Tuesday, April 22, 2014

Just for Fun: a Les Misérables parody about hospitalists and ED docs

Two weeks ago, Alex Smith and I gave a talk at the California Compassionate Care Coalition's 6th Annual Conference and Summit.  The topic focused on the top 10 reasons for health care providers to participate in social media (FYI - all the presentations from this meeting can be downloaded for free on the CCCC website).  The last reason we gave attendees to participate online was that it was just downright fun.  To prove out point, we showed some videos we created and uploaded on youtube, which can be found here.

Paul Tatum sent me another video today that further confirmed my belief that the folks online are hilarious.  Enjoy this video by ZDoggMD (as the hospitalist) in an epic "Les Misérables" parody battle with an Emergency Medicine Physician:

by: Eric Widera (@ewidera)
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Monday, April 21, 2014

What to do when your patient is racist?

by: Alex Smith, @alexsmithMD

I'd like GeriPal reader's help with an issue that has vexed me since medical school. 

As a third year medical student, I cared for an elderly patient in a residential hospice facility with advanced cancer.  Unable to get up and about without assistance, he complained about feeling "trapped" in his room.  So I got him into the wheelchair and we went outside to enjoy the California sun. 

Several nurses passed by on the other side of the street and my patient made horrible racist remarks about them. 

I froze. 

I didn't know what to do.  I felt terrible that he was saying these things about the nurses.  I was also aware that the nurses could not hear him - we were too far away - and that this man was nearing the end of his life.  Nothing I said was likely to change his perspective or his behavior.  I said nothing.  He died two weeks later.  I've felt bad about that lack of response ever since.

I'd like to write a piece about a better way to approach the racist patient.  While there have been provocative stories in the literature (also here and here), there has been little written in the way of a well thought-out approach to the racist patient.  My early sense is that there is almost always more going on than the racism: PTSD, feeling ignored, pain.  We should explore and respond to the underlying issues first. That can be hard.  Racism pushes buttons like few other issues.

I can use your help.  I'm looking for stories about racist patients you have cared for in geriatrics and palliative care.  My sense is racism is more common in geriatrics and palliative care because (1) our patients are older, and lived in a time before Civil Rights; and (2) racist comments may be an expression of vulnerability and distress.

Racism runs a spectrum, from a Jewish provider and a patient with an antisemitic tattoo, to comments directed at other members of the healthcare team (as in my story above), to comments directed at the provider.  I'm interested in all of these stories.  Please respond with stories in the comments.

Some rules:
(1) Keep it anonymous.  Notice how you couldn't identify the patient in my story, but the essence of the story came across?  Some tricks - change the gender, the setting, the disease, the relationship of the caregiver. 
(2) Stories are most helpful if you share how you responded and why

A final thought. I want to write a paper about how physicians should approach the racist patient.  But my sense is that, despite the influx of foreign medical graduates and increasing diversity of the physician workforce, racist comments directed at non-physician members of the health care team are far more common than comments directed at physicians.  Nurses. Nurses assistants.  I just returned from our nursing home where the nurses and nurses aids related story after story of racist patients.  In our hospital, there is far more diversity among the nurses assistants than the physicians.  They are turning patients, responding to call buttons, asking about pain.  Patients may be reluctant to make the same racist remarks to a physician due to social norms. 

What is the physician's obligation to respond when the racism is directed at other members of the healthcare team?  How should physicians respond when a patient asks not to be cared for by minority providers?
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Wednesday, April 9, 2014

Medicare hospice payment reform: not seeing eye to eye

By: Alex Smith @alexsmithMD

Eye-popping numbers from the headlines of the New York Times today - 2% of doctors bill for one quarter of all Medicare payments.  At the top of the 2% is a Florida ophthalmologist who billed Medicare for $21 million in a single year.

So what does this have to do with hospice payment reform, you ask?  Those 2% of doctors billed Medicare 14 billion dollars in 2012 for their services (note this doesn't include the cost of medications, but may include the costs of administering medications, like chemotherapy). 

In 2012, Medicare hospice payments totalled $15 billion.  That $15 billion was for ALL the services hospice provides, including medications, durable medical equipment, etc. 

Medpac, the government organization responsible for making recommendations to congress for changes to Medicare payment policy, has been recommending a number of reforms to hospice payment for years.   In the most recent two years the recommendations have been to freeze Medicare payments to hospices at their current levels.  Adjusting for inflation - this is a cut.  They also reiterate recommendations to root out fraud and abuse in hospice. 

