Monday, September 15, 2014

Competitive Bidding? Is it really competitive or making it harder for patients to get what they need

Over the last few months, ever since Medicare started its competitive bidding process  my colleagues and I, in the UCSF Housecalls program have had a harder time getting our homebound patients the durable medical equipment (DME) they need.   The purpose behind the competitive bidding process seemed like a good idea--lower the costs and reduce fraud that has been occurring with DME.

From the Medicare site:
"The program:
  • Helps you and Medicare save money
  • Ensures that you have access to quality medical equipment, supplies, and services from suppliers you can trust
  • Helps limit fraud and abuse in the Medicare Program"
But in reality, the effects have created less competition, worse access, worse service, and patients dying or declining functionally because of difficulty getting much needed equipment. 

Case in point: a 90 yo woman died from advanced dementia and multiple worsening pressure ulcers, and was not able to get the Alternating pressure pump she needed for her hospital bed. 

Here in San Francisco, the number of DME companies from which we can choose has gotten smaller and smaller.  Some refuse to work with UCSF.  Some have a turn around time of over 1 month.  How do you justify that delay and simultaneously explain and document why someone's wounds are not healing.  And all of this is occuring, without yet talking about the increasing demands regarding documentation for equipment.  The Medicare website is clear about documentation requirements, yet DME companies are coming up with their own format and requirements.  And again, this delays the receipt of much needed DME. 

To say that this is frustrating is an understatement.  But even more importantly, a policy aimed at saving costs is actually hurting patients.  Somehow I can't get my patient a hospital bed, yet I continue to get faxes from DME companies claiming that my patient with dementia who can't answer the phone ordered a back brace, or better yet a penis pump for erectile dysfunction.  It seems that we may need to refocus or better yet, rethink the goals of the competitive bidding process.

As our Housecalls group prepares to write letters to our Congressmen and women, we wonder if any of you around the country are experiencing similar phenomena?  Or is this just happening here in Northern California.

Please share your stories.

by: Carla Perissinotto MD

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A False Hope: Artificial Nutrition in the Dying Patient

My patient was dying and his family was terrified. Riddled with abdominal tumors and engorged gastric blood vessels, Mr. G, a 54 year old Korean man with advanced hepatitis B-related liver cancer would not survive this hospitalization. For weeks, he had suffered from progressive abdominal pain and distention, and had recently lost his desire for food and the ability to take anything by mouth. He had difficulty swallowing anything, and he felt like his abdomen was going to explode when he tried.

His large extended family, his wife in particular, was preoccupied with feeding him. On admission to the hospital she requested placement of a tube or an IV to deliver nutrition since he was no longer eating. She was adamant that we intervene soon, since it was clear to them that he was deteriorating and didn’t have much time. It was hard enough to watch him grow sicker with cancer, but they were not willing to watch him starve to death.

 But, of course, he wasn’t actually starving to death. He was dying of cancer.

Anorexia at the end of life can be one of the most agonizing parts of the dying process for families to cope with. As one of the Palliative medicine fellows at UCSF, I am part of a consult service that is often called upon to help other doctors navigate the discussion around artificial nutrition at the end of life. Despite an awareness of what the medical literature tells us about the risks and benefits of these interventions, I struggle with how tough it is to counsel and guide grief stricken families through these complex decisions.

Is it ethically right to subject a dying patient to the surgical placement of a feeding tube when you feel strongly there is no benefit to be gained? What if if the family insists? Even within the team of providers, there isn't always agreement. My attending felt that the moral distress of the family was so grave that perhaps feeding tube placement might be reasonable as a way to give them peace and avoid conflict. But this patient was at the very end of his life, and I was not convinced.

I listened to their concerns and assessed their understanding of his disease (they knew he was dying) before presenting them with information on what we know about artificial nutrition in patients with advanced cancer. I emphasized that there is no evidence it improves survival, quality of life, nutritional or functional status and may in fact hasten death, if long term complications arise as they do 32-70% of the time. Both tube feeds and TPN can contribute to patient discomfort, decreased mobility and the possible need for restraints.

There is evidence that surrogate decision makers tend to overestimate the benefits while underestimating the risks of artificial nutrition. In one study the majority of patients had no improvement in quality of life after feeding tube placement according to caregiver report. In another study, physicians assessed that artificial nutrition was very unlikely to improve quality of life in cancer patients who survived 3 months or less.

 While Mr G seemed interested in the information I offered, she continued to demand that we intervene. The patient, depressed and scared, was not interested in weighing in on the decision and looked to his wife to advocate for him. My recommendation that we focus on comfort instead of pursuing artificial nutrition given the risks and benefits was not enough to convince her that her that starvation was not what was killing her husband. She explained to me that food was the center of the their most celebrated ritual -- a weekly gathering of extended family for Sunday night dinner -- and the thought of him dying with an empty stomach was almost as distressing as his death itself.

