Tuesday, July 29, 2014

A Letter to My Geriatric Patients



I would like to send my deepest thanks to every one of you for teaching me so much during my Internal Medicine residency. With every lesson, you touched my heart.

I have been an internal medicine resident the last two years and each day you accepted me into the most vulnerable period of your life. I have been there as you face a scary new cancer diagnosis, when you realize your independence may be lost forever, and when your mind has felt shaky and unstable. I have been there as you navigate the trials of watching your child, your life partner, your sibling or loved one as they face death. I have been there even as you approach the end of your life. In those most challenging times, I marveled at the strength of your generation and the tenacity to overcome the unimaginable.

With my sincerest gratitude, I also extend to your generation several apologies. I am sorry I spend more time looking at a computer screen than looking at you. I am sorry my time on the wards is not spent at your bedside but instead in a workroom lined with computer screens. I am sorry for sometimes using medical language you cannot understand and for asking the nurses to repeatedly poke and prod you for blood work. I am sorry for not speaking loud enough for you to hear me and too loud when I assume you have hearing loss. I am sorry that I prescribe you medications you cannot afford. I am sorry that I have taken away your independence and with it, your small pleasures like driving and shopping for food. I am sorry that when trying to treat you with the "gold standard" I instead make you feel worse. I am sorry that my shirts and pants are not always ironed. I am sorry if I at times seem skeptical in miracles of faith. I am sorry that I do not ask you what you really want but I hope you know that through it all, I always have your best interest at heart.

Finally, I am sorry for never saying “thank you” enough during the precious time we have together face-to-face. They call you the Greatest Generation and it truly is an honor to not only meet you but to be a part of your lives. Thank you for making such an impact on mine.

Sincerely,

A Deeply Indebted Resident

by: Megan Rau (@meganismyname)
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Friday, July 25, 2014

Preparing for the hospice and palliative medicine board certification exam



What do the following three things have in common:
  • The Paris Air Show
  • The World Table Tennis Championships 
  • The Hospice and Palliative Medicine Certification Exam

They all happen once every two years! And guess what, this is the year for the Hospice and Palliative Medicine certification exam. Two things to consider to get prepared for the test:

1.  Whether you are preparing to take the hospice and palliative medicine subspecialty board exam or just want to get up to date with the field, then considering joining us at AAHPM’s Intensive Board Review Course. The organizers have created a fast-paced, intensive review of best clinical practices when caring for seriously ill patients and their families.

2. Practice with Blogs to Boards! This is a series of posts from both GeriPal and Pallimed to get physician readers ready for the hospice and palliative medicine boards. We created these for the 2012 exam where every week GeriPal and Pallimed alternated publishing a new question, as well as a discussion of possible answers to the question. We then posted all the 41 questions via the link here.  

by: Eric Widera (@ewidera)
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Wednesday, July 23, 2014

Life and Death After Hip Fractures in Older Nursing Home Residents


Any who has had a loved one who sustains a hip fracture knows that these are life changing if not life-limiting events in the lives of older adults. A recently published article in JAMA Internal Medicine gives further credence to this, as well as giving us evidence to guide our prognostic estimates when caring for someone who sustains a hip fractures in a nursing home setting.

The study by Neuman and colleagues looked at survival and functional outcomes after hip fracture in 60,111 long-term nursing home residents who were hospitalized with an acute hip fracture between July 1, 2005, and June 30, 2009. The primary outcome was death from any cause within 180 days of hospital admission. They also looked at functional outcomes that were based on self-performance for 7 ADLs as recorded in the last available Minimal Data Set (MDS) assessment within 180 days after the index admission.

What Were the Results?

The median survival time after fracture was 377 days (the interquartile range was 70-1002 days).

Six months after hip fracture:

  • 1 out of every 3 (36%) nursing home residents died
  • 1 out of every 2 (46%) male nursing home residents died.
  • Half (54%) of those who were not totally dependent in locomotion prior to the hip fracture had either died or developed new total dependence in locomotion


At one year after hip fracture:

  • One out of two (47%) nursing home residents died
  • Of those who were not totally dependent in locomotion at baseline, 60% either died or experienced new total dependence in locomotion


Nonoperative fracture management, male sex, increasing age, white race, high levels of comorbidity, advanced cognitive impairment, non-femoral neck fracture location, and increasing baseline ADL dependence were all associated with worse survival after hip fracture.

Take Home Points

First, a new diagnosis of hip fracture in a nursing home resident carries with it a worse 6-month prognosis than most newly diagnosed metastatic cancers, with 1 out of every 3 nursing home residents dying within 6 months (for a good read, check out Fred Ko's and Sean Morrison's excellent editorial on the need for palliative care for these individuals).

Second, even if a resident was completely independent in getting around the nursing home, 6 months after a fracture they still had nearly a 50/50 chance of either being dead or being totally dependent on the nursing staff for getting around. However, a more optimistic way to think about it is that these individuals still had a one in three chance of returning to their baseline independent function after a fracture in a nursing home setting.

Third, while the dependence on locomotion is important, there are limitations to this outcome, including that not everyone who is "totally dependent" one week will be "totally dependent" the next week. Why? Well to address this we need to go back to the methods (I know, I’m doing this out of order)

A Finer Point: Why Totally Dependent May Not Mean What You Think It Means

Death is an easier thing to measure than someone's ability to perform activities of daily living (ADL).  You know when someone has died, but when is someone independent or dependent in ADLs?  In nursing homes, each ADL has a specific and standardized meaning that may be different than we may use it in our own practice. The main functional outcome of the study, locomotion on the nursing home unit, is described in MDS as: “how the resident moves from place to place in the room or hall using whatever device is appropriate or needed.” The device can be a thing like a wheelchair, walker, cane, feet, prothesis, or scooter. So if the nursing home resident did the activity completely on their own without cueing or supervision, then they are described as “independent”. If they need just some oversight or cueing then they are described as needing “supervision”. More help than that is “limited assistance” where the staff do some of the activity, and more help than that is “extensive assistance” where the staff do most of the activity. Lastly, complete dependence is where staff do all of the activity for the nursing home resident.

The other important thing to know is that functional status in this study is based on self-performance as observed across all nursing shifts over a 7-day period. So a resident is independent in an ADL if the resident is able to perform that activity “without help or oversight or requiring help or oversight only 1 or 2 times over 7 days”.  The same thing goes with total dependence, the resident needs to require staff to do all of the ADL for all 7 days to be described as dependent.

