Tuesday, May 26, 2015

New guidelines address conflicts over "potentially inappropriate" treatment in the ICU

By: Laura Petrillo, @lpetrillz


Decisions about life-sustaining treatment in the intensive care unit are among the most ethically fraught decisions in medicine, and disagreements between clinicians and families are not uncommon. To provide guidance to clinicians, the American Thoracic Society (ATS) collaborated with the American Association of Critical Care Nurses and other critical care societies to create a policy statement on "Responding to Requests for Potentially Inappropriate Treatment in the Intensive Care Unit," to be published on June 1st in the American Journal of Respiratory and Critical Care Medicine.

Proponents of palliative care will be glad to see that the guidelines recommend an emphasis on good communication in the ICU and early, expert consultation from palliative care or ethics services to prevent conflict. There has been increasing appreciation of the value of palliative care in intensive care, and efforts like IPAL-ICU are making strides to facilitate the collaboration of ICU and palliative care teams. But there is still a long way to go, and the ATS's endorsement of early palliative care in the ICU is most welcome.

When conflicts arise despite proactive communication, the guidelines recommend using specific language to categorize the family request that led to the dispute. The authors use the term "potentially inappropriate treatment" to acknowledge that in some scenarios, the treatment that a family requests may have some physiologic benefit, but the clinician disagrees with the worth of that benefit or the means justified to achieve it. This is a move toward transparency about the competing value judgments inherent in these decisions, in contrast to the past when clinicians had sole power to deem a treatment "futile" if it could not bring about an outcome that the clinician considered meaningful. The authors resurrect the idea of futility, but narrow the definition to apply only to treatments with absolutely no chance of bringing about a physiologic effect, like providing CPR to a corpse with rigor mortis.

The guidelines go on to propose a multi-step process for resolving intractable conflicts that ensures fairness and justice for patients and families. The steps again emphasize good communication and transparency. The authors suggest review by a multidisciplinary committee, and providing families with the opportunity for extramural appeal and transfer if the committee ultimately upholds the clinician's stance on the request.

Finally, the guidelines take a bold step to urge clinicians to lead the way in advocating for policies and legislation about when life-sustaining treatment should be used. The authors suggest that clinicians partner with patients and other "key stakeholders" to create rules that guide how ICU beds should be allocated when scarce, for example, and whether to ever provide intensive care to patients with advanced dementia or in a persistent vegetative state.


At first blush, the ATS guidelines appear to strike a cautious balance of patient autonomy, exercised by families as surrogates, and clinician judgement of best interest. The press release for the article quotes one of the authors, Douglas White, MD, as saying, "Clinicians should neither simply acquiesce to treatment requests that they believe are not in a patient's best interest, nor should they unilaterally refuse to provide treatment."

But on closer inspection, the guidelines take a firm stance on which requests are open to debate. The guidelines assert that clinicians can refuse to provide treatment with no physiologic benefit, and can refuse requests for "legally proscribed" treatments, such as providing ongoing life support to a patient diagnosed as brain dead, in a state where brain death is recognized. This may seem obvious, but there has been an erosion of previously clear lines since the tragic and widely publicized case of Jahi McMath, the 13-year-old patient with anoxic brain injury who was kept alive at her family's request despite a diagnosis of brain death in California.

In addition, the guidelines suggest that when time is so limited as not to permit the recommended conflict-resolution process, clinicians can refuse to provide treatments that they feel certain are "outside of the bounds of accepted practice," leaving room for interpretation. There is also a loophole in states, like Maryland, with statutes that give clinicians the right to refuse to provide "medically ineffective treatment," with the example of a clinician refusing to provide CPR in a metastatic cancer patient with multi-organ system failure.

There is considerable variation in what clinicians believe is within the realm of "accepted practice" when it comes to the provision of resuscitation and life-sustaining treatment. The recommendation that we examine these situations systematically to arrive at public policy about when to offer these treatments is completely reasonable and just, but bound to fan political flames and fear of rationing, given that even legal endorsement of advance care planning met with hysterical fear of "death panels".  Even the idea that clinicians can raise an objection to "potentially inappropriate" treatments on an ethical basis, and consider distributive justice in the context of a decision about a single patient, is itself somewhat radical and counter to current practice.

On a more basic level, I wonder whether the question posed by the authors, "how to respond to family requests for potentially inappropriate treatment" truly captures the issue in question in ICU conflicts.  How often do families bring their loved ones to the hospital and ask for vasopressors or mechanical ventilation by name? Much more often, clinicians provide life-sustaining treatment in an emergency by default, or out of uncertainty, and the conflict arises about when to discontinue it. Or resuscitation is offered even in situations with low likelihood of benefit, and then clinicians are disappointed when patients or families choose it. Can families be faulted for opting for more aggressive care when the healthcare system itself presents such ambivalence about the "appropriateness" of these interventions?  The idea of creating boundaries as a society would be ideal, but if the process will be hamstrung by politics, perhaps clinicians should agree on boundaries among themselves that can be applied fairly and consistently. Or the use of trials of treatment could be more uniformly applied, so that families expect that once treatments are initiated, there will be periodic review of whether those treatments are meeting the patient's goals.

Another idea that merits mention is the presentation of an alternative, so that families do not feel that the options are life-sustaining treatment or nothing. In a different guideline, published last year in the same journal, the ATS presented its "Choosing Wisely" list for critical care medicine. In it, the ATS again endorsed the idea of palliative care in the ICU with its recommendation, "Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort," and the additional comment, "Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focused therapy may be beneficial."

There is still much work to be done to establish the boundaries of "appropriate treatment" for critically ill patients, but the ATS guidelines present a great starting point for discussion and attempt to find routes to transparency and fairness in an ethically murky area.

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Sunday, May 24, 2015

Decision aids in serious illness: dissemination strategy, anyone?

An example decision aid in serious illness: Prepare, www.prepareforyourcare.org

by: Alex Smith, @AlexSmithMD

I was fortunate to be part of a really nice systematic review of decision aids for patients with serious illness by Adrian Austin (senior author Laura Hanson).  This manuscript was published online ahead of print in JAMA: Internal Medicine last week.