 Of course people are tortured by the concept of “starvation” of their dying loved one; food is the basis of life and defines how we show love for each other. But when a dying person can no longer eat, families can be counseled that showing love in other ways -- like respecting the bodies rejection of food, is possible and essential. I explained that artificial nutrition is not food, but rather an industry manufactured mixture of carbohydrates, protein and lipids. In patients whose bodies were close to dying from advanced cancer, food becomes unhelpful and unnecessary. Artificial nutrition, simply put, is not food.

The loss of appetite and the catabolic state that can accompany advanced illness is natural part of the dying process -- and in fact it can even have benefits. The ketotic state generated by the reduction of readily available calories can itself produce a sense of euphoria and is thought to be an endogenous mechanism to ease suffering when we need it the most.

In Jessica Zwitter’s recent NYTimes Well Blog entry, she offers a different perspective on the feeding of our loved ones at the end of life, one couched in the natural history of humanity and bedside caregiving. She writes that for thousands of years, people have hand fed their dying loved ones until their bodies were unable to take more.
 “But hand feeding has increasingly become a quaint piece of human history. We fed until they would take no more, and knew that we had done everything we could. But with the feeding tube, we can, and feel we must, keep going. Patients frequently die with plastic tubes weaving mysteriously under their gowns, entering bodies at unnatural angles, rendering them a little more alien to us. Those who are most needed sit a little further away from the bed, afraid to dislodge tubes that are supposedly keeping their loved one alive. And the patient’s mouth will usually remain dry and empty until the end.” 

In our data-driven approach to complex decision making, this refreshingly simple and rational perspective was helpful in my own approach to this issue. The image of directly hand-feeding our sick loved ones until their bodies aren’t able to eat any more is powerful and timeless. It comes from a basic nurturing instinct of our collective existence, one without G-tubes and PICC lines. It is a comforting reminder that death is as old as humanity and since the beginning of time no human soul has escaped its inevitability.

 Mr. G died peacefully and comfortably in the hospital before any final decision regarding artificial nutrition was made. In his final days he had a few sips of water but remained unable to swallow much else. While it was not the outcome anyone had ever wished for him, I’m certain that we did him and his family a service by engaging them in a prolonged discussion about artificial nutrition over several days rather than immediately subjecting him to a procedure that would not have helped him.

 Of course, it would have been simpler to feed him artificially. While the fee-for-service, time-crunched medical world we operate in certainly would have favored a more interventional approach over the hours spent talking with the family, it would have undoubtedly been of little benefit -- and possibly caused harm -- to our dying patient.

 by Colin Scibetta, MD (@colinscibetta)


1 ) Cervo FA, Bryan L, Farber S. To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics. 2006;61(6):30–35.

2) Mitchell SL, Berkowitz RE, Lawson FM, Lipsitz LA. A cross-national survey of tube-feeding decisions in cognitively impaired older persons.J Am Geriatr Soc. 2000;48(4):391–397.


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Saturday, September 13, 2014

Using the Skills Learned at VITALtalk to Take Out the Trash

We just spent the last several days learning facilitation skills at the VITALtalk faculty development course.  This truly amazing course is meant to give health care professionals like us the skills needed to run communication training programs at our own home institutions.

After just finishing the course, we thought it would be interesting to do something similar to what Alex Smith did in his "Take Out the Trash Video." There, he used some of the communication techniques he learned in palliative care training at home with his wife.  His results were less than perfect.

We figured our advanced skills might be more successful.   See for yourself (if you don't see the video below click here for the YouTube version)

  • Eric Widera
  • Rachelle Bernacki
  • Roshni Guerry
  • Linsey O'Donnell
  • Brook Calton
  • Laura (aka Jillian Gustin)
  • Mark (aka Steve Berns)
  • Susan (aka Sara Johnson)
  • Steve (aka Dave Kregenow)

Note: THIS VIDEO IS NOT PUBLISHED BY VITALtalk (c). It is published by adoring fans who think, all joking aside, that VITALtalk is one of the most transformational courses a health care professional can take. If you are interested in becoming better at patient communication or facilitating teaching around these discussions, we highly recommend you check out to learn about it.
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Friday, September 12, 2014

Urine Catheters in the Hospital: Bad Stuff

When I was a resident, it was routine to place urine catheters (a catheter threaded up the urethra, into the bladder) in older patients when they landed in the hospital.  For some diagnoses, we were even taught that the urine catheter was standard of care.  For example, virtually any patient admitted with a diagnosis of congestive heart failure (CHF) had a urine catheter placed.

While we knew these urine catheters were uncomfortable for patients, we truly thought we were doing the right thing.  Generally, a patient hospitalized with CHF has retained too much fluid.  So, we treated the patient with drugs (diuretics) to get rid of the fluid (by making the kidneys produce more urine).  It is important to get rid of enough fluid, but it can also be hazardous to get rid of too much fluid.  We were taught that it was very important to closely measure how much fluid we were removing, and the only way to do this accurately was with a urine catheter.  This is because the urine catheter makes it possible to directly measure how much urine the kidneys are getting rid of.