Why is all of this important? Although these definitions are standardized, a nursing home resident’s self-performance can change shift-to-shift, day-to-day, and week-to-week based on things like their mood, an acute illness, or even just their relationship to their nurse. So one week you may be “dependent” and another week you may be “limited assistance.” This is likely why in the study we saw a very small group of individuals who were completely dependent prior to the fracture, but after the hip fracture they improved to being completely independent in locomotion.

by: Eric Widera (@ewidera)
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Tuesday, July 22, 2014

Hospice patients should have access to physical therpay to improve function



by: Alex Smith, @alexsmithMD

I'm going to acknowledge up front that this is a rant. 

One of the skilled nursing facilities I work with has a hospice unit.  We occasionally have patients on the hospice unit who might benefit from physical therapy.  The physical therapists that see patients in the skilled nursing facility say they will talk with the patient about their goals, and if their goals are to maintain their current level of functioning, they will work with the patient.  If the goals are to improve their physical function, they cannot offer that type of support.

This seems ridiculous!

If someone has pain, we don't say, "we will keep your level of pain where it is, but we can't  help you if you want to improve."

If someone has social or spiritual issues, we don't say, "we want to maintain your current level of distress, but can't help you if you want to be less distressed."

Why is this happening?  It may be that a part of the problem has to do with resource allocation.  The physical therapists don't have the resources, nor are they reimbursed for their time the same way, for seeing hospice patients as for patients cared for under the Medicare Skilled Nursing Facility benefit, a comparatively high payment.

Another part - and this may be related - is that we don't prioritize functional improvement as much as symptom/social/spiritual improvement for hospice patients.  I gues the idea is that hospice patients will inexorably decline functionally and die.  It's as if physical therapy to improve funciton has been lumped in with life-sustaining treatments.  When did that happen?  Did I miss a meeting?

Granted, most patients on hospice will have an inexorable decline in physical function - something we've written about both on the blog and in journals.  And many hospice patients do not have the ability or motivation to participate in physical therapy to the extent needed to recover function.  Wanting extensive physical therapy to recover function, when there is no possibility of recovery, is often a red flag that goals of care and prognosis need to be discussed in more depth.

But to me hospice, at it's core, is about making each day as good as it can be, for the time that remains.  Being as indepent as possible is an important part of quality of life for many people.  And for a very small number of people in hospice, there is a potential for recovery of some function. 

I have a patient now who might benefit.  He's been delirious in the hospital, but is pulling out of it.  He might benefit from physical therapy to recover some of the additional disability he acquired from lying in bed in the hospital confused for days on end.  Though his family is starting to discuss hospice, they want him to have the best opportunity to improve funcitonally.  I think they're going to say no to hospice.  And that's unfortunate.  Our system should be flexible enough to accomodate him.

OK, I'm done ranting.  Maybe your hospice is different?  Or maybe you want to rant too?  Let's hear it.
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Monday, July 21, 2014

Never Stop Dancing: Breaking Stereotypes of Disability in Older Adults One Step at a Time



We have written a lot about disability in older adults here on GeriPal.  Here are just a couple of examples:
If I had to sum these posts up in a couple words, it would be that successful aging does not equal aging without disability.   If I had to sum these posts in a video, it would be this:



by: Eric Widera (@ewidera)

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Friday, July 18, 2014

Financial Capacity, Alzheimer’s, and the sale of the LA Clippers


More than 5 million Americans currently have Alzheimer disease. One of them happens to be Donald Sterling. There are a lot of directions we can go on a post about this now infamous man and this devastating disease, but the one I would like to highlight is the role that a physician’s determination of financial capacity played in a multibillion dollar sale of a professional sports team.

On May 29, 2014, Sterling was removed as co-trustee of the Sterling Family Trust, which owns the LA Clippers. This removal was based on the certification of two licensed physicians that Mr. Sterling was incapable of carrying out the duties as a Trustee of the trust because of his dementia. Shortly thereafter, his wife, now the sole Trustee of the trust, sold the Clippers to ex-Microsoft CEO Steve Ballmer. Sterling has since claimed that his subsequent revocation of the trust June 9 prevents his wife from completing the Clippers sale, although that appears to be an issue that will be decided by a judge (for a great summary of the facts and the legal aspects of the case, read this USA today piece).

The removal of Sterling as the co-trustee, and therefore the sale of the Clippers, was dependent on the physicians’ assessment of Sterling’s financial capacity. The family Trust allowed for him to be removed if his regular attending, or two other licensed physicians, certified in writing that he was incapacitated. We know, based on the limited court records that the two physicians certified incapacity based on his level of impairment in attention, information processing, short term memory, and ability to modulate mood, as well as risk of making errors in judgment.

So was it right that Sterling was removed as co-trustee? Based on the wording of the trust, the answer seems to be fairly clear. Yes. This also makes sense based on what we know about Alzheimers and financial capacity (see here for a JAMA paper on financial capacity). We also know based on research over the last decade is that the ability to manage finances is one of the first functional activities to decline in Alzheimer disease. Even before the onset of dementia, patients with mild cognitive impairment (MCI) begin to have impairments in complex financial tasks. Once diagnosed with mild dementia, emerging global impairments of both complex financial skills develop, which often rapidly worsen.

What about Sterling’s ability to revoke the trust? Maybe. His ability to revoke the trust (in California, anyway) is likely based on his capacity to make a will, which is a lower threshold than the capacity to be a fiduciary (his role as a trustee).   We know from court records that Sterling appears to have a mild dementia with MMSE of 23/30, but one that is notable for poor performance on executive function tasks like Trails B.  He may very well then be able to revoke the trust, but not have the capacity to be a trustee based on the wording of the trust.

by: Eric Widera (@ewidera)

Trails B



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Tuesday, July 8, 2014

Just "Fix-it"


by: Gretchen Schwarze (Vascular Surgeon)

She seemed awfully angry and at the very least dubious that I couldn’t do more for her father. After 7 hours of surgery trying to salvage her father’s leg, I tried patiently to explain that this new (third) bypass we had just successfully completed was unlikely to provide her dad with a long-term solution. Ultimately, he would lose the leg, if we were lucky he’d have it for another year or two. Accounting for the “unlucky” side of the coin was even more depressing; immediate wound or graft infection, a postoperative heart attack from the liter of blood I had just lost or early graft failure which few surgeons would attempt to reverse given the tenuous nature of the graft to begin with. I didn’t have the heart to mention these things too, she was already upset.