For this study, Austin reviewed nearly 10,000 titles to identify 38 rigorous studies that meet inclusion criteria.  Seventeen were randomized controlled trials.

I'm not going to summarize the article here - suffice it to say there are a number of very promising decision aids to help people with serious illness.  The article is self explanatory, and I highly recommend that people at a minimum look at the tables to see if there are decision aids you might like to incorporate into your practice. Note, you have to be a JAMA: Internal Medicine subscriber to read the article.

I'd like to pose a question, raised in part by James Tulsky in his terrific accompanying editorial.  James says:
Hospitals and health care systems must make the commitment to introduce such tools at the point of care to ensure that patients facing decisions have the resources they need when they need them. Most of the tools reviewed by Austin et al are free and could be disseminated relatively inexpensively.
Emailing with Laura Hanson and Rebecca Sudore after the paper was accepted, we were at a loss as to what the next steps should be for dissemination.  In many ways, we are at a similar point to where we were after conducting a systematic review of prognostic indices for older adults.  We decided (spurred by Lindsey Yourman) to put the prognostic indices in our review online - voila!  ePrognosis.

But these decision aid tools differ from prognostic indices in important respects. Several include booklets.  While many are free, others are proprietary videos that must be purchased.  A few do not appear to be publicly available at all.  These are not as amenable to a website compendium or toolkit, like ePrognosis.

The problem is that busy clinicians will not use these tools unless they are easily available.   Putting them in one place, or linking them somehow, makes a tremendous amount of sense.

So my question for you - does anyone have a dissemination strategy for decision aids in serious illness?

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Saturday, May 23, 2015

Insights into Geriatrics by Cartoonist Roz Chast

Roz Chast, a beloved and well known cartoonist for the New Yorker, has written a brilliant book that should be required reading for the geriatric curriculum. It is entitled “Can't we talk about something more PLEASANT,” and the title comes from her parents’ refusal to discuss their advancing years and the prospect of death. As I read it I literally saw my entire field flashing before my eyes. 

Known for her nervous looking pen and hilarious observations of urban life, she presents a starkly realistic portrayal of the last years in her parents’ lives and their progressive physical and mental deterioration. An only child, she takes on the responsibility of caring for them in their 90's as they face a trajectory of decline that is the bread-and-butter of any geriatrician. Through the artist's words and images, elder care is depicted in a way that is heartbreaking, funny, and quite accurate.

We observe Ms. Chast’s ailing parents through simple pen and ink and watercolor as they trundle through their last years, often in denial. The artist grapples with her feelings of guilt and anger as she takes charge of her parents’ finances and living situation, while deftly documenting the quirks of their personalities and the tenderness of their relationships. She fearlessly steps into their world of frailty and describes falls, social isolation, and cognitive changes, all while juggling her own family responsibilities. Her cartoon panels are peppered with personal photographs and the occasional flashback when we learn of her life as an overprotected, nerdy child with an overbearing mother.

Difficult and important challenges of geriatric caregiving are illustrated, including discussion of advance directives and driving after cataract surgery. Ms. Chast describes her shock at discovering the extent of her father’s cognitive deterioration, and does an outstanding job of presenting the anxiety and behavior changes that commonly occur in people with progressive dementia, as well as the stress and fatigue she experienced as a caregiver. When I read about her father getting lost in his apartment building and leaving the stove on, I was vividly reminded of events I have seen so many times with my patients.

The book realistically presents her interface with the healthcare system, including long waits in the emergency room, visits to the neurologist, and the transitions from assisted living to hospital to nursing home to hospice. On the way, she brushes nearly the entire gamut of geriatric syndromes including falls and fall related injuries, deconditioning due to hospitalization, depression, fecal incontinence, dysphagia, pressure ulcers, pain management, and progressive dependence in ADLs that often accompanies frailty. On the way she describes doctors who have no clue how to deal with frail elderly, and the difficulty of making choices regarding operative interventions in people of advanced age. Throughout her journey, Ms. Chast remains remarkably rational in evaluating her options and abiding by the choices of her parents.

At the very end when her dying mother enters hospice and becomes nonverbal, she presents a series of drawings that eliminate captions in a way that echoes her mother’s wordlessness. This series in particular brought back images from my years working as a nursing home physician.

The most important aspect of this book is the unflinching yet touching way her parents’ trajectory of decline is presented through simple drawings, and the very realistic observations and stream of consciousness that appear in the captions. This book can serve as a starting point for any student or family member interested in principles of geriatrics and the experience of growing old in America. Roz Chast is not a doctor, but with an accurate pen and sharp wit she combines art and medicine to create not just a memoir but a realistic portrayal of progressive frailty and death in a society and culture that usually ignores these issues.

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Friday, May 22, 2015

Outcomes of In-Hospital CPR in Patients Receiving Dialysis

We’ve talked a lot about the prognosis after receiving in-hospital CPR in this blog (here, here, and here to name a few). In a recent issue of JAMA Internal Medicine, Susan Wong and colleagues looked at what happens to individuals on maintenance dialysis when they receive in-hospital cardiopulmonary resuscitation (CPR).  The results are summarized in the infographic above, and discussed in a little more detail below.

The Study

The authors used data from the US Renal Data System (USRDS) registry that enrolls patients after the onset of end stage renal disease, identifying all patients 18 years or older without a prior kidney transplant who initiated maintenance dialysis from January 1, 2000, through December 31, 2010. Importantly, to be included in this study, these patients needed to be on dialysis for at least 90 days (thereby exluding the sickest of the sick). By linking Medicare claims, they determined who in this registry was hospitalized and who got in-hospital CPR (although they excluded ER CPR).

Outcomes of interest included incidence of in-hospital CPR, proportion of patients surviving to hospital discharge after their first inhospital CPR event, and post-discharge survival. Among those who died in the hospital, they also measured the proportion who received CPR during their terminal hospitalization.

What did they find?