It was actually quite true that placement of the urine catheter gave us fairly accurate data on how much fluid we were getting off the patient.  This information sometimes had added value beyond just following the patient's weight.

But there was a BIG problem with this approach.  We only thought of the benefits of putting in the catheter.  We did not consider that placement of a urine catheter is a medical procedure that has risks.

We needed to ask, "does the benefit of getting more information about urine output outweigh the risks of placing the catheter?"  We now know that in the vast majority of cases, the answer to this question is a resounding NO.  But unfortunately, while we are now more aware of the risks of urine catheters, they are still used far too frequently, and we often fail to balance the benefits of the catheter against the very substantial harms.

One of the key harms of the urine catheter is illustrated by a very instructive case vignette published in JAMA Internal Medicine as part of the wonderful Teachable Moments series.  An 80 year old man with was admitted with fluid overload due to kidney disease.  A urine catheter was placed to monitor his fluid status, and after several days he was discharged home in better condition.

Or so it seemed.  Unfortunately, 5 days later he became seriously ill with an infection that started in his bladder (urinary tract infection) that then spread to his blood (sepsis).  He required care in the intensive care unit.  The value on his prior admission of precisely assessing how much urine he was producing was clearly not worth the risk of this disastrous and life threatening complication.

The risk of urine infection is the most discussed complication of urine catheters.  But Geriatricians worry about a much common, and perhaps as serious complication.  The placement of a urine catheter in the hospital almost always leads to immobilization.  Once that catheter is placed, patients just seem to stay in bed all the time.  Dr. Sanjay Saint, an expert on the harms of catheters has referred to urine catheters as "One-Point Restraints" to draw attention to this serious harm.

The immobilization caused by urine catheters causes older patients to become weak and frail.  The urine catheter is believed to be one of the factors that leads to the syndrome of Hospital Associated Disability.  Hospital Associated Disability refers to the common problem of older patients losing their ability to function independently after hospitalization for what are often seemingly minor illnesses.

The bottom line:  Urine catheters are vastly overused in the hospital.  We need to stop thinking of urinary catheter placement as routine.  Rather, it is a risky and morbid procedure that should only be done after a careful assessment of risks and benefits.  In most cases, this assessment will lead to the conclusion the risks far outweigh the benefits.

by: Ken Covinsky (@geri_doc)

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Wednesday, September 10, 2014

Handshakes, handholding, and other dangerous methods of transmitting bacteria

by: Alex Smith @AlexSmithMD

In a recent study in the American Journal of Infection Control, researchers coated a gloved hand in e. coli.  One person with the e coli glove then they shook hands, high-fived, and fist bumped another person with a sterile glove.  Transfer of e coli to the sterile glove was measured.


  • Highest transfer of bacteria: Handshake
  • Lowest transfer of bacteria: Fist bump (high five was in the middle)
  • Difference: Fist bump less than 10% of bacteria transmitted compared to the handshake
  • Explanation: handshakes have the greatest surface area in contact, for a longer time

This has been a practice changing finding for me.  Rarely are articles practice changing.  After reading these findings, I admit, I have shaken hands less.

I have not yet tried to fist bump my patients.  "Hey, I'm your palliative care doctor, punch it in there!  Knuckles!"

I use hand sanitizer before and after each visit, and also wash with soap and water after every third or so encounter.  But I used to shake hands with pretty much every patient, on every single visit, at both the beginning and end of each visit.  And with each family member.  I now generally only shake hands at the initial visit.

Isn't this sad, in a way?  I was happy when ties where found to carry the most germs of any piece of a doctor's outfit.  I hated ties anyway.  But the fist bump beating the handshake?

Has it come to this?

Have we really taken the touch of out medicine to the extent that it will soon be verboten to shake hands?  If shaking hands spreads germs, then a hug is definitely out of the question.  If infectious disease transmission is the only considered factor, then we should just stand in the doorway.  Or communicate with our patients via snapchat.

In geriatrics and palliative care, we probably prize the virtue of caring above all other virtues. We care for our patients by making strong connections with them.

Part of that connection, for many of us, is developed through non-verbal communication, including handshakes, handholding, hugging, and other dangerous methods of transmitting bacteria.

How do you weight these values against this new information about bacteria, amidst a backdrop of increasingly deadly healthcare-related infections?  Even with the terrific success of hand sanitizer initiatives, hands are still a major source of transmission (see this tomb for details).  It's not just about protecting the patient in front of you, but other patients who may have less resilience against bacteria.

Will this information change what you do?

I'm just providing the perspective.

It's in your hands now.