It’s conversations like these that make me feel like there is something intrinsically wrong with the way we conceptualize modern medicine, and by “we” I mean both doctors and patients. I worry that a much deeper issue - a larger social construct - plays a role in decision-making and influences treatment choices because it obscures the limits and boundaries of what health care can provide.

I chose to become a surgeon largely because I couldn’t stand the inadequate feeling that I had while managing chronic illnesses like COPD (emphysema) and diabetes. My ego loved the idea of taking a patient with a problem that was fatal if left untreated (like appendicitis) to the operating room and just fixing it.

Turns out there were a lot of other things I liked about surgery that mattered more so when I chose to become a vascular surgeon I fully understood that I was committing to a career of palliative surgery. Of course there are some exceptions – the 65 year old man with an abdominal aortic aneurysm for example – but for most patients I am merely rearranging the deck chairs on the Titanic. I know I don’t have the solution for PVD – it’s a systemic problem and by the time a patient sees me, he has a lot of it. My job is to take out what I can or go around it, but I am certainly not fixing it.

In 1991 Joanne Lynn and David DeGrazia wrote a brilliant paper about the “Fix-it Model” of medical decision making. (An Outcomes Model of Medical Decision Making, Theoretical Medicine) In it, they posit that contemporary attitudes about medicine subscribe to a mental model whereby disease is defined by a deviation from normalcy and the role of health care is to provide an intervention that “fixes” or returns the patient to normalcy.

Although most medical decisions do not fit this model, it’s hard to deny its influence on both patients and physicians. Consider the vast use of coronary stents in settings outside acute myocardial infarction (Rothberg, Circ Cardiovasc Qual Outcomes, 2013) or the widely-viewed animated video parody “Orthopedia vs Anesthesia” with the infamous line “I have a fracture, I need to fix it.” While the need to repair a bone in a 97 year-old woman in asystole is preposterous, the video is funny precisely because it rings true.

Lynn and DeGrazia expose the hazards of this mental model for decision making particularly for patients with chronic illness and for interventions which have limited/no potential to return the patient to normalcy. Surprisingly few have recognized and championed their concerns. Notable exceptions include William Silverman in his observations about the care of extremely low birth weight babies (Fumes from the Spleen, Pediatric and Perinatal Epidemiology, 1996 and Medical Decisions: An Appeal for Reasonableness, Pediatrics, 1996) and Mark Neuman (Surgeons’ Decisions and the Financial and Human Costs of Medical Care, NEJM, 2010) in his New England Journal commentary about the video parody. Both point out that the “fix-it model” promotes medical decisions that are explicitly permissive of intervention and that the model neglects a broader range of outcomes that are important to patients. As Neuman notes, “It’s as if, on some level, a decision making process has been passed over, and an inevitable operative course, however absurd, [has been] set in motion, not by the patient, but by the fractured bone itself.” (p. 2383)

Recently, my research group has also examined the “fix-it model.” Over two years we listened to and analyzed nearly 80 conversations between surgeons and patients before high risk operations. Although we were looking to hear discussions about the potential use of life-supporting interventions postoperatively, we were surprised to find that surgeons routinely used language consistent with the fix-it model. Many actually used the words “fix-it” and those who didn’t, used words that certainly suggested something was broken and could be fixed. (“And I Think That We Can Fix It”: Mental Models Used in High Risk Surgical Decision Making, Ann Surg, 2014) They described disease as something that was leaking, blocked or damaged and proposed interventions that would plug or patch, repair or remove the problem.

While surgeons used this imagery to explain the patient’s disease and the operation under consideration, they later transitioned to a more deliberative stance. In a few instances, the only reason cited to pursue surgery was to “fix” the problem and these conversations lacked any deliberation or reason to pursue surgery apart from having the problem “fixed.” However, in most cases, the surgeons explicitly challenged the fix-it model as they deliberated in front of the patient about whether to pursue surgery – they noted that perhaps the problem was too broken to fix, or not broken enough to fix, or that maybe what was broken wasn’t actually the source of the patient’s symptoms. They also noted that while they could “fix” the patient’s presenting problem, the patient would not or might not return to normal after surgery due to complications, imperfect outcomes and the impact of surgery on the patient’s baseline health.

And this brings me back to my patient’s daughter. It seems only natural to me that we (surgeons and non-surgeons) use the “fix-it model” to describe both illness and treatment; it’s a good way to explain complex medical information succinctly (something that we believe promotes trust). But like all mental models, fix-it oversimplifies the situation, particularly for older frail patients with multiple chronic illnesses, where there is a broad range of possible outcomes and prolonging life for as long as possible isn’t necessarily the most important goal. Assuming that physicians with good communication skills transition to a deliberative phase that attempts to dispel the fix it model (as I’m sure it would be easy to find physicians who are not good at this), even in the best circumstances are patients able to make this shift after we have defined their disease as an abnormality that can be fixed? When you tell someone that there is no cure, or that additional interventions are burdensome and unlikely to achieve their desired goal, are you fighting a Sisyphean battle that was lost long ago in this deep conception of what health care is supposed to do? I don’t know, but the anger and disappointment in the daughter’s voice makes me think we are up against a firmly entrenched obstacle that will take a lot of work to overcome.
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Thursday, July 3, 2014

Informed consent in social media research



I’m simultaneously a behavioral researcher, an ethicist, and a hopeless Facebook addict, so I’ve been thinking a lot about last week’s controversial study (Kramer et al, PNAS 2014) in which researchers manipulated the emotional content of 689,003 Facebook users’ News Feeds. In summary, users who saw fewer of their friends’ posts expressing negative emotions went on to express more positive and fewer negative emotions in their own posts, while users who saw fewer posts expressing positive emotions went on to express more negative and fewer positive emotions in their posts.

This provides evidence for “emotional contagion” through online social networks—that we feel better when exposed to other people’s positive emotions, and worse when exposed to negative emotions. This finding isn’t obvious, since some have suggested that seeing other people’s positive posts might make us feel worse if our own lives seem duller or sadder in comparison.