Most of the key findings are in the infographic, but I'll just highlight a few here:
  • The vast majority of individuals on maintenance dialysis were hospitalized at least once during the follow-up period (81% of the cohort)
  • Of these individuals who were hospitalized, 6% underwent at least one episode of CPR while hospitalized with a trend toward higher rates of CPR in more recent years. 
  • The proportion of CPR recipients who survived to discharge has increased in from 2000 to 2011 (15.2% to 28%) but there was no substantial change in duration of post-discharge survival.
  • The median survival fromthe time of discharge was 5.0 months among those who survived to discharge.

The Take Home

The results of this study are in line with other studies that suggest less people die in the hospital, but that doesn't mean that their long-term prognosis is any better.  In particular, Joan Teno's work shows that despite a decline in hospital deaths and an increase in hospice use, end of life for Medicare decedents increasingly includes ICU stays, short hospice stays, and multiple health care transitions.   This is particularly true to the dialysis population who undergo CPR.   We are better able to get them out of the hospital alive, but their survival after hospital discharge really has not improved, making them otherwise prognostically eligible for hospice.

by: Eric Widera (@ewidera)

Note: for more on the geriatric and palliative care needs of those with end-stage renal disease see these posts:

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Wednesday, May 20, 2015

Yes, There is a Medical App for That

At this years AGS Annual Meeting, Manuel Eskildsen, Alice Pomidor, Amit Shah, Niharika Suchak, and I led a session aimed teaching how to integrate mobile applications and other emerging technologies into clinical education and patient care.

As part of this session, we created a brief handout for attendees describing some of the apps and resources we use in our own teaching and clinical practice.  We thought it may also be helpful to share this with our GeriPal audience.  We also would love to hear from you on what apps you use in your teaching or clinical practice (please add to the comment section below the handout):
Yes, There’s an App for That: How to Integrate Mobile Applications and Other Emerging Technologies into Clinical Education and Patient Care Apps and Resources List
American Geriatrics Society 2015 Annual Meeting 
Manuel A. Eskildsen, MD, MPH; Alice Pomidor, MD; Amit Shah, MD; Niharika Suchak, MD; Eric Widera, MD 

Apps/Resources Mentioned by Dr. Eric Widera (Clinical Teaching and Patient Care) 
  1. Seeing the world as our patients do: 
    •  VisionSim:   Simulates visual problems (excellent for empathy exercises and teaching importance of addressing vision in comprehensive geriatric assessments) 
  2. Multimorbidity and Geriatric Principles: 
  3. Prognosticating
Apps/Resources Mentioned by Dr. Amit Shah (Massive, Flipped and Spaced Learning)
  1. Flipped Learning 
  2. Spaced Learning
  3. Massive Open and Online Courses and Degrees (MOOCs and MOODs)
Apps/Resources Mentioned by Dr. Alice Pomidor (Patient education mobile application resources)
  1. Socialwellth - “Prescriptive Digital Health”
  2. Health tap: top 10 in various categories, overall top 10
  3. ALZ--Alzheimer’s Association Pocketcard
    • Has clinical information, interactive assessment tools such as clock, educational materials that can be directly e-mailed to patients/caregivers. Free at App Store and Google play)
  4. MNA--Mini-Nutritional Assessment
    • Recommended by American Dietetic Association, Hartford, AMDA, European Society for Parenteral and Enteral Nutrition (ESPEN). Has supporting website at www.mna-elderly.com. Available in multiple languages. App is the short screening version and results can be e-mailed. Free at App Store only for iPhone. Sponsored by Nestle.
  5. webMD--#1 most used general health website with 12 billion page views per year (same group that does Medscape)

Apps/Resources Mentioned by Dr. Niharika Suchak (Mobile Apps in Medical Education)
  1. Epocrates (drug information, drug interactions, pill ID etc.)
  2. Pulm Tools for PORT score or pneumonia severity index calculator
  3. uCentral from Unbound medicine: (5 Minute Clinical Consult, MEDLINE search, calculators, textbooks, guidelines, systematic reviews, etc.)
  4. ePSS (USPSTF health maintenance recommendations by age groups) 
  5. Dynamed (a clinical reference tool for use at the 'point-of-care' with clinically-organized summaries)
  6. Pepid Clinical Rotation Companion (point-of-care reference, drug database, and decision support tool)
  7. Access Medicine (online medical resource with leading medical textbooks, videos, self-assessment, drug database, quick reference, and decision support tools)

Other notable apps not mentioned above that you might want to try:

A curated library for health professional who provide care for geriatrics patients which is updated: http://upmc.com/agingapplibrary. Maintained by Dr. Steven Handler and Dr. Nagib Manov

1. Mobile Apps for Clinical Teaching:
  • Eponyms (for fun!)
  • Agile Diagnosis
  • Diagnosaurus (large lists of differentials for chief complaints)
  • Visual Dx (online and app-- great derm reference)
  • Medical Calculators: QXMD, MedCalc, and Mediquation
  • Antibiotics: Sanford Antibiotic Guide, the Hopkins Antibiotic Guide, or the Antibiotic Advisor
  • Prognosis-Your Diagnosis (teaching preclinical/early clinical students)
  • Radiology 2.0 (cases and teaching)
  • Casefiles
  • Heart sounds teaching apps (many): Best: Littman, Blaufuss (great!), iMurmur
  • Teaching anatomy: Visual Anatomy and Netter’s

2. Mobile apps for clinical care
  • CDC Vaccination schedule
  • Hospice Apps: Vitas, Hospice by the Bay, etc
  • Medscape (full feature reference app) goes with webMD (patient level)
  • Dynamed (like Up To Date)
  • Skyscape (similar to Medscape)
  • Drug information apps:
  • Micromedex (most comprehensive drug information program)
  • Lexi-comp (great drug information app)
  • Epocrates #1 used/rated app by doctors for quick drug info, pill pictures, interactions

