Friday, January 30, 2015

Food is love, or The fundamentals of Long Term Care



Although I usually think with my stomach, I have been particularly preoccupied with how we feed our most vulnerable elders this week. That’s because my Home Based Primary Care team took up the #ThickenedLiquidChallenge in order to raise our awareness of what we put our patients through. The challenge is admittedly biased to make one hate thickened liquids. Participants have to thicken everything they drink with corn starch until it resembles honey in consistency. Those of us who have fed these products to our patients are well aware that “nectar-thick” liquids are much more palatable (i.e. less disgusting).

It has been fascinating to watch a transformation take place as we accept the challenge. Our dietitians are speaking up in team meeting. They are questioning whether or not thickened liquids are consistent with our patients’ goals and wishes. We care for patients at home, so we are well poised to ask this question. HBPC can even bring a provider and the RD out together on a house call in order to discuss the lack of medical evidence about risks and benefits. More importantly, we can sit in the kitchen and address what we definitely know about the burdens of gagging down thickened liquids and the burdens of attempting to enforce a “chin tuck” when feeding thin liquids to a person who has dementia. This is not just patient centered care, it is family centered care.

I’m also a nursing home doc who has taken care of SNF patients for a decade, so I was delighted to see that this week’s Journal of the American Medical Directors Association (JAMDA) has published a special research agenda to improve food and drink intake in nursing homes. It was even more exciting to see an exhaustive literature review of the research, such as it is, about increasing fluid intake and decreasing dehydration. They found modest evidence that dehydration was reduced when nursing home residents had a greater choice of things to drink, when staff were made aware of the need to encourage fluids and became more involved assisting with drinking and toileting. Not surprisingly, it concludes with a plea for well-designed studies.

Getting back to the thickener question, we need well-designed studies that examine quality of life, incidence of pneumonia, and hydration status before and after we choose to abandon thickened water. Qualitatively, I can tell you that my patients with dementia so severe that they were wheelchair bound appeared much happier when liberated to plain water. So did the ambulatory patients. Shoot, so did everyone. And the only significant aspiration I’ve ever witnessed involved a desperate theft of a big hunk of meat from a neighbor’s plate. To be fair, giving plain water carries burdens for help dysphagic patients to drink. After 15 minutes of saying “tuck your chin” before every swallow, I get twitchy with frustration, yet that is what is needed to reduce coughing and sputtering. If I had to choose between my own impatience and my patients’ happiness, I choose their happiness. No question.

At the end of the day, food is love. Drink is no different. It hurts us in subtle ways when we force people to eat and drink the things they hate. We often demonstrate affection through the food and drink we give to those who we love. When the Speech Pathology report comes back showing high risk of aspiration, we should put that love on the table as we discuss goals of care and the burdens of treatment.

by: Theresa Allison


Note: This post is part of the series on the #ThickenedLiquidChallenge.  To watch the videos of this challenge go to our original post here, or check out the videos on YouTube:

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Tuesday, January 27, 2015

What is Reminiscence Therapy and does it work?

Ms. HR is an 84 year-old lady with mild to moderate Alzheimer’s disease (Mini Mental State Exam score of 22) and hypothyroidism for about 5 years, with gradual but steady worsening in her memory over past year. She takes levothyroxine and donepezil. Currently, she lives with her daughter and is independent in her ADLs (activities of daily living) and IADLs (instrumental activities of daily living). In light of the memory problems, her family wonders if in addition to her cholinesterase inhibitor (donepezil), using old photos or videos might help preserve some of her memories. One of our social workers brought up the concept of reminiscence therapy.

Reminiscence therapy (RT), which was introduced over 20 years ago, makes use of life events by having participants vocally recall episodic memories from their past. It may take place in a group setting, individually, or in pairs. It may be structured or unstructured. While the primary aim of RT is to strengthen cognitive memory components, a secondary goal may be to encourage either intrapersonal or interpersonal development. Reminiscence therapy may use prompts such as photographs, household items, music, or personal recordings.

My clinical question was the following: In community dwelling patients with dementia, does reminiscence therapy compared to conventional treatment provide any improvement in cognition and quality of life?

I searched the terms “Reminiscence Therapy” and “Dementia” on Pubmed. In addition to several small descriptive observational studies, I was able to locate a 2005 Cochrane review. This review found only 4 suitable trials with a total of 144 participants - they were very small studies, or of low methodological quality, and each examined a different type of reminiscence work.

Taking studies together, some significant results were identified: cognition and mood improved 4 to 6 weeks after the treatment, caregivers participating with their relative with dementia in a reminiscence group reported lower caregiver strain, and people with dementia were reported to show some indications of improved functional ability. The improvement in cognition was evident in comparison with both no treatment and social contact control conditions. Staff knowledge of group members’ backgrounds improved significantly. No harmful effects were identified on the outcome measures reported.

Thus, the evidence-base for effectiveness of RT continues to rest mostly on descriptive and observational studies, very few RCTs, which are mostly small, or of low quality with some variation in outcome and design. However, given the lack of harmful effects, I did not see any reason not to recommend RT. I believe it may benefit some of the daughter’s strain and increase interactions with among the family members.

Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai

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

Reference: Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence therapy for dementia. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001120. 
Picture courtesy: Amos

Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases
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Monday, January 26, 2015

Pallimed-GeriPal Party at the Annual Assembly of AAHPM-HPNA-SWHPN



Time to gather your peers and join fellow readers of Pallimed and GeriPal for our annual party at the Annual Assembly of AAHPM, HPNA, and SWHPN. Since the last two years were such a success with the progressive party we will be doing that again this year. We will begin at McGillin’s at 8pm. After that follow the hashtag #HPMparty or our Facebook event page where we will be posting updates on the next location.

All are welcome, this is no exclusive crowd. There will be many writers from both websites at the party and we always like to meet readers and hear your feedback.

McGillin’s is near the corner of 13th and Chesnut just a few blocks South of the Marriott Hotel and Convention Center.

