal caregiving system is more affordable than replacing this system with a skilled care system.
  • These estimates may be underestimates because they do not include the cost impacts of caregiving on the emotional and physical health of the caregiver.
Why is this information important?  Policy initiatives are just starting to recognize the importance of informal care.  Many states offer Medicaid's Cash and Counseling Program to reimburse caregivers for low income and/or Medicaid eligible seniors.  This program is in an early, pilot phase, however, and risks budget cuts at the State and Federal level.  We need more support for this program.  And the  monetary recognition of the sacrifices made by informal family caregivers addresses just one small aspect of the problem.  Better training for this work is essential.  Informal family caregivers are often untrained and unprepared, working in isolation for years on end.

Time our country started listening.

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Tuesday, November 4, 2014

December's Consumer Reports: Gadgets, Gear, and Hospice & Palliative Care


The December issue of Consumer reports is truly amazing. It’s filled with articles to help consumers find the right headphones, smart phones, and smart watches. One hot new piece of gear that is rated quite highly by consumer reports in this issue is something you may have heard about once or twice before, Hospice and Palliative Care.

You can access the for free all of the articles on their website at this link. This is a really well thought out webpage that is written by consumers, for consumers and includes the following resources:
  1. The story of Paul Scheier's life and death: The website includes a 17 minute long video that discusses the importance of hospice and palliative medicine, addresses myths often connected to these programs, and includes a tear shedding journey of Paul’s life and death.
  2. A guide on how to pick a hospice 
  3. Advice about advance directives including a link to an app by the American Bar Association called My Health Care Wishes (Android and iOS) that lets you store advance directives and related legal documents on your mobile device.
  4. A section on "when things go wrong" that includes a link to the American Geriatrics Society's Health in Aging Foundation to help consumers find a geriatrician!

by: Eric Widera (@ewidera)
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Monday, November 3, 2014

Advance care planning cold calls, crowdfunding palliative care, and pocket card decision aids

by: Alex Smith @AlexSmithMD

Every once and a while, a new innovation comes along that makes you go, "Wow!" or, "I never would have thought of that" or, "Not sure if it will work, but I'm sure interested to find out."

The following three are interesting not only because of the ideas themselves, but also because of the different ways they are going about funding: for-profit (Vital Decisions), both for-profit and not-for-profit (ResolutionCare), and non-profit (Caring Advocates).

1.  Cold calling patients with serious illness and engaging them in advance care planning conversations.  Vital Decisions, a large and growing for profit company, obtains lists of patients with serious illness from insurance companies.  Counselors working at Vital Decisions call patients and engage them in advance care planning conversations.  NPR did an interesting story on this company in August.  As Bob Arnold said at the end (to paraphrase), "would it be better if the patient's doctor, nurse practitioner, or social worker did this? Yes.  But this is better than what patients have currently been getting."  Major outstanding question: can you conduct advance care planning conversations effectively over the phone with someone you don't know?

Source - Wikimedia Commons
2.  Crowdfunding palliative care.  ResolutionCare based out of Humboldt county in Northern California has launched a crowdfunding campaign on indiegogo to raise $100,000 in November.  The money will go toward building a palliative care service for patients with serious illness, particularly those living in rural areas.  The care model is based on Project Echo, a remarkably successful program that started at the University of New Mexico to improve care for rural patients with Hepatitis C.  The central idea is that expert palliative care specialists on the ResolutionCare team will use video technology to conduct video consults with doctors and other providers at outlying practices.  This will increase the reach and impact of the the ResolutionCare team, and hopefully, increase the quality of palliative care delivered by the providers who consult.  Major outstanding questions: is palliative care similar enough to hepatitis C treatment that the Project Echo method will be effective? Do video palliative care consults to healthcare providers improve the quality of care for patients living with serious illness? Will people give money to crowdfund palliative care?




3.  Pocket card decision aids.  Dr. Stan Terman in Southern California is on a mission.  His mission is to ensure that patients who later develop advanced dementia will not be forced to endure treatments they would not have wanted.  His nonprofit company, Caring Advocates, has created a series of pocket cards to help people plan and make choices about the type of care they would prefer in various states of health.  An example is below.  He has also produced some provocative videos that might be used for teaching.  For example, he made a YouTube video version of his talk at the American Society of Bioethics and Humanities titled, "Must we all die with forced hand feeding in advanced dementia?"  Hard to not click on that, isn't it?  Compelling story of a woman in Canada with a clear advance directive who is being hand fed despite her directive and her daughter's wishes - he has video of the patient and her distraught daughter. Major outstanding questions: do pocket cards work as decision aids?  Will they be widely used?


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Sunday, November 2, 2014

Advance care planning tool PREPARE, now in Spanish!

by: Alex Smith @AlexSmithMD and Rebecca Sudore @PrepareForCare

Do you have Spanish-speaking patients?  If you do, then point them toward PREPARE in Spanish

The rising tide of palliative care has not lifted all boats equally.  For example, hospice use among African Americans decedents increased from 5% in 1992 to 34% in 2010.  However, hospice use among white decedents increased even more, from 10% to 46%, over the same time period.  Hospice use increased at a faster rate among whites than African Americans.  The gap actually got bigger.

We haven't paid enough attention to disparities.  There is a real risk that many of the services, tools, and skills of palliative care may benefit majority patients more than minority.  The explosion of palliative care may have the unintended effect of increasing ethnic disparities rather than reducing them. 

That's just one of the reasons that work like Prepare in Spanish is so important.
We previously blogged about the launch of PREPARE (prepareforyourcare.org), an innovative online advance care planning tool.  The central idea behind Prepare is to move advance care planning upstream, to help patients and surrogate decision makers prepare for in-the-moment decision making. Advance directives are not enough.

PREPARE is a program that uses videos and personal stories to help people identify what matters most in life, communicate with loved ones and clinicians, and make informed medical decisions based on their values. PREPARE is appropriate for any person at any stage in their life and at any stage of readiness to engage in advance care planning.

Prepare was launched to the public in 2013. Since then it has received close to 50,000 unique visitors from over 115 countries.

Through generous support from the California Healthcare Foundation, PREPARE has been “transcreated” into Spanish after careful pilot testing within the Spanish-speaking community. (espanol.Prepareforyourcare.org)





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