3. Mobile apps for patient use/patient education use:
  • UK’s NHS Health Apps Library: apps.nhs.uk (reviews apps for accuracy and posts them by topic for patients) 
  • DrawMD (great for patient education when you need clear anatomy pictures)
  • HealthTap overall top 10 for iOS (2014): 1) MyFitnessPal.Com 2)Weight Watchers 3) Lose It 4) White Nose Lite 5) First Aid (Red Cross) 6) Runkeeper 7) Stoke Riskometer 8) Emergency First Aid and Treatment guide 9) Instant Heart Rate 10) Fooducate 
  • Healthtap overall top 10 for Android (2014): 1)Weight Watchers 2) White Noise Lite 3) Lose It 4) First Aid (Red Cross) 5) Runkeeper 6) Emergency First Aid and Treatment guide 7) Instant Heart Rate 8) Fooducate 9) Glucose buddy 10) Pocket First Aid and CPR
  • Best Alternative Medicine App: About Herbs (Memorial Sloan Kettering)
  • Best Medication Apps: Meditation Oasis; Mindfulness Trainer
  • For General Medical Knowledge: webMD and Mayo Clinic apps
  • For Arthritis: ArthritisID
  • Hearing screening: UHear
  • Find cheaper medications and costs of medications by pharmacy: GoodRx and GoodRx.com
  • Pill reminders (many): 1) Drugs.com Pill reminder 2) RxmindMe 3) Pill Monitor 4) MedMinder

Read more »

Tuesday, May 19, 2015

Finding the Workforce to Care for an Aging Population

Returning from the American Geriatrics Society Annual Scientific Meeting, I am struck by the thought that the United States’ health care policy is functioning without a compass. We are at the beginning of a tremendous demographic change in this country, but are we adequately preparing US physicians to care for an aging population?

Most residency education in the US is funded through Medicare. Given Medicare’s charge is primarily to care for adults over 65, you would think that Medicare would emphasize training physicians to meet the needs of an aging population. Yet the statement that sticks with me from AGS is this: “10,000 new beneficiaries enroll in Medicare every day, yet we lose 5 geriatricians every week.” Astounding!

Moreover, the additional trends in geriatric education actually point to less support for training physicians to care for older adults. The Reynolds Foundation, which has been a tremendous supporter, is a foundation designed to spend down its assets and will soon no longer be a source for innovative grants to improve delivery of care to older adults. Likewise, the main grant for training geriatrics clinician educators, the Geriatric Academic Career Award, will not be funded by the Health Research Services Administration this year. How will we create the clinicians that we need for our future without support for the educators who will teach them?

My wife would remind me that when you are lost (and our health care policy is lost in this regard) it is time to stop and ask for directions. Of course the modern equivalent for directions is the GPS map. I propose it is time for a new GPS, this one inspired by the National Service Corps. We need a National Geriatrics and Palliative Service Corps. It can be our new compass to provide the US the health care workforce we need to care for older adults.

(Note: I include palliative care with geriatrics here recognizing the distinction between the two, but in the knowledge that most palliative care patients are in fact part of the Medicare population and that palliative care workforce suffers from the same issues as geriatrics. You need both geriatrics and palliative care together to make a GPS for health care policy.)

The National GPS Corps should consist of three elements:
  1. To promote geriatric or palliative care training, all residents who complete a geriatric or palliative care fellowship shall have half of their student loan burden relieved through federal debt forgiveness or payment to private lenders. Crushing student debt is a key factor driving trainees to higher paid specialties and this will make geriatric and palliative care training more feasible. 
  2. To promote excellent geriatric and palliative care academicians, those who opt for a second year of additional academic or research training will have all subsequent student loans forgiven or paid. 
  3. To promote clinicians practicing in geriatrics and palliative care rather than further specialty training and to allow for appropriate geographic distribution across the country, those who only complete one year of fellowship will be eligible for further debt forgiveness after completion of a three or five year clinical commitment in a designated geriatrics/palliative care service area. 
In addition, we must create teachers who can train the workforce to meet our countries needs. As Congress works to create the National Geriatrics and Palliative Service Corps, the act should also fully fund both Geriatrics Academic Career Awards (GACAs) and Palliative Academic Career Awards (PACAs) to allow junior faculty to train to be master educators that lead educational efforts to reach all physicians in all specialties. The National Geriatrics and Palliative Service Corps will be an excellent complement to both the Geriatrics Education and Training Act and the Palliative Care and Hospice Education and Training Act or PCHETA (which must also pass and soon!)

With regards to geriatric and palliative care workforce, our health care policy is lost, but this is the GPS that can get us back on the path.

by: Paul Tatum

Disclaimer: This piece is the opinion of the author alone and does not represent the opinion of the American Geriatrics Society nor the American Academy of Hospice and Palliative Medicine.
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Monday, May 11, 2015

The AGS Annual Meeting Program Cover

I am thrilled that the AGS is using my images on the cover of their Annual Meeting program. The collection of photos is the result of years of travel across America photographing aging. The message in this design is that our country's aging population is vast and diverse. In my images I try to portray the inner strength of my subjects that has enabled a long life, and explore spiritual connectedness with the world and society. I also like to show the commonalities of growing old and how the elderly fit within our culture, and present a realistic and positive view of the human journey that most of us will experience.  

Aging is not a popular topic to look at, as most people would rather see flowers, dogs, parakeets, or cute kids. Few people embrace images that tweak insecurities about wrinkled skin and thoughts of mortality. Ageism permeates the mass media's imagery of growing old, which contributes to stereotypes and negativity. In my view, the lack of images of aging in mass media contributes to our culture's collective denial of the aging process and distortion of expectations. Indeed, a great number of images of aging on prime-time television are in commercials for erection medications and incontinence products.

However the phenomenon of aging is intertwined with the fabric of every human life, particularly for those who choose geriatrics as a specialty. The impact of the aging demographic on our society and healthcare system has yet to be measured, but we as geriatricians are acutely aware of its immense scope.  