The journal and authors clearly did not anticipate a wave of online criticism condemning the study as unethical. (Full disclosure: one of the authors is also a researcher at UCSF, though I don’t think I’ve ever met her.) In particular, the authors claimed that participants agreed to Facebook’s Data Use Policy when they created their Facebook accounts, and this constituted informed consent to research. Looking at the Common Rule governing research on human subjects, it’s clear that the requirements of informed consent (including a description of the purposes of the research, expected duration, risks/benefits, compensation for harms...) are not met just because subjects click “Agree” to this sort of blanket terms of use. There are exceptions to these requirements, and some people have suggested that the research could have qualified for a waiver of informed consent if the researchers had applied for one. I'm not so sure about that argument, and in any case the researchers hadn’t.

While the online discussion about this study has been fascinating, I think there are a few points that haven’t received as much attention as I think they deserve:

1. This controversy is taking place against a backdrop of more critical scrutiny of informed consent among ethicists. While bioethicists in general have traditionally advocated strong informed consent requirements in the name of participant protection and self-determination, in recent years there has been an opposite trend emphasizing that such requirements are burdensome and may inhibit important research. Last year we saw a controversy over a neonatal ICU clinical trial, in which many experts criticized regulators’ strict interpretations of informed consent. More recently, some prominent figures have suggested that informed consent requirements in medical research should be relaxed, particularly for “big data” studies made possible by electronic medical records and coordinated health systems. Much like with the Facebook study, these researchers and ethicists believe that new technologies hold promise for new ways of conducting research to promote health, and worry that these possibilities may be closed off by our existing ethical frameworks.

2. What’s “research”? One irony of this controversy is that Facebook manipulates users’ News Feeds all the time—they don’t show you everything that your friends post, but use a filter that they’re always tweaking “in the interest of showing viewers the content they will find most relevant and engaging.” (In other words: so that you’ll keep coming back and they can show you ads.) These tech firms take a relentlessly empirical approach to everything. Google once ran 41 experiments to figure out which shade of blue made users more likely to click on ads.

These activities aren’t categorized as research falling under the Common Rule, as typically construed, because they’re not designed to develop or contribute to generalizable knowledge. So, e.g., if Facebook had a purely internal purpose for figuring out how to manipulate users’ emotions by adjusting the News Feed filter, this controversy wouldn’t have arisen. What opens them up to ethical criticism here is that they tried to answer a more general scientific question and published their findings in PNAS.

As others have pointed out, this division creates weird disincentives. Experiments on Facebook users to improve Facebook’s own processes and make more money don’t receive this level of scrutiny, but experiments to answer general questions (and that are publicized in scientific journals) do. But the risks to subjects are probably greater in the first case, since Facebook will keep those studies and findings proprietary, and the social benefits are smaller.

3. Social media and technology are creeping us out. I agree with the critics of the study that it didn’t meet existing requirements for informed consent in research; however, I don’t think that’s why people have responded to the story as they have. As in most cases, "the scandal isn’t what’s illegal, but what’s legal." In other words, what many of us really want to know is: what other experiments are Facebook/Google/Apple/Amazon/Samsung running on me that they’re not required to tell me about?

Like many people, I have complicated and ambivalent feelings about my dependence on these technology giants. As a researcher, I think that these feelings are a defining feature of our modern lives, and would be worthy topics for further empirical study. In a sense, the broad outcry over this study is an illustration of why such research is so important, though I worry it will have the unintended result of making future academic-industry collaborations in this space less likely.

by: Winston Chiong
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Wednesday, July 2, 2014

Practice Change Leaders for Aging & Health: Jedi Training for Geriatric Professionals



This is your big opportunity!  The C-Suite is giving you 10 minutes to make a business case for your new service line to improve the health and delivery of care for older adults at your institution.  Wow, I've watched Shark Tank on TV and I'm already sweating...(and I wake up from my dream).  But more seriously, one morning before a project presentation, my 6-year old son, now a big fan of Star Wars, shouted out to me with his best Yoda voice, "Use the force, Dad!".  As I begin the transition to mid-career in medicine, I got inspired to seek further Jedi training to grow and cultivate leadership skills.  I have been fortunate to be part of the Practice Change Leaders (PCL) for Aging and Health program for 2014.

The Practice Change Leaders is a national program to develop, support, and expand organizational leaders who are committed to achieving transformative improvements in care for older adults.  The program, founded by Dr. Eric Coleman, is jointly supported by the John A. Hartford Foundation and Atlantic Philanthropies.  This is a 1-year journey where participants complete a project at their institution aimed at improving care for older adults.  The project becomes the vehicle for the hands-on learning of critical leadership skills.  With the support of national Senior Leaders who provide mentoring, Practice Change Leaders engage in self-directed learning acquisition and content expertise to become more effective leaders.

The best part of the experience so far is the shared pod learning with great feedback from Senior Leaders for your project and skill-building seminars from national leaders.  How do you foster cultural change and a sense of urgency at your institution?  How do you get more consumer engagement in your project?  Last month in Chicago, at one of the 3 highly interactive national meetings, my peers and I had an amazing opportunity to give a business case presentation of our project to an expert panel (think of a wise, supportive Jedi Council).

As geriatricians, we are aware of innovative approaches to enhance the health and function of older adults, yet often the greatest challenge is effective leadership to successfully implement evidence-based, best practices.  But how do you become a change agent at your institution?  I did not go to business school or take any formal leadership courses.  I identified with Julie Thai's recent geripal post on the Geriatrician Syndrome, defined "a pathologically modest view of self in the context of one's role as a physician caring for older adults; cardinal features include: inability to accept praise and downplaying the significance of one's role in medicine".  Most geriatricians I know are not comfortable about promoting their work and talking about themselves.

As I reflect and look ahead, my passion and clinical interest is improving advance care planning and the quality of conversations in the outpatient setting to ensure patient wishes are explored, expressed, and honored.  I am still a Jedi in training, but I highly recommend the PCL program for any geriatric healthcare professional interested in furthering their career satisfaction and dreams, learning how to implement clinical programs, and being an active participant of the national movement toward improving care for older adults.

To learn more about the Practice Change Leaders for Aging and Health program, please visit www.changeleaders.org.  From the website you may request an application (due August 27, 2014) and attend one of several informational calls to ask specific questions (you are welcome to join the calls anonymously).  Please check your "geriatrician syndrome" at the door to come in and join us!

by: Steve Lai (@SteveLaiMD)

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Monday, June 30, 2014

After Pronouncing

The following post is adapted from something I read at the San Francisco Veterans Affairs Geriatrics, Palliative, and Extended Care memorial service.  The case has been anonymized to protect confidentiality. 
- Alex Smith @AlexSmithMD

Many of the veterans we care for are fortunate to have family and friends with them during their last days. Some of you are here today.