Thanks to longtime GeriPal reader Aunt Sue for the idea for this post.  And for pointing me to this blog, that contains a link to this funny video primer about how to fist bump.

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Tuesday, September 9, 2014

The Advanced Direct Care Worker - A New Profession for a Growing Older Population

With 10,000 Baby Boomers turning 65 every day, the fastest growing jobs in the country are also some of the most critical to ensuring quality of care for older adults: the direct care workforce.

The Department of Labor says personal care aide and home health aide positions are the second and third fastest-growing occupations in the country. These occupations also provide between 70 and 80 percent of paid hands on care for older adults and individuals with disabilities. Of the 30 fastest growing occupations, they are also the two least paying (with an average annual median wage in 2012 of $19,900 and $20,800, respectively). Because of low wages, lack of benefits, and often-strenuous work, the vacancy and turnover rates for direct care work is high. It’s estimated that turnover rates amongst home care workers are between 44 and 65 percent. This occurs right at the time when we must be strengthening the workforce to care for older adults, nearly 90 percent of whom want to age at home.

How can we meet the market demands for more care at home and ensure this critical workforce is respected and recognized for their contribution? The Eldercare Workforce Alliance, in a recently released brief, offers one proposal. While not a cure-all, the creation of an Advanced Direct Care Worker position – a rung in the career ladder above home health or personal care aides - may help to address the challenges we face in providing quality care to older adults across all settings.

Created in response to the 2008 Institute of Medicine report, Retooling for an Aging America, the Alliance, through the vision of our diverse 30 member organizations, seeks to find ways we can ensure all older adults - now and in the future - receive quality care from a well-trained and coordinated interdisciplinary care team. We believe that every person caring for older adults should be trained to understand the unique social, physical, and mental health needs of older adults. To do so, especially in light of the aging of America, we must ensure all health care providers are working at the top of their skill set.

Through roundtable discussions and an online survey, nurses, social workers, physicians, and family caregivers explored the potential role an Advanced Direct Care Worker could play in filling gaps in care and promoting efficient care delivery. After analyzing feedback from the multidisciplinary groups, the Alliance concluded that with the proper training, support, and supervision, an Advanced Direct Care Worker may be able to perform more advanced tasks, assist with navigating the health care system or identifying community resources, or be specifically trained to care for individuals with dementia or palliative care needs. Such roles may help to alleviate family caregiver stress and promote full utilization of other team members’ skills.

As an example in the brief notes: Family caregivers may need to rush home from work at lunchtime to administer medication or a tube feeding that direct care workers are prohibited from administering. Hiring a nurse to perform these procedures, typically performed several times a day, is neither feasible nor efficient. Therefore, allowing nurses to train and delegate these tasks to an Advanced Direct Care Worker could ease the burden on family caregivers.

This brief is just a first step. Many state scope of practice laws will affect what role Advanced Direct Care Workers will be able to play. But testing out these roles will be essential to recruiting and retaining a workforce that will become more and more important as the population of older adults increases to 20 percent of the population by 2030, the most older adults our nation has ever seen. In addition to supporting the existing direct care workforce, we must also make sure all people providing care to older adults are competent in geriatrics or gerontology.

As we look at ways in which we can improve quality of care, let us consider this opportunity to both meet the needs of our nation’s seniors and value the role of direct care workers.

By: Nancy Lundebjerg and Michèle Saunders DMD, MS, MPH
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Monday, September 8, 2014

Knocking on Heaven’s Door: A Book Review

Knocking on Heaven’s Door” by Katie Butler is a book that will resonate with most of our GeriPal readership. In it she writes about a medical system that is all too enamored with expensive high-tech interventions while high-touch, low-cost interventions are rarely reimbursed yet desperately sought after by family caregivers. It is a theme that we have written about before on this blog, but her story sheds a light on the dysfunction of our health care system when it comes to someone dealing with a chronic, progressive illness like dementia.

Butler leads us through the story of caring for her father Jeffrey, a World War II veteran, professor, and father of three who suffered a stroke in his late 70s. With the honesty that I can only imagine comes from Butler’s time as a reporter, she opens up a world where caregiving duties fall on the shoulders of wives and daughters, of which the medical system and others rely heavily on but provide far too little support.

Butler’s father becomes more frail and more dependent on others as he develops a progressive dementia. The one thing that Butler family would for him to be less dependent on, his pacemaker, is one thing that the family found impossible to discontinue, with doctors stating that deactivation of this device would “be like putting a pillow over your father’s head.”

This past week we have written about putting pacemakers in and turing them off. If any of what we talked about interested you then “Knocking on Heaven’s Door” is a must read. The mix of reporting, personal journal, and instruction manual also makes it an important read for caregivers of older adults with chronic illness. Lastly, this is a perfect gift for those physicians who refuse to deactivate devices like pacemakers because they feel like it is somehow more special than any other life sustaining treatments.

by: Eric Widera (@ewidera)

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Thursday, September 4, 2014

Is Deactivating a Cardiac Pacemaker Euthanasia?