In explaining my motivation to both practice geriatrics and photograph aging I would like to quote my mentor, Leslie S. Libow, who introduced me to the field in an article published in The Gerontologist in 1982:
"It is the humanism that excellent geriatrics represents, especially in dealing with the frail elderly and their families. Here we see clinicians committed to health care approaches that balance curing and caring, touch and technology. Basically, then, the emphasis is on life and fulfillment by patient and professional. The quality of the approach to the frail elderly is a key measure of our health system's compassion and competence, not merely for the elderly but for those of all ages." 
"Our work is pleasure, yet the outsider often wonders how we do it. Like so many of you, I enjoy older people. I like the art of medicine. I like the process of science. I am attracted to humanism and social-psychological dynamics. I favor the underdog. I enjoy a struggle and advocacy. Geriatrics and gerontology have satisfied those desires in me more than a person can hope for."

* * * * * * * * * * * * * * *

Reference for this post is: Libow LS. Geriatric Medicine and the Nursing Home: A Mechanism for Mutual Excellence. The Gerontologist 22 (2) 134-141; 1982.

Dr. Jeff Levine’s photography exhibit entitled “An International Celebration of Aging” will be at the University of Michigan Medical Center  in the Taubman Gallery from June to August, 2015 as part of their Gifts of Art program.

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Sunday, May 10, 2015

Celebrate nurses week by stopping the customer satisfaction nonsense

by: Alex Smith, @AlexSmithMD

Happy nurses week!  A special double happiness to the nurses who are also mothers today.

This year, as we celebrate the awesome nurses in our lives, let's take a moment to consider what makes a terrific nurse.

First, by way of gathering information, let's consider the healthcare industry's present views on excellence in nursing.  Let's think about how this conception of excellence in nursing aligns with our own perspectives.

In a recent Atlantic article, titled "The Problem with Satisfied Patients,"Alexandra Robbins writes about the economic incentive hospitals face to improve patient satisfaction scores.  This is a high stakes issue for hospitals, as their bottom line in terms of Medicare dollars is now tied to patient satisfaction scores.  Most of these scores, derived from a patient survey called HCAPS, rely on ratings of nurses.  For example:
“During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”
This sounds reasonable on the surface, but then look deeper to see what sorts of issues patients were concerned about when they rated nursing care poorly on this section.  Again, from the Atlantic:
  • “My roommate was dying all night and his breathing was very noisy”
  • “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
  • An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery).
What, exactly, do these comments have in common with high quality medical care?  Nothing.  Zero.  Zilch.  And yet hospitals are hiring "customer relations" experts to train hospital staff, and nurses in particular, in how to become more Disney.

Now think of the terrific nurses in your lives.  Are they terrific because they act like Disney concierge services to patients?  Now certainly that wouldn't exclude them from being terrific, but those are not the qualities that come to my mind when I think of terrific nurses.  I think of: strong, compassionate, "real," able to confront challenging patients in a way that I could never do as a physician, resourceful, creative, and watchful for errors or early signs of distress.  Note that "finds Splenda and extra pastrami" do not appear on this list.

This whole patient satisfaction thing has gotten out of hand.  It's a tremendous amount of money being spent on the wrong thing.  Of course, treating patients with respect and dignity is important.  That's not the same thing as satisfaction, though.  Patient satisfaction thing places the emphasis on making patients happy, not healthy, feeling pampered, not prepared for the worst.  

It's the same thing in doctoring, by the way.  A recent article in JAMA oncology by Kimberson Tanco examined patient perception of physician compassion after more vs less optimistic messages about prognosis.  Unsurprisingly, patients were more satisfied with scenarios in which they saw doctors give more optimistic messages to a patient with advanced cancer than lest optimistic.  Duh.  Wrong question!  Of course it seems better to hear, "You don't need a rectal today."   (when you actually do). Or your care mechanic says, "There is nothing wrong with your car."  (When the brakes are about to give).  How about asking patients, "did you get the information you needed to make the decisions you needed to make?"  Or, asking the bereaved spouse after the patient died, "Did you feel prepared when he started to get really sick toward the end?"

But back to nurses, where the focus should be this week.  We'll give the last word to two nurses.  First, Amy Bozeman, who is quoted in the Atlantic article decrying the focus on patients as customers: 
“Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.”
Second, a nurse named Kim from San Francisco, quoted in the Atlantic from her blog emergiblog:
A hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better.
Let's celebrate nurses for excellence in nursing, and call for a stop to this customer satisfaction nonsense.

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Friday, May 8, 2015

#ThickenedLiquidChallenge on Making Sense of Alzheimers

by: Alex Smith, @AlexSmithMD

Check it out folks, the #ThickenedLiquidChallenge is now a featured video on MakingSenseofAlzheimers.org, a new site out of U Penn run by Jason Karlawish.  The purpose of the site, as they describe it:
Making sense of Alzheimer's is a creative space for people to understand the past, present, and future of Alzheimer's disease.  It is an evolving forum, a gallery of ideas, a museum without walls.
This a brilliant site.  It features personal stories, like that of Dougald MacArthur, a writer, director, and former head of the MFA program in Acting at Temple.  The story is told by his wife Christine MacArthur who marvels at his ability to laugh and enjoy life in spite the Alzheimer's that generally renders him completely unintelligible.

It features poetry, like Twitch, by Deborah Fries.about the complicated feelings a person might feel upon being asked to donate part of a body, like a brain, for scientific research.

It features thoughtful videos, like the one titled "Should we still read Still Alice?"  In the video, Jason Karlawish likens what Still Alice has done for Alzheimer's to what Uncle Tom's Cabin did for Slavery: raising the issue to a level of public consciousness through fiction.  He also describes his complex reaction to the book and film, particularly in light of the protagonist's young age relative to the overwhelming majority of people living with Alzheimer's, which may be misleading.

And now...Making Sense of Alzheimer's features the #ThickenedLiquidChallenge!

The video for the #thickenedliquidchallenge is centered around the story of Helen, a woman with advanced dementia we cared for here at the San Francisco VA Medical Center (we have permission from Helen's son and proxy to disseminate this story).

On Making Sense of Alzheimer's we tell the story of how Helen was prescribed thickened liquids and a pureed diet when she was hospitalized, as she had been for years while being cared for at home.  In fact, she had a big sign on her door that said "Thickened Liquids Only."  This was right around the time that we started the #thickenedliquidchallenge.  Helen was eating and drinking very little.