Some veterans have no family or friends. Over the years, these veterans have either pulled away, or been pushed away, from their loved ones. Let us take a moment to remember the these veterans.

Last year I was asked to come and pronounce that a veteran had died in our hospice unit. I had just taken over for another attending physician and had not met this veteran while he was alive.

“Did he have any friends or family?” I asked. “No,” said our social worker, “we contacted everyone we could reach. We’ve tried for weeks. None of them would come. They are too angry.”

I went in the room. He appeared to be at peace. I conducted my examination. Then it seemed as if there should be more to do, some way to remember him, and acknowledge who he was as a person.

Who would grieve for him? It was obvious that his life had been difficult. He had been homeless. His face bore the ravages of his time on the streets.

Every person, if you go back far enough, was loved, at least by someone in their life. Even if they are not loved now. Before the anger and the arguments and the illness. Before the isolation.

Hopefully, if you go back far enough, a mother held this person, then a child, in her arms and loved him.

I held that thought of this veteran being loved by his mother in my head, as I thought of this poem, by Joan Siegel, about a dying mother.  About the love between a mother and her child.  About how we hold on to memories of our loved ones, take them with us, and leave a part of ourselves behind.

To My Daughter by Joan Siegel

When it comes time
let all the words be spoken
that must be
so that I may take your voice with me
for the next ten billion centuries
mine will be with you
like a packet of letters
handwritten over the years
to unfold anytime
read
hear me speak
in the voice that used to put you to bed
telling the story of all our days
fingered in the retelling
like pages of your books
the best parts dog-eared
pressed smooth by thumbprints
and the refrain of all our nights
as you slipped away
I loved you before dinosaurs 
Even before the stars 
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Wednesday, June 25, 2014

Snow and Lollipops: Reflections on caring for the dying while raising children



Over the past year of my palliative care fellowship, I have learned that the discoveries made by the dying are not always that unlike the discoveries of my newly growing children that somehow get lost to us who are hopefully somewhere in the middle. While I am far from a philosopher, it is with humility that I would like to briefly share 5 lessons I have learned from my three year-old son, Ezra, as a reflection of the many wonderful people whom I have been privileged to care for over the past year.

Lesson #1: Snow

“Snow” is a children’s book about the adventures of two little children on a snowy day. They throw snowballs, sled, ski, and build a snowman together. Then in the midst of their fun day, the sun comes out and their snowman starts to melt. Ezra, who has never seen snow, looked at me worriedly the first time he heard the story and asked, “Mommy, am I going to melt?” Even at three years of age he confronted impermanence. He slept in our bed that night, scared, and needing to be held by we who loved him, needing reassurance that he would not melt. We have all witnessed the impermanence of lives lived well, lives lived in regret, and lives shortened too soon. But in these moments of fear, wives have crawled into the husband’s hospital bed, sons have hugged their fathers tightly with dignity, and mothers have held hands with their daughters before their last breaths.

Lesson #2: Lollipops

One day after a long family hike, we gave Ezra a small lollipop. It was red like 3D glasses and seemed flimsy next to his joy. I asked him what it tasted like. He answered “red.” It did not taste like strawberries, cherries, or licorice. It simply tasted as he perceived “red” would taste. As I have grown as a physician, I have learned to appreciate that sometimes things just are. Pain may be pain. Not necessarily sharp, dull, aching, radiating or electric. Just as love can be love and healing healing indescribable and without question.

Lesson #3: Tantrums

Ezra has to eat his broccoli before pizza, share his favorite toys with his younger brother, and brush his teeth before bed. I do not let him sleep at the playground or stay up until 10 o’clock at night. He does not eat cookies for breakfast nor play games on the iPad. Any one of these or a long list of circumstances might lead to a tantrum. While it is hard to acknowledge in the midst of him crying and stomping, nearly all tantrums stem from the absolute amazingness of a world with pizza and technology and friends worth talking to for hours. Tantrums happen because life is good and yet is also filled with boundaries. While no patients have lain prone on the floor screaming in my office, the disappointment of a recurrent cancer or failed chemotherapy regimen is the grief of loving this life fully and facing our own human limitations.

Lesson #4: Easter egg hunts

We celebrated Easter with a small egg hunt. Plastic eggs filled with goodies were scattered throughout the park. While we were preventing his younger brother from running into the street, Ezra took the liberty of exploring the contents of each egg well after his chocolate quota had been reached. When we finally noticed, Ezra continued, saying “uh-oh, I opened another one” as he peeled off another chocolate wrapper and quickly popped it into his mouth. Over the past year, I have witnessed hope. Simple hope to eat one more chocolate as well as vast, inspiring hope for a cure, hope for reconciliation, hope to have years, months, or even minutes more to live even when being told no.

Lesson #5: I’ll miss you

Every night we read books together, sing 2 songs, then I tuck Ezra into bed, give him a kiss and say “I love you. I’ll miss you. Sleep well.” Because even after a difficult day, the time between good night and good morning starts to feel long and I miss the boys sleeping in the room beside me. I have seen many people die over this past year of fellowship and years of residency, but I remember most the big, large, deep love I have seen fill hospital rooms and homes. So on behalf of all of those who were lost this past year, I write with a full heart, to our loved ones who have gone before us “We love you. We miss you and sleep well.”

by: Laura Koehn (@lauraekoehn)

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Wednesday, June 18, 2014

Motivating Aging Friendly City Design with a Personal Touch



The WHO Global Network of Age-friendly Cities and Communities (GNAFCC) promotes the generation of knowledge on how to assess the age-friendliness of a city or community, and provides guidance on how to create age-friendly urban environments. All members of the Network share a commitment to creating physical and social urban environments that sustain age-friendly, healthy, livable communities for older adults.

Having the option to age independently within one’s community is a fast emerging global prerogative. Cities and communities can share experiences by joining the network directly or through sister organizing bodies such as the American Association for Retired Persons (AARP). They can access the global resources and approaches cities and communities are taking to define baseline measures for policy and practice and exchange results under commonly defined domains and categories.