Date: Thursday, February 26th. Start time 8pm. End time TBD

Where: Depends:

Starting location: McGillin’s Olde Ale House
  • 1310 Drury Street, Philadelphia, PA 19107 
  •  Near the corner of 13th and Chestnut

Map:


 

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Friday, January 23, 2015

Working with rather than against speech & swallow therapists #ThickenedLiquidChallenge


Photo by Joan Teno

By Alex Smith @AlexSmithMD and Sarah Stranberg, Speech Pathologist, University of Pittsburgh Medical Center

Consider the following vignettes, common in both geriatrics and palliative care:

1. A 93 year old woman with advanced dementia is admitted to the hospital for the third time in the past 6 months for an aspiration pneumonia. The admitting team orders a speech and swallow consult.

2. A 68 year old man suffers a massive ischemic stroke. After 15 days in the ICU he has recovered minimal function.  The neurology team requests a speech & swallow consult to justify likely need for PEG (a hole into the stomach for artificial feeding through a tube).

In each of these cases, my initial reaction has always been “Noooooooooooooooooo!!!!! Don’t place the speech and swallow consult!” I worry that the consult will place the patient on an inevitable path toward a PEG tube, without assessment of goals, values, and alternative approaches such as hand feeding.

However, at the annual Foley retreat of the National Palliative Care Research Center, Bob Arnold suggested a different approach. He has been working with his speech & swallow colleagues to develop a palliative approach to patients with difficulty swallowing. Here are some of the changes:

Old speech and swallow recommendations

• Unsafe for feeding
• NPO. Needs feeding tube

New speech and swallow recommendations

• High risk for aspiration
• Assess goals and values related to feeding and nutrition

This is a great idea, and something we should try more broadly around the country. For more detail, attend the workshop at the HPNA/AAHPM Annual Assembly on “palliative dysphagia” Saturday at 1:15.

This post appeared first on Pallimed as part of a wager on the World Series.   We are re-posting on GeriPal as part of the series on the #ThickenedLiquidChallenge.   To watch the videos of this challenge go to our original post here, or check out the videos on YouTube:
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Wednesday, January 21, 2015

Do thickened liquids benefit people with swallowing problems? #ThickenedLiquidChallenge



There are a lot of people with swallowing difficulty who are currently getting thickened liquids.  For instance, in one study published in 2004 in the Journal of the American Dietetic Association, one out of twelve nursing home residents in the U.S. were getting thickened liquids. Of these individuals getting thickened liquids, 30% were getting honey consistency thickened liquids and 60% were getting nectar thick (which is less viscous than honey thick).

If this many individuals are on thickened liquids, there has to be some evidence to back it up, right?

Evidence for Thickened Liquids

Thickened liquids are most commonly used in individuals with dysphagia to improve the ability to safely swallow liquids with the hopes of preventing aspiration, pneumonia, and death. Most of what we have regarding the benefits of thickened liquids comes from bedside or videofluoroscopic evaluation looking at risk of aspiration during the evaluation.   However, what we really care about is not the short term risk of aspiration of thin liquids during the exam, but the longer term outcomes like pneumonia which is the primary cause of death seen with aspirations.

The best evidence we have on the risks of pneumonia or death after treatment with thickened liquids comes from a randomized controlled trial published in 2008 in the Annals of Internal Medicine.  The study included 515 hospital or nursing home patients age 50 years or older with dementia or Parkinson disease who aspirated on thin liquids during videofluoroscopy.  The patients were randomized to drink all liquids using a chin-down position, or to drink nectar-thick liquids, or to drink honey-thick liquids. The main outcome of interest was 3-month cumulative incidence of pneumonia.  The authors of this study also looked at mortality at 3 months and at adverse effects. What they found was the following:
  • There was no difference in rates of pneumonia between the chin-down-posture and thickened liquid intervention (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P _ 0.53)
  • Drinking the thinner nectar-thick liquids was associated with a lower incidence of pneumonia than drinking the thicker honey-thick liquids, although this was not statistically significant (HR, 0.50 [CI, 0.23 to 1.09]; P: 0.083)
  • The combined outcome of at least 1 dehydration, urinary tract infection, or fever event was more common in the group getting thickened-liquid [9% vs. 5%, P of 0.055).

There are a couple of big limitations to this study when trying to generalize it to the patients that we see on a daily basis.  The biggest is that while all the patients had aspirations on exam, the study included only those patients who did not benefit preferentially from either chin tuck or thickened fluids on videofluroscopy.  So, we still don't know if those who seem to benefit from thickened fluid during videofluoroscopic evaluation actually have better long-term outcomes on these diets.

What are the harms:

Having taken the thickened liquid challenge (#thickenedliquidchallenge) I can attest to some of the biggest side effects from thickening the fluids that we normally drink: thirst, dry mouth, dehydration, and a feeling of fullness. I was dying of thirst 12 hours into the challenge despite trying to take in enough thickened liquids. Part of this was due to the fact that I just wasn't taking in enough fluid because of the poor taste of the thickened liquids and because the thickener made me feel full from all that starch. This is consistent with current research that individuals who take in thickened liquids consume less fluids than if they were to consume regular thin liquids. The other part that added to my discomfort was was that thickened liquids never really quenched my thirst no matter how much I drank of it.

The Take Home Point

Does thickening fluids help individuals with swallowing problems?  Despite my research into this question, I'm left with the unsatisfying recognition that I just don't know.    It does appear to help decrease risks of aspiration of liquids during videofluoroscopy, but we don't have very good data to say that it will prevent aspiration pneumonias or death.  It is at best an educated guess.