“He’d feel okay about not replacing the pacemaker’s battery when it ran down, he said. But turning it off, he said, would be “too active.” Later he would tell me that it would have been “like putting a pillow over your father’s head.”
These are the words of Katy Butler in her book “Knocking on Heaven’s Door – The Path to a Better Way of Death” in which she writes about her families ordeal in trying to have her father’s pacemaker. It is also something that I’m hearing more about, in particular health care professionals refusing to deactivate a pacemaker due to concerns that doing so would be akin to euthenasia.

Separating Euthanasia and Deactivation

Why is pacemaker deactivation neither physician-assisted suicide nor euthanasia? I think one of the easiest ways to look at it is by asking what is the intent of a particular intervention and what are the means that will be used to meet that intent. For both physician-assisted suicide and euthanasia the outcome that is intended is the relief of suffering through death.  However, the primary intent in pacemaker deactivation is to respect the patient and surrogates request to discontinue the unwanted treatment. The intent is not to terminate the patient’s life, although death may be an anticipated outcome in those who are at least significantly pacer dependent.  Additionally and very importantly, death is not the means to meeting the intent of deactivation.

If it isn’t euthanasia, is it ethical to deactivate a pacemaker?

It is very clear that many physicians have moral distress over deactivation of a pacemaker. Studies have shown that many physicians view cardiovascular implantable electronic devices as distinct from other life-sustaining therapies. Furthermore there is a view that pacemakers are different from AICDs or other medical interventions commonly withdrawn as the end of life, as a pacemaker replaces a natural cardiac physiology, it is automatic, it is implanted, and its action is not felt by the patient.

The problem with this viewpoint is that there is very little to support it either ethically or legally. Patients have the right to refuse or withdraw treatments, even if the treatment prolongs life and immediate death would follow a decision not to use it. This applies to ventilatory support, dialysis, AICDs, or pacemakers.   Nor does it matter if a patient has an underlying rhythm that is incompatible with life. If this were true, ventilator withdrawal or discontinuation of dialysis would also be limited to those who are healthy enough to survive extubation or dialysis discontinuation.  

Furthermore, if it is believed that the patient could have initially refused placement of a pacemaker, there is little justification that she (or her surrogate) can now no longer discontinue it. Continuation of her life was equally dependent previously on the placement of the pacemaker as it is now on continuation of the pacemaker function.

What to do when a health care provider refuses deactivation?

Send them to the experts. I would print them out the recent expert consensus statement from Heart Rhythm Society written in written in collaboration with representatives the American College of Cardiology (ACC), the American Geriatrics Society (AGS), the American Academy of Hospice and Palliative Medicine (AAHPM); the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), and the Hospice and Palliative Nurses Association (HPNA).   Key points from this very in-depth statement include:

  1. "A patient with decision-making capacity has the legal right to refuse or request the withdrawal of any medical treatment or intervention, regardless of whether s/he is terminally ill, and regardless of whether the treatment prolongs life and its withdrawal results in death."
  2. "When a patient lacks capacity, his/her legally-defined surrogate decision- maker has the same right to refuse or request the withdrawal of treatment as the patient would have if the patient had decision-making capacity."
  3. "Legally, carrying out a request to withdraw life-sustaining treatment is neither physician-assisted suicide nor euthanasia."
  4. "The right to refuse or request the withdrawal of a treatment is a personal right of the patient and does not depend on the characteristics of the particular treatment involved (i.e., CIEDs). Therefore, no treatment, including CIED therapies, has unique ethical or legal status."

by: Eric Widera (@ewidera)

NOTE: Comment on any of the pacemaker posts this week or talk about it on twitter and you'll be entered into a drawing to win one of the paperback versions of Katy Butler's book "Knocking on Heaven's Door: The Path to a Better Way of Death."
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Wednesday, September 3, 2014

Who is more likely to get a pacemaker, someone with or without dementia?

It’s pacemaker week here at GeriPal. What’s pacemaker week you ask? It’s a fun filled week of posts on pacemakers. To start us off, let me ask a simple question.  Who is more likely to get a pacemaker, someone with or without dementia?  The answer to that question is answered in a research letter published this week in JAMA Internal Medicine by Nicole Fowler and colleagues.

The study used date from Alzheimer Disease Centers from September 2005 through December 2011 to look at how often cardiac implantable electronic devices are placed among older adults with and without cognitive impairment.