Eric Widera was the attending on the palliative care consult team asked to see her.  He happened to be standing next to the sign on her door when the primary team came by, and challenged them to justify the thickened liquids order.  When they couldn't justify the order, he asked them to remove the thickened liquid restriction.  Lo and behold, she started drinking regular consistency water without coughing or aspirating.  She started eating and drinking more. She perked up.  She was transferred to hospice in our nursing home, with the goal of focusing on comfort, allowing a liberalized diet. 

You can see Helen smile in the video after drinking some regular consistency liquids.

My favorite part of the video are the shots from all of the Youtube Videos of people taking the #thickenedliquidchallenge.  Including: The Palliative Care Research Cooperative, Mike Steinman, Suzanne Gordon, Holly Yang, David Oliver, and a host of others I don't even know. 

It's remarkable to see these videos together in the same place.  The most amazing and humbling thing about the #thickenedliquidchallenge is the way it's spread organically beyond the GeriPal community.  One of the most rewarding aspects of the challenge has been the way it's helped people re-think prescribing thickened liquids, and the dialogue it's started between physicians and speech language pathologists.

Keep on drinking and challenging.


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Thursday, May 7, 2015

Fatal Falls Rising in Older Adults

The Centers for Disease Control released a sobering report on mortality due to falls and other unintentional injuries in older adults.   The good news:  death from motor vehicle accidents has fallen since 2000, and death from other unintentional injuries such as suffocation, fire, and poisoning remain relatively rare.  The bad news:  between 2000 and 2013, the age-adjusted rate of death from falls in older adults nearly doubled, from 30 deaths per 100,000 adults to 57 deaths per 100,000 adults.  Among adults at the upper reaches of age, the death toll from falls is even more striking.  In 2012-13, there were 226 deaths due to falls per 100,000 adults.

Figure 2. Age-adjusted death rates, by cause of death among adults aged 65 and over: United States, 2000–2013

While concerning, these numbers only scratch the surface of the total burden of falls in older adults. According to the CDC, in any given year, one in three older adults will have a fall, and 20-30% of adults who fall will suffer a moderate or severe injury.  These injuries and the fear of falling can have profound impacts on quality of life and subsequent morbidity and mortality.  As a results, the total mortality burden from falls likely far exceeds the immediate risk of fall-related death cited in the CDC's latest report.

Why are fall-related deaths increasing?  The answer likely is complex, and includes changes in the distribution of underlying chronic illnesses as well as better reporting of falls as a contributor to death.  Whatever the cause, more action is needed, and emerging initiatives and interventions - such as a falls reduction program being studied by a consortium of Pepper Centers - will be vital to the solution.

by: Mike Steinman
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Wednesday, May 6, 2015

Anticoagulation in Elders who Fall

If you had suggested to me only a short time ago that older people who fall should be taken off of anticoagulation, I would not have hesitated to agree. After all, first, do no harm, right? And isn’t the adage “less is more” absolute in geriatric medicine? But if there is one message I have learned through my internal medicine and geriatrics training, it is to always question “absolutes.” 

Mr. A was 91 years old when I first met him and when I took him off warfarin, which he was taking for atrial fibrillation.  He had many falls, lived alone, and required a walker to walk steadily but often did not use it in his very cluttered home. One week later, he fell right in front of our office sustaining a broken nose and I patted myself on the back. One month later, he awoke with aphasia and was admitted to the hospital for suspicion of stroke.  Thankfully, his event cleared within 24 hours, but the message it conveyed cued me to look further into the data we have on anticoagulation and falls – bringing me to the question, "In older adults with atrial fibrillation who are at high risk of falling, does bleeding on anticoagulation or stroke without it portend the greater morbidity/mortality?"

Risk of bleeds with falls 
Only one-third of patients who qualify for anticoagulation for atrial fibrillation receive it, with falls being listed time and again by primary care physicians as one of the top reasons for not starting or stopping this treatment. But what is the risk of major bleeding, especially of intracranial bleeding, in patients at high risk of falls? After all, the data is clear that anticoagulation worsens the risk of spontaneous intracranial hemorrhage. Hemorrhage also increases with age regardless of anticoagulation, so a knock on the head while on blood thinners could only possibly skyrocket that risk, right? Not necessarily.  In 2012, a prospective cohort study of over 500 patients discharged on oral anticoagulants found no significant difference in risk of major bleeding - including intracranial hemorrhage - at one year between those at high risk of falls and those who were not. (1)  One limitation was that there were very few major bleeding events and even fewer fall related bleeds (three!) Also, the average age in the study was 71 years, so this may not be applicable to our frail 80 and 90 year olds who are more likely to bleed. 

Risk of stroke without anticoagulation 
If bleeding and stroke rates both increase with aging, how do we balance the two? And just how large is the stroke risk without anticoagulation? Atrial Fibrillation Investigators (AFI) found that the average risk of first stroke for a patient >65 years old with at least one risk factor  is 5.7% per year, and by age 75 that risk rises to 8% per year (2). And in patients with only one risk factor for stroke, age greater than 75 demonstrated the strongest risk prediction (3). Anticoagulation with warfarin has been shown to historically lower that risk by at least two-thirds (2). So, how does this stack up to the risk of major morbidity and mortality from bleeding? Using pooled data from major atrial fibrillation trials, a decision analytic modeling study showed that a patient would have to fall 295 times per year for the risk of warfarin therapy to outweigh the benefit of stroke prevention (4). But is this just fancy math? Maybe not. A database study of over 20,000 Medicare beneficiaries found that despite higher incidence of intracerebral hemorrhage in patients identified as high risk for falls, if they also had at least a moderate stroke risk (CHADS=2), anticoagulation with warfarin was protective of mortality (5). While an obvious limitation is the data extraction using billing codes, a strength of this study over other studies described was the average sample age of 80 years. 