The uncertainty of benefit is really the take home point.  When we talk to patients and family members about potential interventions for dysphagia, we must be honest with the fact that we don't have very strong evidence that it will prolong their lives, although we may have some evidence that it will decrease aspirations.   We also can tell them that thickened liquids may increase their chances of becoming dehydrated, it may not quench their thirst, and they may not like the taste.

by: Eric Widera (@ewidera)

Note: This post is part of the series on the #ThickenedLiquidChallenge.  To watch the videos of this challenge go to our original post here, or check out the videos on YouTube:


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Monday, January 19, 2015

The Thickened Liquid Challenge - #ThickenedLiquidChallenge




Our hospice and palliative care team decided this weekend to do the "Thickened Liquid Challenge.”  This is a simple challenge that is mainly focused on putting ourselves in the shoes of our patients who are prescribed thickened liquids (or perhaps I should say drink from their cups).

The rules are simple:
  • 12 Hour Challenge: All fluids must be thickened to “honey consistency” using a beverage thickener for a 12 hour contiguous period. Food does not have to be thickened.
  • Mini-challenge: drink an 8 ounce drink thickened to honey consistency (coffee, wine, juice, water, or any drink of your choice)
  • Videotape yourself and include an announcement that you accept the challenge
  • If you fail the challenge you must donate $20 to a geriatrics or palliative care charity of your choice (see notes below for some suggestions)
  • At the end of your challenge, nominate a minimum of three other people/teams to participate in the challenge. 
  • When posting the challenge online, please use the hashtag #thickenedliquidchallenge

We’ll spend some time on the next post about the data behind thickened liquids for individuals with dementia and other diseases where swallowing is an issue (spoiler alert: it’s not good, despite the fact that 8% of patients in skilled nursing facilities are taking thickened liquids).

by: Eric Widera (@ewidera)‬

Note: here are some good hospice, palliative care, and geriatrics charities to consider:

Geriatrics: 
Hospice and Palliative Care: 
Other notable organizations:

12 Hour Challenges Accepted (if you do a 12 hour challenge, we'll post it on GeriPal even if you don't finish):











Note: This post is part of the series on the #ThickenedLiquidChallenge.  To watch the videos of this challenge check out the videos on YouTube:

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Saturday, January 17, 2015

Institutionalized and Interventionalized: the ways we care for the medically fragile



by: Diane Stonecipher, RN

As a young nurse, some 30 years ago, I worked in a large academic medical center, famous for its cardiovascular surgery. The environment was exciting, scary, cutting edge and steeped in humanity. Anything that could be done was done, yet these physicians were pioneers, not profiteers. They were making discoveries and doing procedures on the cusp of progress. Fearless and skilled, they were not particularly comfortable with death or failure and I was often in the position of tending to the daily needs of patients who no longer saw their surgeon frequently. Uncomfortable in the OR, I was very at home at the bedside. It was here where I learned so much about these patients and here where I could ask what they wanted and they were free to tell me. I never thought twice about getting Mr. B some sushi and Chinese food or Mr. M a small bottle he could hide for his “nightcap.”

I also noticed how much the family members appreciated that once nothing more could “be done” they no longer had the weight of the guilt, confusion and stress of decisions. Maybe if instead of saying, “he will die if we don’t…” we had said, he is going to die and we can make that less painful and frightening, these patients and their families could have had this peace earlier. Maybe if they were not made to feel awkwardly guilty if they didn’t consent to having everything done, their true courage may have been more recognizable. And maybe, suddenly, when the tide turned against them, they did not feel that people were avoiding them, they could have embraced the tide.

I was a nurse for 15 years before I had my first child and ironically (or not), our first son suffered a catastrophic brain injury during labor. Heading home after a month in the NICU, he looked pretty perfect, despite his rocky entry. Two months later, an MRI revealed what we already knew. His head had not grown and his brain looked like swiss cheese. Given a dismal prognosis, my husband, a family practice resident, and I decided to care for him and love him and pass on the feeding tube. He was breastfeeding successfully if not skillfully. So, we would give him what he needed and what he wanted: touch, smell, taste and comfort.

We went on to have two more sons and the pressure from the medical and early intervention specialists mounted for him to have a feeding tube. Their wisdom was that he was underweight and spoon feeding was unnecessarily time consuming for him and us. Our wisdom was that we were going to be lifting him his whole life, we were willing to make the time to feed him and there was not much else he wanted to do. This kind of feeding was important to him and to us.

He had a lot of reflux and the pressure to place a feeding tube continued. Reflux was common for “these kids” and a feeding tube, if placed in conjunction with a Nissen procedure, would mitigate that. Desperate, but not convinced, we had him scoped and lo and behold, he had pyloric stenosis. They still wanted to Nissen and PEG him, but we opted for just the pyloroplasty. He is now 23 years old, still cortically blind, quadriplegic, profoundly impaired, he is eating as happily as ever. He has never had aspiration pneumonia and has long outlived his tribe. He has been hospitalized only 3 times, although he has been on hospice twice.

I use this example because it is the simplest to illustrate how our society has institutionalized care for the medically fragile (especially for the very young and very old) and interventionalized that care often for convenience and profit. I think when a patient or family member hears, “they will die if we don’t…” they have a reaction. If instead they heard “We are doing this because we don’t have staff to feed your mother by hand” or” there is higher reimbursement when we place a gastrostomy tube in your loved one,” families might think again. Essentially, physicians have done to children like our son what they do to the elderly and terminally ill; profited in the name of care, even if they are not consciously aware of this. How one wants to be cared for has been overridden by a drive for profit and restricted by time. These parameters are neither morally nor medically sound. A business model is not a health care model.

The hospice and palliative care community, caring for infants to elders, is tasked to turn this system around. It is time for the pioneers to return.

Photo courtesy of Nancy Lundeberg ©2014

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Wednesday, January 14, 2015

Geri Tech: It's the little things


There's a lot of interest in using technology to improve the lives of seniors, especially here in the Bay Area. This Christmas my grandmother received as a gift this little gadget which to me so beautifully captured both the promise and pitfalls of such tech.

It's a headlight. For a walker! Brilliant. Maybe.

If you want to help seniors, first you need to identify a problem. Falls are a big problem. Many falls occur at night, when a person gets out of bed to use the bathroom in the dark.