Now certainly fraud and abuse exists in hospice.  Certainly hospice is not the ideal model for frail elderly patients.  As Joanne Lynne recently wrote, "The prognoses of people dying slowly of the degenerative conditions of old age have unpredictable timing of death, need nursing care and housing more than opioids and counseling, and generally have needs that do not match the hospice paradigm."  We can't turn a blind eye to the faults of hospice.

But if you have to root out fraud and abuse in Medicare, don't you think there is more low hanging fruit in excessive payments to very few physicians than in payments to all hospices?  Go after the 2%!!!  Going after hospice just seems...well... myopic.  Lay off already!

Random extras:
  • In the New York Times, you can search for Medicare payments to doctors in 2012 by physician's name, specialty, and city.  Fascinating!  I put in Geriatric Medicine in San Francisco.  Pretty low numbers, less than $100,000 (except for one guy - what is he doing?) Then Hospice and Palliative Care in San Francisco - just one fellow who must have been dilligent about billing in 2012.  Now put in ophthalmology or oncology.  Wow!  Some people billing $1, $2, $3+ million!  That's the 2%!!  Geriatrics and Palliative Care - WE ARE THE 98%!!!
  • The Joanne Lynn quote is a comment left on a terrific commentary by Kimberly Johnson, famous palliative care researcher from Duke.  Kim Johnson is in turn commenting on a fanstastic study by Melissa Aldridge about differences between for-profit and not-for-profit hospices, finding that for-profit hospices are more likely to provide community outreach to minority and low income communities.  Dr. Johnson argues that she doesn't care as much about the reasons they are making the outreach, as she cares about the outcome of greater enrollment of minority patients in hospice.
  • The latest MedPac recommendations are out!  Interesting wrinkle - they argue that Medicare Advantage (managed care payed for by Medicare) now include hospice.  To date, Medicare Advantage patients have disenrolled from managed care in order to receive Medicare hospice.  Some have speculated this creates a bizarre incentive for managed care plans to move high cost seriously ill patients into hospice.  Others have noted that managed care plans may do a better job of moving patients into hospice when it meets patient's goals, and doing so earlier in the course of illness.  The idea behind the reform is to allow Medicare Advantage to innovate, by paying them to include hospice serivces as part of their "package."  This may provide incentives for things like concurrant care, for example.  This one eyeballs like a good idea on first pass - anyone have objections?
Read more »

Tuesday, April 1, 2014

#Geriatrics and #Palliative Care Consults via #Twitter!

by: @AlexSmithMD

Here at GeriPal, we have really tried to push the envelope with the use of social media in geriatrics and palliative care.  We're announcing here that we have taken things to a whole new level with our recent pilot study of geriatrics and palliative care consults via twitter.

Here we publish our first ever geriatrics consult via twitter.  We have anonymized the identity of the caregiver and patient to protect confidentiality.

Notice how using twitter leverages the strengths of twitter: namely, organizing the creativity and expertise of the whole twitter community to provide optimal care for patients.

Also, you should read this post, including the comments at the bottom.

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Monday, March 24, 2014

3 Blogs Waiting to be Started: PediPal, PalliTech, and GeriPal EM

Every once and a while Eric and I are contacted by people hoping to start a blog.  Sometime people follow through and start a new blog.  One terrific example is GeriTech, a blog about technology to improve care of older adults, started by Leslie Kernisan, MD.  See her recent post about the need for a good blood pressure monitoring app.

Here are 3 blogs that are just waiting for the right dedicated people to get started.  Some of these are ideas that have been talked about but haven't taken off yet.  Maybe you, dear reader, will be the one to get one of these blogs going?