Novel Oral Anticoagulants (NOACs) – throwing a wrench in the works? 
But just as I’m finally getting comfortable with the data on warfarin, we have new agents with new risk profiles. Plus, they come with the caveat that if your patient suffers an intracranial hemorrhage when on a NOAC, there is no antidote to reverse it. Yet thankfully, the data we have points that the intracranial hemorrhages sustained on NOACs are fewer and less severe – possibly due to the shorter half-life of the drugs and quicker wash-out even despite not having an antidote (6). So, in spite of the highly discussed fear of lack of antidote, anticoagulation in our older patients with atrial fibrillation at risk of falls still seems in favor. 

Conclusions and Caveats 
The data is mounting that providing anticoagulation for patients with atrial fibrillation regardless of age and risk of falling is safer than withholding it, although most of the data excludes our oldest old and frailest frail. In the future, greater use of anticoagulation in this population will help us study the risks and benefits, and guide treatment decisions. Perhaps, the most astonishing point I learned from this exercise was the value of rechecking your gut reaction with available literature as a guide, keeping in mind that the application of the data lies somewhere in the marriage of the art and science of medicine. That is the essence of evidence-based medicine.  

1. Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012 Aug; 125(8):773-8.
2. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994 Jul 11; 154(13):1449-57.
3. Olesen JB, Lip GY, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011 Jan 31; 342:d124.
4. Man-Son-Hing M, Nichol G, Lau A, Laupacis A. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999 Apr 12; 159(7):677-85. 
5. Gage BF, Birman-Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med. 2005 Jun; 118(6):612-7.
6. Caldeira D, Barra M, Pinto FJ, et al. Intracranial hemorrhage risk with the new oral anticoagulants: a systematic review and meta-analysis. J Neurol. 2015 Mar; 262(3):516-22.
Photo courtesy Martin Cathrae 

by: Mallory Otto, MD, Geriatrics fellow, 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 palliative medicine and the attempt to provide patient-centered care with the use of best available evidence. 
Ravishankar Ramaswamy, MD
Section Editor, #GeriCases
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Monday, April 27, 2015

Victory Day in Moscow: Honoring the Older Generation

I had good reason to miss the 2012 AGS meeting as the dates overlapped with Victory Day in Moscow. Victory Day is the Russian national holiday commemorating surrender of the German army on May 9, 1945. The country fought for 6 bloody years and lost millions of civilians and soldiers, and throughout Russia and much of the former Soviet Union there is an outpouring of patriotism. My goal for the trip was to photograph elderly WWII veterans who come to display their uniforms and medals. What I found was an amazing and touching public tradition of honoring the older generation.

Victory Day in 2012 was two days after Vladimir Putin's inauguration and there was a heavy military presence. In the days leading up to the event I watched as demonstrators were hustled away by police in riot gear and taken away in crowded vans. On Victory Day central Moscow was locked down and many streets and subway stations around Red Square were closed. I was able to get to Tverskaya Street, a wide boulevard where a parade of tanks and mobile missiles passed cheering spectators. Afterwards I went to the plaza in front of the Bolshoi Theater where a large gathering was taking place. 

The custom is to give flowers to the elderly veterans and older citizens of the generation that defeated the Nazis. Most looked proud, some looked lost, some cried, and some sang songs or recited poetry. There were lots of hugs and serious catch-up on gossip. They shared sausages and vodka, memories and tears. Some brought their wartime picture albums, proudly showing off photos of themselves in the prime of youth. Circles formed around accordion players and people danced, the music reflecting the wartime spirit from another time. Many veterans were in full dress uniform, their chests covered with medals. Parents ordered children to stand next to them for photos, and often the kids were stiff with fright. Some veterans told war stories while wildly gesticulating with their hands as crowds gathered around to listen.

Flower by flower, the elders received so many that they were impossible to carry. Some had friends or family to carry them, some had small carts, and some had nobody to help them. Late in the afternoon red flags fluttered as they packed their picnic baskets and flowers to head home. A serious looking woman wandered in circles while hugging a portrait of Stalin. In the distance the sun reflected off the arsenal tower of the Kremlin. As I turned back to my hotel I wondered how many veterans will be around to celebrate Victory Day next year to pass on the memories.

* * * * * * * * * * * * * * * *
Watch a video of my day in Moscow:

Follow me on Instagram @jlevinemd, and see more art and photos on my blog.

Dr. Jeff Levine’s photography exhibit entitled “An International Celebration of Aging” will be at the University of Michigan Medical Center from June to August, 2015 as part of their Gifts of Art program.

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Thursday, April 23, 2015

Being Superman

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

My all-too-frequent experience going from house to house visiting the ill, aging population is this: many and perhaps most people being served in our communities are sadly lacking in actual advocacy. I often feel like I only apply “Band-Aids”. (Recent case in point; explaining the treatment choice to an 84 year old patient who didn’t realize the doctor’s intervention was permanent, something for him to manage at home. He asks me, “You mean I have to live like this?”) In every medical setting the average lay person while preparing to go home from their latest hospitalization needs an interpreter to understand what the hospitalist who just left their room was saying. Discharge instructions seem to fall on overwhelmed ears. And having worked in the circus of admissions and discharges of chronically ill patients in the hospital setting, I know the nurse/social worker/discharge planner/palliative care team must be: “Faster than a speeding bullet, more powerful than a locomotive and able to leap tall buildings in a single bound”.

I spoke with an elderly woman this past week about going back to the hospital if her symptoms worsened again. She was clear that if she was dying she would want “no heroics”, but was uncertain if she would in fact want to pursue hospitalization, saying “only if it was easy to fix me”. I thought to myself; how easy is it to fix anyone at 89 years of age, and where do the heroics start and stop? Our conversation had only just begun! Before trying to fix all the chronically ill elderly people who live alone, (or with their elderly partner who is also frail and elderly), who enter the revolving door of emergency room visits and frequent hospitalizations- let’s have a REAL CONVERSATION. It’s not just about getting them out, or keeping them out of the hospital. Far too many small, rural hospitals don’t even have a palliative care team to begin these talks. Incomplete knowledge, lack of understanding and decision making ability within a complex medical system is too often the norm, (and patients have things done “to them” in the “best interest of the patient”).