Next you need to conceptualize effective solutions. We have many imperfect tools and strategies to help prevent falls at night, ranging from bedside commodes to reducing nighttime fluid intake to leaving lights on. The solution here is a light that attaches to the walker.

There's a lot to like. It's small, lightweight, and unobtrusive, yet has a strong LED light and long-lasting battery. The soft, stretchable plastic housing wraps simply but securely around the walker's horizontal brace. You just push the button to turn it on.

I push the button. It starts strobing like a Berlin disco. Dizzily, I push it again, and it relaxes to a slow blink. Once more and finally it's steady like a normal light. Fourth push to turn it off. Why does it have three modes? Why is the only obviously useful mode, the normal light, the third? Why does it strobe at all? Did they envision that the primary use of this light would be to alert oncoming motorists when elders walked their walkers along highway shoulders in the dark? Maybe they weren't thinking of the problem I thought they were thinking of.

My grandma tries to turn it on. She pushes and pushes but nothing happens. Maybe she's pushing in the wrong spot. Can she find the button? It's the same blue color as the rest of the device (in the photo above we had already painted it with nail polish to make it stand out). With no color contrast, the only hint that it's a button are some tiny ridges in the plastic. Alas, she can't feel the ridges - peripheral neuropathy has rendered her fingers mostly numb. And you actually need to push pretty firmly right in the center. She can't push hard enough with her finger. She finally gets it by pressing in the middle of our paint job with her fingernail. She seems undeterred by the strobe, but it still takes her a while (and quite a bit of concentration) to cycle through to the "steady light" mode. She wonders aloud if she should keep a screwdriver in her walker pouch to help turn it on.

I'm imagining someone with poor vision, numb fingers, and urgency desperately trying to get this darn thing to turn on in the middle of the night while their bladder holds out. My grandma, fortunately, has a bladder of steel. She took the gadget home to try anyway. I advised against the screwdriver.

So much about this gadget is right. It's cheap, simple, and might effectively help with a real problem. But it's done in by the little things. It should have a big, raised, brightly contrasting button that doesn't require much force to push. Maybe even have the button glow in the dark. And it should have two modes: on and off. My grandma could have told them as much. I can't help thinking that the manufacturer never had anyone over 40 try to actually use it. Yet it is specifically marketed as a "mobility light" for "mobility aids".

What are the lessons for tech mavens striving to fix our elders? Keep it simple. Test your product with the same elders you think might use it. If you're making a product for a walker, test it with elders who use walkers. Account for weakness, tremors, and sensory impairments. Good intentions and even good ideas are not enough - it's the little things that really count.

by: John Newman
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Choosing life: a story of the value of palliative care

by Leanne M. Yanni, MD

Minooka pasture 2008

It’s a name. It comes across in our Electronic Health Record as a consult is placed to the Palliative Care Team. Mary Tulane; age 67; ovarian cancer. I call her hospital doctor and ask, “How can our team be of support?” He replies, “She is refusing tests and her family is asking a lot of questions about her disease. They seem anxious and confused.” This is often how a consultation begins; a consultation that most often turns into a relationship.

A Palliative Care Team is a team of individuals with specialized training in serious illness.

As the doctor on the team, I assess how patients are feeling physically as well as how they are functioning which tells me a lot about the future trajectory of their illness. I then translate this medical information into an understandable framework that is used by patients and families to make important, often life-impacting decisions.  Understanding the emotional and spiritual response to serious illness (for example, fear, anxiety, spiritual tension, caregiver stress, and cues for complicated grief after a loved one’s death) requires the expertise of social workers and chaplains who are just as essential to the Palliative Care Team as doctors and nurses.

Melissa, a palliative care social worker, and I review Mary’s chart together. We immediate recognize the unfortunate yet common scenario that prompted the consult. The patient’s illness is worsening. She is being offered more treatment but her last treatment made her so sick. She is tired of being in the hospital. Her family, trying their best to care for her, is overwhelmed.

Prior to our meeting, Melissa visits Mary in her room to introduce herself and our service. A time is set to meet with Mary along with her husband Jeff and daughter Angie. The nurse caring for Mary sets up chairs for us to sit comfortably by her bedside. I introduce myself and Mary introduces Jeff and Angie. As I shake hands with them, I notice her husband’s downcast gaze and her daughter’s tearful eyes that seem be asking for help.

As Melissa and I quietly take our seats, I realize that the most important role I have is to set up a safe space for this conversation. “Mary, we are here today to listen to your story. This will help your health care team understand how best to support you. Would it be alright if I asked you some questions?” Mary calmly agrees.

I begin with inquiries about her upbringing, her schooling, and her work and family life. Tension in the room eases as Mary begins speaking of growing up on a farm, where she has ridden and raised horses since she was a child. They still own several horses that she rides in the pastures of her rural home. As she shares this with us, she turns her head and gazes out the hospital window. Softly she says, “When I was 15, my mother was very sick. We didn’t know what was wrong. My dad took her to the hospital and she never came home.”

Ill at ease, her husband interrupts the moment to explain that they had recently retired. They were on a road trip and Mary began to feel ill. They thought it was just a stomach bug, but over several days her stomach became painfully bloated. They were shocked at the emergency room test results; she had a large mass in her pelvis and had accumulated fluid in her abdomen. From that point on, he states, it has been a roller coaster of medical tests and treatments followed only by news they didn’t want to hear. Jeff states, “Mary has lost her strength; she was able to walk down the road just a few months ago and now can barely walk around the house.”

At this point, Mary sighs heavily and says, “I’m so tired.”

There is silence. With the gentle cue of Melissa’s hand on my shoulder, I wait.

Then I ask, “Mary, what have your doctors told you about your illness?” She pauses, then finding strength states, “It’s cancer that started in the ovary. It spread before I knew it was even there. At first, they said that treatment would help me live a long time. Even with all the treatment I’ve had, though, the cancer is growing.” Her husband adds emphatically, “But there is more we can do, Mary. The doctor said there are drugs your body hasn’t seen yet and even a doctor in New York who can help us.” “New York?” she responds, “That is so far away.”