Over the last two years, the City of Chicago in partnership with Northwestern University has conducted an assessment of the city’s age-friendliness in accordance with the terms and conditions of Mayor Rahm Emanuel’s membership in the World Health Organization’s Global Network of Age- Friendly Cities. Utilizing the World Health Organization’s Age Friendly protocols and resources, the Department of Family and Support Services (DFSS) has begun to build an evidence based profile of older Chicagoans using a range of methods and drawing on a variety of funding sources. Methods to date have included: focus groups with older adults using senior centers, an environmental scan of popularly cited age-friendly indicators for livable communities, q sort interviews with key stakeholders working with older adults in the community; a community wide survey for all older Chicagoans. If you work with older adults in the City of Chicago please friend the Age-Friendly Chicago Survey on Facebook here or send out the survey link (http://www.surveymonkey.com/s/ChicagoAgeFriendlySurvey).

by: Jay Bhatt DO MPH, Northwestern Feinberg School of Medicine &
Rebecca Johnson Ph.D, Northwestern Feinberg School of Medicine
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Thursday, June 12, 2014

World Elder Abuse Awareness Day (WEAAD) is June 15 – Take Action to Protect Older Persons



It is estimated that 5 million older Americans are abused, neglected and exploited each year yet only about one in five of those crimes are ever discovered. WEAAD was launched in 2006 to promote a better understanding of abuse and neglect of older persons and to highlight its significance as a public health and human rights issue.

Each year communities and organizations around the world plan activities and programs, both small and large, in an effort to make a difference in the lives of vulnerable elders. Consider taking a moment to visit the Administration for Community Living (a part of HHS) website on WEAAD, for a variety of tools, tips and resources you can use in support of efforts to raise awareness about the importance of preventing, identifying and responding to this often hidden problem (World Elder Abuse Day Tools).

by: Joan Abrams, MPA
Associate Director UCSF Northern California Geriatric Education Center
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Monday, June 9, 2014

Behavioral Symptoms of Dementia Should Be Treated WIth Behavioral Approaches



Persons with dementia often suffer from behavioral symptoms such as agitation and aggression.  For the caregiver, these symptoms can be very distressing.

Consider the case of a daughter trying to take care of her mother.   Daughter is doing her best, and after a long day of work, comes home to take care of her Mom, and help with her activities of daily living.  While trying to help her mother bathe, Mom gets angry, swings her arm toward her daughter, and yells, "why do you always try to hurt me?"  The daughter loves her Mom, but stuff like this is often the breaking point that makes transfer to a nursing home necessary.  And it is not like Mom's agitation will be much better in the nursing home.  Often, the nursing home will treat Mom with an antipsychotic drug.  The drug will be marginally effective at best at improving the agitation, and will also increase the risk for stroke, heart attack, and death.

There has got to be a better way.

Well there is a better way. A MUST READ article recently published in the Journal of the American Geriatrics Society describes a pragmatic drug-free approach towards understanding and managing dementia behaviors.  The approach is grounded a skilled and careful analysis of the behavior.  The approach goes by the acronym DICE, and considers patient, caregiver, and environmental perspectives.

The 4 DICE components are:

Describe the Behavior:  In our bathing example, a careful description would reveal that Mom gets verbally and physically aggressive at bath time.  Mom seems uncomfortable, and says "it hurts."  The daughter wonders if Mom is doing this on purpose.  She thinks it is important that she give Mom a bath every day.

Investigate to identify possible causes of the behavior:  In our bathing example, one would discover that Mom has arthritis, but is not on any pain meds.  Moving Mom's arms and legs causes pain.  Further investigation reveals that when Mom gets angry, the daughter gets angry and uses harsh, confrontational language.  Daughter does not know that agitation and aggression are common in dementia.  There are no grab bars in the bath which contributes to Mom's fear.  The daughter notes that Mom took daily baths all her life, and she feels it is her responsibility to keep things as normal as possible for Mom

Create a Management Plan:  To continue our example, Mom might be prescribed acetaminophen an hour before bathing.  The daughter would learn that aggressive behaviors in dementia are not intentional.  She could be taught to respond in a calm voice, learn how gentle touches might reassure her mother, and avoid sudden movements.  A new normal routine could be established that may allow for bathing several times a week, and explore possibilities such as sponge baths.

Evaluate:  After these steps are tried, one can work with the daughter to see which steps are working, and make refinements as needed.

This is the kind of practical stuff that is not taught in medical school or residency.  Also, these are the types of high caring, time consuming interventions that may be hard to implement in most office practices.   Kind of a shame that there is much more profit in doing scans and procedures on dementia patients than on actually doing interventions such as DICE that will really help the patient and caregiver.  But a clinician that learns the DICE approach will gain a lot of satisfaction from making a big difference for their patients and those who care for them.

by: Ken Covinsky (@geri_doc)

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Friday, June 6, 2014

An antidote for our emotional distance

 
By: Laurel Coleman, MD

I have been pondering Danielle Ofri’s NY Times column, “The Silence of Doctors Around Alzheimer’s” for the past few weeks.

Dr. Ofri’s article raises some very good points, and this excerpt especially caught my attention:
“Most doctors are required to get recertification every 10 years, to undergo a battery of tests and training courses to keep us up to date and to identify shortfalls in our medical skills. We don’t, however, do any periodic checks on our inner selves, to uncover any lapses in our emotional core that might affect the care of our patients.  
Just because the diagnosis of dementia can be difficult and treatments frustratingly limited doesn’t mean we can shy away from this disease. We need to face down our own uneasiness, confront our own disconcerting reactions, so that we may be there in full for our patients, their families and, indeed, ourselves.”
Well-intended clinical pathways and algorithms that are designed to achieve good care do not address the “lapses in our emotional core.” How do we examine ourselves for these lapses, identify our own fears and denial, and equip ourselves to be present “in full?”

Of course, just taking a moment to realize how we feel when interacting with a person with dementia is the first step in changing how we behave and ultimately improving the quality of our care. Dr. Ofri’s article challenges us to think about the “how” and the “why” of any uneasiness that we might experience in this context.

I am reminded of the author Henry James’ challenge to be, “finely aware and richly responsible," and of being a person "on whom nothing is lost." He argues that literature and the arts are crucial to our moral development, and quite possibly an excellent antidote to the “lapses in our emotional core” that Dr. Ofri identifies.

Therefore, I think we should try to encounter Alzheimer’s Disease in a different way – outside the office or the hospital. Go to a play, read a book, or watch a movie. The arts reach us at our core, and they often invigorate and inspire us in a more lasting way than a professional article or lecture. Here are three specific suggestions that I have found helpful recently.

Try to see “The Genius of Marion,” an outstanding documentary film about a woman and her family as they come to terms with this illness in a way that honors her humanity. It will be on PBS stations, September 8th – or check for local showings on “Geniusofmarian.com”.