Of the 16,245 participants who had at least one baseline visit and at least 1 follow-up visit in the study period, 45.8% had no cognitive impairment, 21.3% had Mild Cognitive Impairment (MCI), and 33% had dementia. Rates of new pacemaker placement in these folks were as follows:
  • 4 per 1000 person-years for participants without cognitive impairment 
  • 4.7 per 1000 person-years for participants with MCI
  • 6.5 per 1000 person-years for participants with dementia

When adjusting for baseline demographics such as age, sex, race, intensity of pacemaker use in the the patients hospital referral region, cardiac comorbidity burden, functional status, and type of dementia, the authors found that:
  • Patients were 1.6 times more likely to receive a pacemaker if they had dementia than if they didn't have any cognitive impairment
  • Patients were 2.9 more likely to receive a pacemaker if they had severe dementia than if they didn't have any cognitive impairment.

So I guess that was a long answer to a simple question.  Now we know a pacemaker is more likely to be placed in someone with dementia (and even more so in someone with severe dementia), our next post will address the issue of what happens when people consider turning them off.

by: Eric Widera (@ewidera)

NOTE:  I'll also be reviewing Katy Butler's book "Knocking on Heaven's Door: The Path to a Better Way of Death" this week. Comment on any of the pacemaker posts this week or talk about it on twitter and you'll be entered into a drawing to win one of the paperback versions (for twitter, just make sure you include @geripalblog in the tweet)

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Wednesday, August 27, 2014

Debate: should palliative medicine physicians be required to certify in their primary specialty?

Cool picture of Kingfisher from Wikimedia Commons - has nothing to do with the post.
by: Alex Smith, @AlexSmithMD

It's been 10 years since I became certified in Internal Medicine, and that means it's time for me to re-certify.  My clinical practice is small, as I'm mostly a researcher.  The entire focus of my clinical practice is palliative care.  I used to attend on the wards, but I don't anymore.

Can I just say how much I hate studying for the boards...again?  MKSAP again?  Really?  Why am I reading about some obscure disease that I have no interest in remembering as a palliative medicine physician?

Hospice and Palliative Medicine is one of the few sub-specialties to require board ongoing maintenance of certification in the clinician's primary area of specialization - be it internal medicine, family medicine, pediatrics, radiation-oncology - whatever it may be (medicine subspecialties count - you could be certified in Oncology and Palliative Medicine, without maintaining your internal medicine certification).  Cardiologists, gastroenterologists, oncologists, you-name-it-"ologist" are not required to maintain certification in their primary area of specialization.  Same goes for Geriatricians - they're not required to maintain primary board certification either.  You can be a geriatrician and never re-take the internal medicine or family medicine boards again in your life.

Some people are starting to question if palliative medicine physicians be required to maintain certification as well.  Maybe we should only be required to maintain certification in hospice and palliative medicine.

Seeming tangent: A recent article in the New York Times decried social media as stifling debate.  We surround ourselves in our online worlds with like minded people, contributing to the polarization of America.

Therefore, in the spirit of promoting debate in social media, I will now debate myself about requiring palliative medicine physicians to maintain certification in their primary specialty.  I will enumerate points, as my brother (a debater) might do on debate cards.

Palliative medicine physicians should be required to certify in their primary specialty

1. Requiring primary specialty certification is less politically threatening to specialty boards and societies.  Palliative medicine is not "stealing" their business.  Without this requirement, many people would abandon certification in their primary specialty.  This might jeopardize these important relationships and support from our specialty societies.  Palliative medicine becomes a competing specialty, from their perspective, rather than a sub-specialty.

2. Palliative medicine doctors have to be grounded in a specialty.  Palliative medicine is unique in that people come to the profession from so many diverse specialty backgrounds - in fact palliative medicine set a record for the number of sponsoring boards when it went up for accreditation.

3. We are better doctors with our specialty certification.  Grudging admission - some parts of studying for the boards have been refreshing.  There are things I feel happy re-learning that may be important to the care of my patients.  I read a MKSAP question about osteonecrosis of the hip yesterday, and was reminded of patient with a cancer who had been on long term steroids and developed hip pain.  Without the broad differential, we would have assumed it was due to metastatic disease and never considered osteonecrosis.

Palliative medicine physicians should not be required to certify in their primary specialty

1. Specialty certification is not useful clinically.  For those of us who only practice palliative medicine, there is little need for learning the vast majority of stuff required for core specialty certification.

2. Taking the time to re-certify, including board prep and maintenance of certification, comes at a cost.  There is a limited amount of space in our brains.  As I'm stuffing internal medicine knowledge back in my brain, I worry that I may be excreting important palliative care knowledge.  (This may not be true - I may be excreting unimportant fantasy basketball knowledge).  In any case, time spent studying for core certification is time not spent learning and practicing palliative medicine.

3. It also comes at a monetary cost.  Board certification is expensive!  I just dropped several Benjamin Franklins on board prep material alone.  Total cost is easily over a thousand, and that money comes out of my salary, not grant funding.  In 5 years, I'll be paying and going through the studying again for palliative medicine.  More people might certify in palliative medicine if they didn't have to ALSO maintain certification in their primary specialty.