I sense the discord between them. Mary has suffered through treatment that has prolonged her life to this point, but it’s been difficult to endure. Her husband has lost control to a cancer that is seemingly now in charge; he is responding with a fighting urgency. While Mary sees more treatment as a burden, Jeff sees it as “choosing to live.” As is often the case, choosing to continue medical treatment becomes an artificial representation of choosing life over death.

I ask Mary, “What is most important to you right now?” Mary states that she wants to be at home. During the day, she wants look out into the pasture and at night, she says wistfully, “I just want to sleep in my own bed.”

I ask Mary what she thinks about more treatment for her cancer. “Even if it gave me another month, if that month were in the hospital,” she says, “I would say no.” Jeff is looking at Mary as she says this in a clear, strong voice. She is talking to me but she is really talking to her husband, telling him what she couldn’t say directly - what she felt he wasn’t ready to hear.

Mary’s daughter Angie now speaks up: “Mom, if you want to be at home, we can do that. We can support you and care for you, whatever is needed.” Jeff reaches for Mary’s hand with both of his and bows his head. He searches for the strength he needs to take this step.

In a very short time, Mary has been able to express what is important to her, how she feels about her illness and, most importantly, her family has heard her. Really, this was their conversation.

Melissa and I help them through the process of understanding next steps. It takes several days to bring her symptoms of pain and nausea under control. Mary also has unresolved spiritual tension surrounding her mother’s death for which we engage a palliative care chaplain. After addressing these needs, Mary is discharged from the hospital to her home ready to live, even as she is dying.

Several months later, Jeff calls the office and asks to speak with me. He says, “Mary is dying now, it may only be a few days. With her bed near the window, she can see the pasture from where she lies. Since we left the hospital, she kept saying how happy she was to be home. She would say it over and over again. I just wanted to thank you.” His words echo deeply, I feel them, and then they fade.

I hang up the phone and see a new consult come across our Electronic Health Record. Edward Hobbs; age 82; Congestive Heart Failure. I call his hospital doctor and ask, “How can our team be of support?”

Dr. Yanni is Medical Director of Palliative Medicine at Bon Secours Virginia.


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Tuesday, January 13, 2015

Will You Wish With Us?



By: Kim Evanoski (@CareManage4All)

So I am waking up in the dark and, at the end of the day, driving through the dark finishing the work day; it leads to wanting “wishes” granted for some simple life treats like warm sun light through the car window.

 The act of "wishing" is pretty significant in palliative care, if you really think about it fully. It happens weekly, if not daily, where personal struggles require "wishing".

 Do you have "wishing" happening on your watch?

 In my practice, “wishes” are validated for the sheer empowerment of the act.

 "Wishing" is actually a significant activity. It provides a therapeutic and thoughtful process that I would like to encourage. I think "wishing" is important to all matters human. "Wishing" brings a tremendous amount of open thinking towards improving our internal and external worlds. And in that open thinking, "wishing" should be allowed in statement form with no judgment given whether explained or not. "Wishing" creates thoughts for me of hope, tolerance, insight, creativity, perspective, laughter, wisdom, and fun.

 What does "wishing" create for you?

 As we head into the light of the New Year, let us acknowledge and share our "wishing" as a healthy way to care for ourselves and to care for the world around us.

 Wishing you the comfort of “wishes”.

Photo courtesy of Nancy Lundeberg ©2014
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Monday, January 12, 2015

Prognostic Factors for Survival in Multiple System Atrophy


An 88 year-old male with probable multiple system atrophy-parkinsonism (MSA-P) with at least 4 years of gait instability complicated by fall and cervical fracture, sick sinus syndrome status post pacemaker placement, postural hypotension requiring midodrine and fludrocortisone, achalasia status post BOTOX® injection and dilation, urinary retention status post chronic indwelling Foley catheter presented to the Geriatrics outpatient clinic to explore hospice care. In a brief background search of MSA, I found that there are 2 distinct presentations of MSA – cerebellar and parkinsonian. In discussing his prognosis with the patient, I wondered if in patients with MSA, does parkinsonism phenotype predict better survival than the cerebellar phenotype? And are there other disease specific or patient specific features that predict survival in MSA patients? 


I searched the terms “multiple system atrophy, survival” on PubMed Clinical Queries (website url), which I have often found more useful than regular PubMed general search. To narrow my results, I selected the “Prognosis” category and “Broad” scope for the search. I found a systematic review of pathologically confirmed cases of MSA identified through search of MEDLINE and other published reference lists from 1887 to 2/1995.

Individual patient data was reviewed, although there was no mention about assessment for validity of the individuals case reports and case series. Of the total of 433 cases included in the analysis, 358 cases were reported from 1971 through 1994. Chi-squared test for heterogeneity showed significant heterogeneity in age of onset, autonomic features, parkinsonian features, pyramidal features and MSA type across the board. The mean age onset was at 54.2 years of age, and mean survival around 6 years. Majority of the cases (> 80%) had autonomic features or parkinsonism.

The only significant predictor of increased survival were younger age at onset, more recent publication, and presence of cerebellar features. The results were not altered when accounting for the life expectancy of the general population over time from 1887 through 1970 and from 1971 through 1994. There was a trend toward worse survival when the case had more than one clinical features (parkinsonism, autonomic, cerebellar, pyramidal)

Back to the Patient: Using the information from this systematic review and patient’s clinical picture of likely at least a 4 year of disease duration and multiple clinical features, his clinical presentation confers to worse survival. When this was discussed with him and his family, in light of his rapid functional decline over the last 10 months, our patient agreed to enroll into hospice.

Take-home Points:
1. Age of onset for MSA is around 54 years. Older age of onset is a predictor for worse survival.