An excellent new book produced by Dr. Peggy Noel of MemoryCare in Asheville, NC includes 3 one-act plays about the experience of Alzheimer’s Disease. They were selected from a national competition and performed by local actors in Asheville for a standing room only audience. I left the performance with renewed energy and compassion for the patients and the caregivers that I see in my practice. “The Memory Care Plays” book provides the scripts so community groups can produce them locally – or you can just read them personally. “The MemoryCare Plays” is available on Amazon.

The gripping novel by Lisa Genova, “Still Alice” is being produced as a movie – soon to be released to theaters with Julianne Moore in the lead role. It is unique in that the narrative comes from the person with dementia – opening up a new perspective for us as physicians. What does it feel like to experience Alzheimer’s, to become unmoored from the intellectual skills and talents that we have so long cultivated?

If we are to be more “finely aware and richly responsible,” then we need to examine our inner self. We are faced with a difficult and incurable disease, but we can be better health care professionals when we engage dementia through the arts. Don’t shy away from Alzheimer’s Disease. Try the antidote, because your patients need you.

By: Laurel Coleman MD, @lmcmd
Augusta, Maine
Member, Alzheimer’s Advisory Council, HHS

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Thursday, June 5, 2014

House calls go Hollywood



Mindy Fain, Chief of Geriatrics at the University of Arizona, penned a fabulous Op-Ed in today's Los Angeles Times extolling the virtues of home care medicine to what is surely a wide new audience. Readers of GeriPal are probably familiar with how house calls can provide safe, effective care that is both cherished by patients and cost-saving to boot - but I hope visibility like this will help the message sink in with policymakers as well!

Coincidentally, I had the pleasure of meeting Dr. Fain this morning as we both arrived at a scientific workshop designed to engage geriatricians and basic scientists in a conversation about how to move recent advances in aging biology into the clinic. What a day! House calls to mouse models to clinical trials and back again. It is an exciting time to be a geriatrician!

by: John Newman
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Neuropalliative Care: Call to Action and Top 10 Pointers

When I chose to pursue a residency in Neurology, the first response from my medical school acquaintances was “But, you seem so normal.”

I laughed politely while simultaneously angling myself so they could no longer see my self-drawn neuron tattoo. Inevitably my medical school classmate's follow-up statement was “I could never be a neurologist. It’s too depressing.”

But when I revealed my choice of specialty to laypersons, the first response was awe. Then I broke the bad news that I was not going to be a Neurosurgeon.  Then they would ask “well what do you do if you don’t operate?” What followed was often a longwinded explanation on my part but could have been summed up with the statement “I think about and treat patients with neurologic problems.”

After completing my training in Neurology, I chose to go into the subspecialty of Hospice and Palliative Medicine at which time I again heard “that must be so depressing,” and responded to “what exactly is that?”

To me, being a palliative neurologist means that I think about and attend to the suffering of patients with neurologic illnesses.  Most of our patients are dying of their neurological illnesses.  These are not curative conditions. And Neurologists provide the bulk of the care for some patients - stroke, Parkinson's disease, epilepsy, multiple sclerosis, and brain tumors.

I have worked with many neurologists who are skillful communicators, well versed in conversations around breaking bad news, delivering prognosis, and attending to patients’ and families’ suffering. I have been inspired by the care they provide. However, many neurologists are not as equally skilled in these areas as they are in other aspects of neurologic care. I certainly was not. I needed to complete a fellowship to even start gaining proficiency.

In February, the journal Neurology published an article by Dr. Alexis Dallara and Dr. Dorothy Weiss Tolchin titled “Emerging Subspecialties in Neurology: Palliative care.” They eloquently describe the great need for the integration of palliative care into the field of neurology while acknowledging the gaps in neurology training and representation in the field. As they discuss, the ACGME requires neurology residency programs to provide training in end-of-life/palliative care topics but they note:
“Fewer than 5% [of Neurology residency programs] provide internal clinical rotations, and fewer than 3% provide external clinical rotations.” 
I was fortunate to be a part of a residency program at UCSF that recognized this need. They have supported me in my interests in palliative care and continue to do so.

Still, at this time:
“Fewer than1% of neurologists are board certified in hospice and palliative medicine, and fewer than 2% of palliative care clinicians are neurologists.” 
Meanwhile, the number of patients with dementia continues to rise as the population ages, young men and women are disabled with multiple sclerosis, fathers and mothers are suffering from Parkinson’s Disease, friends are devastated to learn they have glioblastoma and we need to provide better care, care that is patient centered and compassionate.

As I finish my fellowship in palliative care, I am eager to return to Neurology with a new perspective.

While I am practicing neuropalliative care I will keep the following cheat sheet of pointers in my neuro bag, next to my reflex hammer.  These pointers may apply to any field, but I view them through the lens of Neuropalliative care.

  1. Acknowledge that many of the illnesses we treat are life-limiting and have major impact on patient and caregiver's quality of life. You are practicing palliative care!!! 
  2. Sit down. 
  3. Be quiet.
  4. No one wakes up thinking they will have a stroke. Pause and remember the gravity of this day. 
  5. Ask for their understanding of their illness. It will save you time and build rapport.  Focus on the relationship.  The first goal of any new patient/family encounter is to build relationships.
  6. Listen. I have heard many neurologists say that if you do not have the diagnosis after obtaining the history, retake the patient's history. But caring for the patient is far more than providing a diagnosis. Apply this same skill to their social history and experience of their illness.
  7. When making recommendations as a consultant, the first recommendations pertain to the standard of care. The next recommendations must always apply that standard of care to the unique patient’s own standard, context, and goals.
  8. Prognosis. We struggle with providing helpful and accurate estimates of prognosis for many reasons, but everyone knows you cannot predict the future. They are asking for your valuable opinion based on the evidence and your experience. In your opinion, what is the functional outcome in the best case scenario and worst case scenario. Be consistent with other providers and the family.
  9. You are not alone. Rely on your team of social workers, chaplains, and nurses.
  10. Ask a Geriatrician! They may have far more experience doing palliative care for patients with advanced neurological conditions, particularly dementia.  
 by: Laura Koehn, @lauraekoehn
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Wednesday, June 4, 2014

Embracing Direct-to-Consumer Advertising by Focusing on Stopping Medications



There are plenty of examples of direct-to-consumer advertising that the pharmaceutical industry use to lure new customers. Just like the Cancer Center ads we discussed in the last GeriPal post, these ads almost universally do this by making emotional appeals to the consumer, as well as focusing on the benefits rather than presenting any real discussion of risks.