4. Palliative medicine is its own specialty.  We are as deserving of being a stand alone specialty in our own right as any other field (oncology, geriatrics, etc).  Why should we be held to a different standard?  It demeans the field.

If I was not required to maintain certification in my primary area of internal medicine, would I do it?  I'm not sure, though I think the answer would be no.  It's just not worth it to me to go through the process.

What do you think? What would you do if not maintaining your certification was an option?  
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Tuesday, August 12, 2014

What books inspired you to go into #geriatrics or #palliative care?

by: Alex Smith @AlexSmithMD

I just read a wonderful categorization of books about aging on Lousie Aronson's blog.  She categorizes books about aging into five types: informational, memoirs, wellness and longevity books, general non-fiction, and literary works.  My favorite category are the wellness and longevity books, you know the ones, about how if you eat enough "blueberries and kale" you will not "have to age or die."  Louise graciously declines to state the names of such books, only noting that the authors initials are often followed by the letters "M" and "D".  To that I would simply add that the author's name often contains the letters "O" and "z". 

In any case, I have been planning for some time to start a thread about books that inspired us to go into the fields of geriatrics, gerontology, palliative, hospice, and end-of-life care. 

Was there a particular book that pushed you along on your path to your current profession?  Please list books that inspired you in the comments!

I know there were several for me.  In medical school, a formative stage in thinking about what I wanted to do with my life, I read these two books:
  • A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life, by Timothy Quill.  Tim Quill presents 9 poignant stories of caring for patients who are dying, their families.  He delves deeply into ethical issues that arise in the patient-physician relationship when patients are near death, including physician assisted suicide. 
  • Dying Well: Peace and Possibilities at the End of Life, by Ira Byock.  Also based on stories of caring for dying patients, Ira Byock moves more seamlessly into the emotional/spiritual realm than other physician authors.  My favorite is chapter seven, where he describes a prescription for dying patients to say to loved-ones (I've used it for loved-ones to say to dying patients as well):
    1. I forgive you
    2. Please forgive me
    3. Thank you
    4. I love you
    5. Goodbye
These books are long form narratives that tell several stories in one coherent collection. Contemporary  micro-forms of these narratives use Facebook, blogs, and twitter.  Perhaps the next generation will recall being inspired by posts and tweets, rather than books. 

In that vein, and on the topic of goodbyes, I'll close with this Facebook post from a physician friend, Kevin Yee, reprinted with permission:

As a primary care physician you often know when you are seeing your patient for the last time before they die.

You don't say good bye because you do not want them to feel as if you've stopped being there for them after such a long journey.

And as you walk out of the exam room you gently lay your heart aside, just as you have hundreds of times before, and see your next patient.

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Friday, August 8, 2014

Surgical decision-making for elders: GeriBoards, prehab, and other great ideas

by: Alex Smith, @alexsmithMD

A while back people realized that outcomes of surgery in older people were probably better than previously believed. This led to a widespread perception that we were being ageist by not being aggressive enough in offering surgery to older adults.  We started operating on more older adults. We identified new ways to operate on increasingly elderly and frail patients.  If you look into geriatric surgery now, you will mostly find a bunch of stuff about how to optimize surgery for elders.  (Example - I was recently asked to review the orthopedic surgeon society's new guidelines on management of hip fracture.  It was all about this surgical approach or that approach, this screw or that piece of hardware, with almost nothing about the decision to have surgery or not.)

However, there is a new group of physicians researchers who are concerned that the pendulum has swung too far.  They are concerned that we are performing too many surgeries on high risk older adults.  These surgeries too frequently result in poor outcomes that older adults care about, like death or loss of functional ability.  And too often, these surgeries take place with too little thought and deliberation by the referring physician and surgeon about the decision to have surgery or not. 