2. Cerebellar predominant feature is a predictor for increased survival.

3. Recent publication date is a predictor for increased survival, although there may be unaccounted confounder not included in this analysis. Clinical relevance of this finding is limited.

by: Pei Chen, MD
Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai

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

Picture courtesy: Paco CT

Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases
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Thursday, January 8, 2015

Let's Talk About Prognosis

GeriPal's very own Alex Smith recently gave an absolutely fabulous "Ted-like" talk in which he made the statement that "prognosis needs to be a part of everyday medical care."  Unfortunately, as he so eloquently states in the video (which can be watched here), it isn't always taken into account.



To dive a little deeper into the lack of prognosis in health care decision making, lets just take a look at cancer screening.   Individuals with a limited life expectancy are exposed to all the immediate harms from a screening test, yet may not live long enough to see any of the benefit (the concept of lag-time-to-benefit).   Yet, people with limited life expectancy still get these screening tests as evident by the following studies:
This is part of the reason that we created the ePrognosis: Cancer Screening decision support app to help guide conversations with elderly patients of whether to start, stop, or continue breast cancer and/or colorectal cancer screening. We recently updated it to give it a new look and feel, and for all you non-iPhone users, we are close to releasing a version that can be used on any mobile device (and yes, it will remain free of charge).

In Alex's video, he leave the audience with a challenge, one that I'll give to the GeriPal viewers as well.  Alex asks the audience to use "ePrognosis once a week for the next month.   See how it changes your perspective.   See how it changes the conversations you have with your patients."

by: Eric Widera (@ewidera)

The ePrognosis Cancer Screening app

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Wednesday, January 7, 2015

Sudden death with trimethoprim-sulfamethoxazole while on ACE-inhibitor or ARBs




What? It’s already 2015. But, I have so many great articles published in 2014 that I need to post about! Well then, for my next series of posts I’m going to do a quick round-up of articles published last year that we haven’t already talked about on GeriPal.   This first on the list shows an association between sudden death in those who were given trimethoprim-sulfamethoxazole (co-trimoxazole) while already on renin-angiotensin system blockers (i.e. angiotensin converting enzyme inhibitors (ACE-inhibitors) and angiotensin receptor blockers (ARBs).

The Study

This was a large nested case-control study published in the BMJ last year.  It included residents of Ontario who were 66 years of age or older and were treated with an ACE-inhibitors or ARBs.   The cases were those who had sudden death and who received an outpatient prescription for either co-trimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin within 7 days of death.  Each case was matched with up to four controls on age, sex, presence of kidney disease, and diabetes.

The Results

Of the 1,601,542 patients in this cohort treated with either an ACE-inhibitor or ARB, 39,879 died suddenly.  Of these deaths, 1,110 occurred within seven days of a prescription for one of the study antibiotics.

In the primary analysis, trimethoprim/sulfamethoxazole was associated with a significantly increased risk of sudden death compared those who received of amoxicillin (odds ratio 1.38, 95% confidence interval 1.09 to 1.76 after adjustment). Ciprofloxacin also had a smaller but still significant increased risk of sudden death compared to those taking amoxicillin (1.29, CI of 1.03 to 1.62).

So What?

Now we don't really know if there is a causal relationship between use of trimethoprim-sulfamethoxazole and sudden death, and we can only speculate on what may be the reasons behind the association. The authors hypothesize that it is due to trimethoprim’s ability to raise potassium levels. However, we don't have any data on serum potassium concentrations. There are also limitations to this trial that prevent a definitive answer to what we are supposed to do clinically. For example, the cases and controls were very different (the cases were more likely to have heart failure, renal failure, and all together more co-morbidities). There also may be an issue of confounding by indication, as we don't have any data on why these individuals were prescribed these antibiotics.

Again, so what?

So, what do we do with this information? I’ll be more cautious when prescribing trimethoprim-sulfamethoxazole, especially in those taking ACE-inhibitors and ARBs. In a previous publication by the authors of this study, there was a seven sevenfold increase in the risk of hyperkalemia induced hospital admissions in ACE-inhibitors and ARB users taking trimethoprim-sulfamethoxazole compared with those exposed to other antibiotics. So at a very minimum, I'll keep a closer eye on those potassium levels.

by: Eric Widera (@ewidera)

For a more in-depth discussion on this paper, check out the editorial here or this wonderful post on #NephJC.


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Tuesday, January 6, 2015

Back to basics: are we losing sight of what hospice care is all about?

Photo by Joan Teno

by: Amy Getter, a hospice nurse who blogs regularly at hospicediary.com

In our ever-challenging and changing medical system, the current hospice and palliative care movement has undergone heightened scrutiny, increased regulatory stipulations, and in general has become a part of the federal government’s health care crisis (just review Medicare Conditions of Participation and billing requirements to get a head full of terms and guidelines to be overwhelmed by it all). Yes, hospice has become big business.

I am a hospice nurse. I have seen the changes in the past decade, as Medicare requirements become more stringent and hospice has moved from grassroots to mainstream; and the “evidence-based practice” mantra has precluded use of medications and treatments that have historically been effective but now lack current “research validation”. Or new results from a few cooperate-funded studies who have the most to gain by predetermining that certain treatments are not effective change our practice, and I can’t help but wonder about bias. Or large pharmaceutical companies, (providing much of the funding sources for many of the studies on medications), suddenly phase out older medications that are not profitable. Or politics become involved in deciding things like what opioid medications should be approved for public use and how people’s choices at the end of life must be managed by laws and public approval.

And I must pose the question, “Are we losing sight of what hospice care is all about?” I see younger nurses coming into the hospice profession, and learning about “best practice”, being taught that the “experts” know best. That “evidence based practice” is THE answer.

I am reminded of the middle of the last century, when birthing practices became managed and performed by experts in white coats in medical facilities, new technology and expert roles slowly removing the simplicity and normalcy of birth. I am not trying to over-simplify a complex experience, truly: not every birth and death is uncomplicated and many need to have advanced medical care. Thank goodness for advances and treatments that were hitherto unknown! But I am advocating that we not have total reliance on the science of death and dying, remembering how both birth and death have sacredness and mysticism that cannot be quantified. For centuries, birthing and dying are the human experience. Is it really only now, with our medical advancement, that we know how to provide ease of suffering in both states of humanness?