What if someone used a similar concept, but instead of trying to get people to take a drug, they try to convince patients to stop one. That’s just what Cara Tannenbaum and colleagues did in a paper published in JAMA IM, albeit they called it direct-to-consumer patient education and empowerment.

The Study

In brief, the authors of this study conducted a cluster randomized trial in Quebec in which a total of 303 long-term users of benzodiazepine medication aged 65-95 years were recruited from 30 community pharmacies. These pharmacies were randomized to either a control arm or the educational intervention arm.

The educational intervention was an eight page booklet that was mailed to the patient (and can be downloaded here) describing the risks of benzodiazepine use and a stepwise tapering protocol. Like other direct-to-consumer advertising, they also include a patient testimonial "intended to augment self-efficacy."

What they found was striking. Complete cessation of benzodiazepine use in the 6 months following randomization was achieved in 40 of the 148 (27%) in the intervention arm compared to 7 of the 155 (5%) in the control arm. Even better, the number needed to treat for any discontinuation or dose reduction was 3.7 in an intention to treat analyses.

The Take Away

Health care professionals should embrace direct to consumer advertising as it isn't going away.  How?  Just imagine a world (or just the US and New Zealand as I think they are the only Western nations that allow direct-to-consumer advertising) where after every time a drug company markets a drug to consumers, especially a potentially habit forming drug like the ad below, these companies also have to pay for an intervention like this one that gets those very same people off of their drug when it is no longer indicated or inappropriately prescribed.  Now that would make me sleep more comfortably at night.



by: Eric Widera (@ewidera)
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Monday, June 2, 2014

The Business of Selling Hope Part II: Direct-to-Consumer Cancer Center Advertising




The majority of cancer patients with incurable stage IV lung or colon cancer think that the chemotherapy they are receiving might cure them.  This was the finding of a study that we discussed in a previous GeriPal post.  Much was discussed about the failure of prognosis communication and the potential role that denial played in the outcome of this study.  But open up a magazine or turn on the TV and you find some other force at play, one that is in the business of selling hope and fear.  One that is best summed up by the following quote from a cancer center advertisement:
“My doctor back home gave me ONLY a few weeks to live. That's when I made the ONE decision that saved my life. I went to [X cancer center]. That was seven years ago. And counting”
We have written about potentially deceptive cancer center advertisments like this in the past, but a recent Annals of Internal Medicine article for the first time helps quantify the practices that these centers are using to bring in patients and referrals.  The authors set out to characterize the informational and emotional content of direct-to-consumer cancer center advertisements. They looked at local and national advertisements in the top 269 U.S. consumer magazines and on 44 television networks in 2012 to evaluate:
  • What types of clinical services these cancer centers promoted to consumers, including whether supportive services were address (including nutritional services, complementary and alternative therapies, spiritual services, psychosocial services, physical or occupational therapy, and palliative care).
  • Whether they addressed the risks, benefits, costs, and insurance availability when discussing clinical services.
  • Whether they used an emotional appeals in their advertising.
  • Whether they used patient testimonials.

What they found

The authors found in their sample that 102 cancer centers included the following content in their direct-to-consumer advertising:
  • Types of clinical services promoted
    • It probably comes at no big surprise that treatments are most often promoted (88%) compared to screening screening (18%) or supportive services (13%). Sadly, only 2% of advertisements mentioned palliative care or symptom management services (e.g. “pain management”)
  • The amount of information provided about these clinical services
    • Again, not a big surprise here either. Benefits of advertised therapies were described a whole lot more than risks (27% vs. 2%). Importantly though, when benefits were described, they were rarely quantified (2%), and no advertisements quantified risks. It was only the rare cancer center advertisement that mentioned coverage or costs (5%), and none mentioned specific insurance plans.
  • The use of emotional advertising appeals 
    • Emotional appeals ruled the day (81% of adverts). The majority (61%) used language that evoked hope (i.e. “your last hope”). 41% of adverts used used fighting or battle language (“I fought, I won.”). 30% evoked fear (“I didn't know if anyone survived pancreatic cancer.”) On the bright side though as I thought it would be much worse, slightly less than a third discussed patient comfort, compassion, symptom management, or quality of life
  • Patient testimonials 
    • Nearly one half of advertisements included patient testimonials, which were usually focused on survival, rarely included disclaimers (15%), and never described the results that a typical patient may expect.

Take Home Point

Cancer centers, even the most prestigious and academic ones, have positioned themselves to be in the business of selling hope.  If you don't believe this study, just do a quick youtube search for both subtle and not so subtle references that play on both hope and fear:

Cancer Center #1: "I was given three months to live..."


Cancer Center #2: "Good morning cancer, watch your back."


Cancer Center #3: "Your best chance of winning is here"


Cancer Center #4: Man with pancreatic cancer: "The five year survival rate is single digits, and here it is eight years later."



by: Eric Widera (@ewidera)
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Monday, May 26, 2014

Support Veterans' Access to Hospice


Memorial Day/Decorations Day

In Columbia, MO the parade went off without a hitch. The Golden Eagles parachuted right onto their marks amongst the various downtown buildings at the start of the parade and of course they nailed their landing. It is a fitting time for all of us to pause and remember those servicemen who died while serving their country.

And in fact, it is an appropriate time to honor all veterans for their service.

I have always enjoyed working with the Veterans Administration (VA). My hospice is an active participant in We Honor Veterans. And I have always found the quality of care delivered locally to be superb, and I think the VA leaders that I have personally known are dedicated to their jobs and superb leaders, so I have found recent news reports of access problems quite disappointing.

But this Memorial Day, I want to bring to your attention a less publicized access issue that impacts veterans: access to hospice.

Current statute does not require the VA to cover hospice care for veterans who had not enrolled in the VA system in the past for prior care, or do not fit the family income and asset brackets identified by the VA. The current VA hospice directives are subjective to each individual VA facility and interpreted differently by different caseworkers.

Congressman Chris Collins R-NY wants to make sure that no veteran is denied access to hospice. Working with concerned veteran advocates, Collins drafted the Care for our Heroes Act to make all veterans eligible for VA hospice care. This is a bill that should pass.

Tell your Congressman/Congresswoman to support Care for our Heroes Act (HR 4725). You can find you representative here: Find your Representative

by: Paul Tatum (@doctatum)
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