Many of my elderly patients have not talked to each other, their families, or their doctors, or are aware about any of the following: What are all the options for care, how much treatment do they want to pursue, including aggressive care to prolong life, or the “simple procedure” that the doctor advocates but in fact is life prolonging, and what is the quality of life that is important to them? These are conversations that need to happen now, continue at the next primary care doctor appointment, and be written in Advanced Directives and POLST forms so choices are made before the next 911 phone call. Hospital personnel have the chance for authentic conversations about completing advanced directives, (please don’t just hand the paperwork to the 88 year old spouse of the patient who is being discharged home with another CHF episode. How many of my homebound patients show me the advanced directive paperwork, still empty, at my first visit?...TOO MANY!)

Until everyone understands what the hospitalist is talking about when he delivers the prognosis for their multiple system failure and advanced disease, with the approaches and treatments that can be initiated, people will continue to receive futile, unwanted treatment and end of life care will include more life prolonging procedures, prolonged suffering, and we will continue in the merry-go-round of “medicalization” of the dying process with a lack of real advocacy.

This means, yes, we need palliative care consults, but also, at every opportunity…be mindful, to listen, understand, share and help people actually comprehend and address their choices, and what quality of life means to them, and ensure their wishes are written down, and followed. We have to at least try, at every opportunity, to be engaged in the never-ending battle for truth and justice, changing the world… one patient at a time.

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Tuesday, April 21, 2015

Not All Hospices are Alike

by: Patrice Villars

We all want the best possible end of life care for patients, our families, ourselves. Most of us don’t have a clue that Not All Hospices are Alike.

Here is one story (patient identity and characteristics have been changed to preserve anonymity):

Brianna, a 61-year-old woman with metastatic esophageal cancer and renal insufficiency, had been served by our outpatient palliative care clinic for over two years, alongside our oncology team. She had been previously referred to a home health agency by her primary care provider’s RN for assistance with medication management, physical and occupational therapy. So when the time came to transition to hospice care at home, the RN referred Brianna to the home health agency’s ‘sister’ organization, Hospice X. Easy peasy.

Not long after she was admitted, I started to receive phone calls from her partner (I’ll call him Mr. Brianna) re. unsatisfactory pain management and requests for opioid medications refills the hospice agency, per Mr. Brianna, didn’t cover., specifically, her methadone for long-acting pain control and oxycodone for breakthrough pain. When I called Hospice X to inquire about her condition and discuss her plan of care, I was unable to reach anyone who had access to her record or knew her situation. The hospice supervisor, upon my request, returned my call to discuss my concerns. She gave me a run down on Brianna’s vitals, reported that her pain was controlled, then read me a couple lines about what hospice is supposed to cover per Medicare guidelines. Then she ‘looked up’ whether or not methadone or oxycodone was covered. Clearly, I was talking to someone without expertise in hospice care or the hospice Medicare benefit, much less anyone who could work with me to develop Brianna’s care plan.

Within a few hours, I received a call from Hospice X’s medical director. “I’m a palliative care doctor… medical director of Hospice X”. We discussed my concerns regarding Brianna’s experience of her unsatisfactory symptom control. She was now taking almost 300mg of oral methadone a day. “What is your plan”, I asked, “for symptom control when she is no longer able to swallow safely at the end of life?”

“I guess I should think about that”, he replied. OK, this is when I went internally ballistic and knew that was not a ‘hospice’ agency that understood end-of-life care. He started to ‘educate’ me that liquid morphine is used at that time. (Fill in your own personal outraged reaction here.) After an easy Google search of the physician, I learned he was not board certified Palliative physician (I suppose it would have been worse if he were) and that he had a disciplinary action against him from the Medical Board within the past year for inadequate record keeping.

Long story short, after numerous concerns by Ms. and Mr. Brianna, including:
  • Every time a nurse came to the house, s/he brought someone who sat in the car during the home visit. (HIPPA violation?), making them both feel unsafe.
  • Hospice X wouldn’t refill her oxycodone (not on their formulary, despite renal insufficiency with baseline creatinine of 3.0).
  • The nurses counted her pills at every visit to make sure she didn’t take too many, which made her feel like she was doing something wrong or bad if she needed more to control her pain.
  • Her symptoms (pain, nausea, insomnia) were getting worse, not better.
Brianna and her partner tried to work with Hospice X; they felt uncomfortable ‘firing’ them and transitioning to another agency. Brianna liked one of the nurses. Mr. Brianna, with our strong recommendations, finally let hospice X know they were dissatisfied and wanted to change hospice agencies to Hospice SH. Hospice X discharged (not transferred) her, stating she did not meet hospice eligibility, as she wanted “aggressive” treatment, inconsistent with the hospice benefit. (Which, I suppose, is partially true. She wanted aggressive pain and symptom management.)

Finally, I was able to get her admitted to Hospice SH (super hero). At the second home visit, the Hospice SH nurse called me to discuss transitioning her care to their (beautiful) inpatient hospice house for patients who require acute symptom management at the general inpatient (GIP) hospice rate. They had already made two visits to the home that morning, offering intensive symptom control, emotional support to Ms. and Mr. Brianna, and in-depth discussions about potential settings for ongoing care.

I have been blessed to have worked with two amazing hospice agencies in my career and have high standards. – high, achievable standards. The hospice world has changed dramatically since I left that work ten years ago. In my institution, all nurses, discharge planners, social workers, and physicians can refer to any hospice agency. Hospice Xs and Hospice SHs look the same to most families and health care professionals unfamiliar with the nuances of hospice and end-of-life care needs. In my experience, many hospice Xs market well – flyers, lunches, office paraphernalia with logos, etc, offering programs that claim to smoothly transition from home health to hospice. These programs may serve the referring providers well, but not necessarily the patients/families.

Be careful out there. Not All Hospices are Alike.

Here are some links to help with choosing an agency:

Photo Credit: ©2014 Nancy Lundebjerg 
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