I heard, again, from hospice staff this week, how a family should let the patient be transferred out of the home and placed “where experts in end of life care could care for him”, while the loved ones could just be “the family”, coming to visit and sit at the bedside. And I was a little horrified, that we, the hospice “experts” are succumbing to the lie that caring for the dying is so complicated and combersome, we must rely on “experts” to provide the answers and often even the care. I do not believe we, “the experts”, can provide the same level of solace as a person who has loved a dying family member all their lifetime. I am and always will be an advocate for the patient and family, with the conviction and goal in hospice nursing to create confidence in family members. They can be the ones who comfort and care for their own dying loved one in their own home whenever possible. Isn’t that what most of us hope for, when we die, to be at home with family?

For centuries, caring for the dying relatives was a part of life lessons taught while children grew up in multi-generational living environments, and saw the normalcy of caring for ones’ elders through the lifespan. I like to believe that the basics of care for a dying person can be taught in an atmosphere of simplicity and loving kindness, and the gift that family receive from providing the care is a part of the lasting memorial to that loved one. In fact, this has been my experience time and time again.

I empathize with wanting to standardize and compartmentalize dying, we all would like to have it tidied up and handled for us. It might seem more palatable in the white halls of the medical experts. But I am certain that dying will always involve the messiness and unexpectedness that birthing also entails. Nor does the current body of evidence preclude learning from centuries of how people die.

I am, and will always be, thankful to my dying patients, the only ones actually experienced in dying, who have shown me time and again to STOP, leave my agenda behind, LISTEN to their hopes and desires, and bring perhaps some insight, but not all the “answers” to their bedside. After all, as I have said before, I might be the hospice nurse, but THEY are the experts.
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Monday, January 5, 2015

Does doll therapy reduce agitation in dementia patients?

This post is the first in the #GeriCases series, in which we discuss a clinical case in geriatrics and the attempt to provide patient-centered care with the use of best available evidence.

Mrs. GM, an 84 year old woman with moderate dementia with behavioral disturbances, comes in accompanied by her daughter to the office. Daughter was feeling overwhelmed trying to care for her mother, and very angry and frustrated that she can’t seem to get help. Mrs. GM lives alone and is independent in her ADLs and most IADLs despite having dementia. The problem is that at night she becomes confused and starts shouting and banging on the walls. She wakes up her neighbors who call the police. Her daughter doesn’t know what to do and thinks that her medications (including an anti-psychotic) are not helping. I wondered if there was another way to help her. I remembered that in the nursing home, some residents who were very agitated were given dolls. I wondered if doll therapy was an option instead of rotating to another anti-psychotic.

My clinical question was: In community-dwelling patients with moderate dementia, does doll therapy lessen episodes of aggression and agitation as compared to antipsychotics and non- pharmacologic interventions?

I searched PubMed using search terms: “doll therapy dementia” and found a review article. The aim of the article was to have a comprehensive review of studies that used dolls as therapeutic intervention for patients with behavioral disturbances associated with dementia. Authors had a broad search strategy because as expected, there were not a lot of studies on this subject. The authors found 125 articles which were narrowed down to 11 studies which were a combination of observational, focus groups, and semi-structured interviews; nearly all were conducted in nursing homes and only 1 in a hospital ward being the exception. In total, sample included 448 patients with dementia and 49 healthcare professionals, of which 40% (190 participants) were from lower quality studies.

All of the studies found doll therapy to be of some benefit to patients. Patients became calmer, more interactive with others including physicians and other residents. They also had increase in dietary intake thought to be due to an improved dining experience since they were more social with the dolls. Majority of people that related to dolls were women and they connected with other residents who also had dolls. One of the studies mentioned of a few women with dolls that would sit together in a circle and cradle their dolls. Some became so attached to their dolls that they became agitated and aggressive when the dolls were taken away either by staff or another resident. Interestingly, some lost interest in their doll after a few months. Furthermore, some staff members and healthcare providers felt that doll therapy was demeaning and infantilized the patient. Limitations of this review included questionable validity of included studies, lack of a standardized tool to measure improvement in agitation and variability in the use of dolls as the intervention. Also, none of the studies included community-dwelling people with dementia.

Despite the review not giving me a clear answer about the effectiveness of doll therapy, especially in community dwelling individuals, the intervention is relatively cheap and without the risks that antipsychotic and other pharmacologic interventions carry. It is worth trying as long as the family understands the rationale and doesn’t think the dolls are demeaning. When I mentioned using a doll as a treatment strategy, her daughter laughed at the idea because her “mother isn’t much of a nurturer”. She said she would consider it if her mother’s agitation did not improve.

by: Niharika Ganta, MD, MPH

Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases
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Welcome to #GeriCases


I want to welcome all GeriPal bloggers and readers to this new series of geriatric patient cases (#GeriCases) under the realm of Evidence-Based Medicine (EBM).

EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

In fewer words, it can be explained by the model by Haynes, et al.


Even though patients would like to believe that clinicians have all the answers to their medical problems, clinicians often face questions and uncertainty when evaluating patients. EBM urges the clinicians to utilize best available evidence in light of their clinical expertise and patient preferences. This requires skill and time: to identify the question, look for evidence in the literature, evaluate the article for its validity and applicability and finally be able to apply it to the patient in front of the clinician.

These short blog posts are the work of significant evidence search and appraisal by geriatrics clinicians – fellows and faculty in the Department of Geriatrics and Palliative Medicine at Icahn School of Medicine at Mount Sinai. They will start with a short description of a geriatric patient case (without patient identifiers), followed by a clinical question. This question will be addressed in subsequent paragraphs by a systematic search of the literature and appraisal of the article/s, finally ending with how patient care was impacted by the practice of EBM. I hope you enjoy them and find them useful. Feel free to post your comments.

by: Ravishankar Ramaswamy, MD
@RavRamaswamy
Section Editor, #GeriCases
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Tuesday, December 30, 2014

Tramadol-induced hypoglycemia: another reason not to use it


Note: This post was originally published on PalliMed as part of the World Series of Blogs Payback-Ed.