This post identifies some of the superstars in this new group and summarizes some of their great ideas about how to address this issue:
  1. Emily Finlayson is a colorectal surgeon at UCSF who has published a number of studies calling into question the thoughtfulness of surgical decision making for nursing home residents.  Mortality for major abdominal surgery is far higher for nursing home residents than non-nursing home residents and functional status declines markedly following surgery for nursing home patients treated with surgery for colon cancer.  Emily is designing a new "prehab" clinic for frail older adults undergoing elective surgery.  This prehab clinic will include a Comprehensive Geriatrics Assessment and goals of care discussion by a geriatrician, with triggers for referral to palliative care. 
  2. Gretchen Schwarze is a vascular surgeon at the University of Wisconsin who has described two fascinating phenomena in surgery: (1) "buy in", or the unspoken pact that surgeon's feel they have made with patients to not deviate from an all out push to recover from surgery in the first 30 days post-op, including a refusal to listen to patient or family demands to stop life-support; and (2) problems with the "fix it" metaphor for surgical decision making.  Gretchen posted about fix it on GeriPal.  She also described a novel approach to surgical decision making using the "best case" and "worst case" scenario, including a visual of the surgeon's best guess of where the patient will end up on that spectrum.
  3. Mark Neuman is an anesthesiologist at the University of Pennsylvania who is the only anesthesiologist I know interested in health services research and geriatrics.  Fascinating!  We should have more.  He published the terrific piece on hip fracture in nursing home residents Eric wrote about for GeriPal last month.  Mark was also senior author of this awesome perspective for NEJM about a radical redesign of surgical decision making for high risk elders (first author Laurent Glance, MD, U Rochester).  My favorite idea from this perspective: GeriBoards.  We have multidisciplinary tumor boards for patients with cancer, including the surgeon, oncologist, and other care provders. Doesn't it seem logical that we should have multidisciplinary geriatric surgery boards?  The primary care doctor or geriatrician, who has a long relationship with the patient, can weigh in on the big picture, the anesthesiologist can weigh in about the risks from their perspective, and PT/OT can weigh in about the realistic potential for recovery of function.  They can deliberate together and follow the patient as a team.  Yes!  We should be doing that.
  4. Zara Cooper is a trauma surgeon certified in palliative medicine at the Brigham and Women's Hospital in Boston focused on decision making for older adults and seriously ill patients with life threatening surgical conditions.  Zara is working with Rachelle Bernacki, Susan Block, and Atul Gawande to develop a structured "check list" based approach to surgical decision making for high risk patients. 
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Wednesday, August 6, 2014

Potpourri from clinical work VII

by: Alex Smith, @alexsmithMD

The following are some reflections from being on service recently.  Not enough time to develop these into full posts.  If these issues tickle you, please respond in the comments!  To see previous potpourri's from clinical work follow the links to I, II, III, IV, V, and VI.
  1. David Reuben wrote a terrific perspective describing "The Hospital Dependent Patient."  These are patients who, usually elderly, who have chronic illness exacerbations that frequently land them in the hospital.  In the hospital they have a high quality of life, when surrounded by nurses and treatments that can only be delivered in the hospital.  I cared for one such patient.  He had frequent episodes of low blood pressure following dialysis, landing in him in the hospital over and over again.  He also had early dementia.  He could remember enough to think that he should be in dialysis most days, even when it wasn't his usual day.  Normally tired and sleepy, in the dialysis unit of our hospital, he came alive, talking animatedly with his "community" of care providers.  In goals of care discussions, this patient was clear that he enjoyed his quality of life and had no issues with returning repeatedly to the hospital for care.  As Dr. Reuben points out in his perspective, hospital-dependent patients are a product of our medical progress.  We have yet to grapple as a society with how to provide care for this increasing population of patients.  Nor have we addressed in a mature way the ethical issues around setting limits - if any - around what care our system should support and can afford for Hospital Dependent Patients.
  2. Cough is a tough symptom to treat sometimes.  I had a patients with cough and dyspnea on exertion due to idiopathic pulmonary fibrosis.  He did not believe that the opioids were helping him.  The pulmonary team suggested gabapentin, but my read of the literature is there is only case report level evidence.  The patient died before we could try alternatives.  What have you used for chronic opioid refractory cough?
  3. We had a patient who we communicated with just fine in his room.  No issues.  Then we had a family meeting.  Big room, lots of providers, including the medical team and 3 consulting teams.  We get about 1/3 of the way into the meeting and the patient says, "I can't hear what your saying."  Turns out he had hearing loss and we had no idea!  Brings home to me the importance of this issue.  In the room, alone, with the door closed, and 3 feet away from the patient's head, communication may be just fine.  But in a large family meeting, you may find a completely different experience.  Should we be screening for hearing loss in all of our patients over the age of, say, 75?  How should we screen?  Do you have ready access to pocket talkers for patients who have hearing loss?
  4. We cared for a man who experienced a hip fracture in the nursing home the other day.  His geriatrician care providers and surrogate decided that, as his pain needs were minimal, and he was in his 90s with dementia, they would not persue surgery.  Several months later we saw him and he was able to walk short distances to the bathroom, but did not try to venture out to the front desk as he did before the fracture.  Hindsight is 20/20, but it seems they made the right choice.  Other people's experience with non-operative managment of hip fracture?  Eric wrote about outcomes of hip fracture among nursing home residents last month.
  5. One patient requested that we start each mornings visit to his room with a joke.  What fun!  I told him some from my 6 year old son, like:
    1. "What's your favorite jam?" "Peach" "What's your least favorite jam?" "Grape" "But what about a traffic jam?"
    2. "Why is a nose not 12 inches long?" "Because then it would be a foot"
    3. This one is from Darth Vader's twitter feed (you follow him, right?) "How did Luke Skywalker stub his toe on the planet Endor?" "Ewoked into a tree."
    4. This one is from our team psychologist, "How do you make seven an even number?" "Take out the S"
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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.


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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