In 2013, there were 43.8 million prescriptions for tramadol filled in the U.S. It has a slightly different method of action from many other pain medications, as tramadol is both a mu-opioid receptors agonist and a reuptake inhibitor of serotonin and norepinephrine. It is also thought that the opioid activity is due to both the parent compound and the more active O-desmethylated metabolite (which, like codeine is metabolized by CYP 2D6 and therefore gives the same big inter-individual differences in pharmacokinetics).

The overall efficacy as a pain medicine is comparable to that of other weak opioids. Most people know it is associated with serotonin syndrome as well as seizures especially when used with other medications that lower seizure threshold. A new study that came out in JAMA IM reveals a pretty robust association between tramadol use and hospitalizations for hypoglycemia, even in those without diabetes.

The Study

The authors of this study put together a large population-based cohort of patients from the UK who were either initiating tramadol or codeine therapy for non-cancer pain. They excluded those who were prescribed other opioids, as well as those with cancer and those previously hospitalized for hypoglycemia in the year before entry into the study.

The authors also did a whole bunch of different types of analysis to prove their point (nested case-control, cohort and case-crossover analyses) that would take me five blog posts to write about (if you are interested in the details, here is the link to the article). They also controlled for a boatload (yes that is a technical term that I’m using) of potential confounders.

The Results

The analysis included 334,034 patients (28,110 taking tramadol and 305,924 taking codeine). Tramadol and codeine users were similar on nearly all baseline potential confounders. The authors found in this cohort:
  • Tramadol use increased by more than 8 from 1999 to 2011 
  • Patients taking tramadol had a significantly higher risk of hospitalization for hypoglycemia (odds ratio 1.52) 
  • The risk of hospitalization for hypoglycemia was highest in the first 30 days of use (OR, 2.61) 
  • Patients NOT on a diabetic medication were at increased risk of developing hypoglycemia severe enough to be hospitalized compared to those those taking diabetic medications (adjusted odds ratio of 2.12 vs 1.11)

The Take Home Point

A lot of health care providers have the misconception that tramadol is a safer alternative to more traditional opioids like morphine. This study adds further evidence that this is just not true, and that we should add hypoglycemia as a risk, even in patients who do not have diabetes.

by Eric Widera, MD (@ewidera)


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Friday, December 19, 2014

What you can do today to pull the plug on Sarah Palin's "death panel" myth


Perhaps enough time has passed that when you think about Sarah Palin, her antics seem almost cute in their absurdity.  You know, "I can see Russia from my house!" or nicknaming herself a "Mama Grizzly."  With any luck, you might think, the biggest dent she'll leave on American history is her quirky run for the vice presidency that will make for great Trivial Pursuit fodder one day.

Unfortunately, one seriously un-cute gift that Sarah Palin gave the American people during her five minutes of fame just keeps on giving.  In August 2009, she coined the term "death panel" in a Facebook post intended to smear Obama and malign the Affordable Care Act.  She said,

"The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health care. Such a system is downright evil."

To what evil piece of legislation was she referring?  Of course, the part in the Affordable Care Act that proposed reimbursing physicians for advance care planning.  Palin's claim was immediately debunked, but the smear worked: the "death panel" ripples significantly jeopardized the passage of the bill, the idea of creating a reimbursement code for advance care planning was scrapped, and many Americans swallowed the poisonous idea that the government has a secret plot to ration healthcare via advance directives.  Never mind that the entire point of advance directives is to give people more, not less, control over their healthcare, and people want to talk about these subjects with their doctors, but report that they are rarely asked. 

I still hear reverberations of Palin's twisted logic in conversations with patients and their families, five years later.  The other day, I was talking with the son of a woman in her nineties who was delirious and clinically unstable in the hospital.  She did not have an advance directive, but had recently begun to share her preferences for end of life care with her family: no heroic measures, she told them. But her son was not comfortable with the suggestion of a do-not-resuscitate order, and repeated over and over to me, "I just don't believe her.  I don't think she wants to die!"  He was adamant that her quality of life and mental status were good before this hospitalization.  I gently countered his reasoning, and told him that refusing CPR and mechanical ventilation if her heart or breathing stopped did not mean she wants to die, nor would making a decision about how to respond in the moment of her death change the care she would receive up to that point, and in particular, would not hasten her death.  He did not need to prove to me that she was valuable, or loved, in order for her to continue to deserve good medical care. 

I wonder if we rewound the clock and deleted Sarah Palin's post, if my patient's primary care doctor would have taken the time to explore her values and preferences, and document them (with the benefit of reimbursement for his efforts) so that her son wouldn't feel like he needed to make that decision on his own.  I wonder if Sarah Palin hadn't forged a false association between honoring a person's preferences about resuscitation and their perceived worth in society, my patient's son might have had more confidence in the medical system continuing to care for her even if she didn't want CPR and mechanical ventilation at the very end. 

Though Palin's inflammatory, baseless post set back the movement toward patient-centered care at the end of life by years, the tide is finally starting to turn.  The Institute of Medicine report on Dying in America stated that "advance care planning is critically important to ensure that patients’ goals and needs are met," and suggested the development of quality standards for clinician-patient communication and advance care planning.

And in exciting news, as posted on Geripal earlier this month, the Center for Medicare Services (CMS) included codes for reimbursing physicians for advance care planning in the Medicare Physician Fee Schedule released on October 31st, for the first time.  Unfortunately, CMS did not agree to start reimbursing for these codes yet, but indicated its receptivity to this idea in the future.  They also welcomed comments on the subject on their website.  Pallimed has a great post with more detail here.

If you haven't yet, please take a moment now to leave your comment for CMS in support of advance care planning, and gain back the ground we lost to death panel fear-mongering.  The opportunity to post is open until December 30th-- consider it a holiday gift to your favorite Mama Grizzly.

By: Laura Petrillo (@lpetrillz)
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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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