  1. PediPal - A Pediatric Palliative Care Blog.  We've carved out a niche by focusing on the intersection of Geriatrics and Palliative Care.  Pediatrics is in a remarkably similar position.  In part our success was born out of some existing tensions between the fields of Geriatrics and Palliative Care.  I suspect (though I'm not in the know) that some degree of tension may exist between pediatric and adult palliative care. 
  2. PalliTech - Technology for Improving Palliative Care.  Leslie has done outstanding work in the field of Geriatrics.  The same should be done in Palliative Care.  As I'm writing this, in the background a webinar on Palliative Care Technology is playing (sponsored by the Coalition for Compassionate Care of California), and the speaker Jill Joseph is talking about ACTIVE - Assessing Caregivers for Team Intervention Through Video Encounters.  This technology allows caregivers to videoconference in to participate in hospice interdisciplinary team meetings.  This is such a neat idea!  A PalliTech blog could feature, review, and disseminate new and useful technologies in palliative care.  Also related - new perspective on mHealth and need for regulation in JAMA.
  3. GeriPal EM - Geriatrics and Palliative Care: Emergency Medicine.  I used to do research about palliative care in the emergency department, and my most cited article is a qualitative study about emergency providers (docs, nurses, social workers) and their perspectives on palliative care (discomfort).  I got out of this research because emergency medicine is such a new field, that it's rightly somewhat insular and protective.  Change should come from within, and I'm not an emergency medicine doc.  There is some terrific innovation in creating Geriatric and Palliative friendly emergency departments.  Related - new geriatric emergency department guidelines; and story in New York Times.
Look forward to reading your blogs!  Any other blog ideas?  Please list in the comments. 

And if you're not ready to start your own blog, you're welcome to write on GeriPal.  You could be the "GeriPal Technology Writer," or lead for an "Emergency Medicine Series".

by: Alex Smith
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Tuesday, March 11, 2014

New treatments for hep C: aging patients, unconscionable prices, missing voices

Promotional video by Gilead pharmaceuticals, makers of a new drug, urging people to talk to their doctor about treatments
"We have a cure we cannot afford" - so said Dr. Steve Pearson at yesterday's meeting of the California Technology Assessment Forum, or CTAF.  I was a first time panelist.  See this story in the Washington Post about the meeting.

New treatments for hepatitis C are pretty amazing.  Old treatments included injections that made people pretty sick (basically like having the flu for months) and were about a coin flip as far as effectiveness.  New treatments may include pills alone.  We still need more data on these medications, particularly for subgroups of patients such as those with advanced liver disease, but the early results are very encouraging - 80 to 90+% cure rates in some patients.

Several problems complicate the good news story here.

  • The treatments are remarkably expensive, about $1,000 per pill.  As one panelist noted, these prices are unconscionable.  
  • The US Preventive Services Task Force recently recommended that all baby boomers be screened for Hep C.  About 3/4 of all patients with Hep C are boomers (estimated 2 million boomers infected). If even half of these patients who screen positive are treated, it would completely bankrupt our healthcare system.  
  • The disease does not harm the vast majority of people with chronic infection.  But it does lead to cirrhosis or liver cancer in about 1/5 individuals over the course of 20 years.
  • The group with the most disease - the baby boomers - are aging.  They're about 50-70 right now.  Over  20 years they'll be 70-90.  We know little about the risks and benefits of treatments in the context of older adults who may die of other conditions, or have multiple medical problems in addition to hepatitis C.
  • The outcomes for the new drugs are "sustained virologic response" (SVR) meaning the virus is not detectible in the blood.  This is not the outcome people care about.  People care about not getting cancer, cirrhosis, or dying.  Those are long term outcomes. We don't know about these long term outcomes yet.  While there is a correlation between SVR and these outcomes, many promising treatments have changed blood markers only to fail to achieve the promise of long term outcomes.  These failures have come at considerable cost and harm (for example, Hormone Replacement Therapy).
  • Many of those with hepatitis C are absent from the table - incarcerated, using alcohol, or IV drugs.  

Regarding this last point, a group of protesters showed up at the CTAF meeting. They were supposed to show up before lunch to comment, but were late, and instead had to settle for silently holding up signs protesting the high price of new drugs.

One of the ethical issues at stake here is concern for vulnerable populations.  If this was a highly organized group - like say the gay community during the early days of the HIV epidemic - I suspect we would see tremendous pressure on pharmaceutical companies to lower costs.  Instead, they can't get it together to show up to the meeting and have a seat at the table.

My concern is that we'll end up with greater disparities in healthcare.  My suspicion is these treatments will prove effective at reducing long term outcomes patients care about.  Those who can afford high priced private plans will have access to these medications.  Those who cannot afford high priced plans will rely on low cost or public plans that will pay for these treatments in only limited cases.  And we will have millions of people who screen positive due to universal screening in baby boomers, and cannot afford treatment.  They will be left worried, and maybe wishing they didn't know.

We should either not screen, or lower the costs.  We can't do both.

by: Alex Smith
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Monday, March 10, 2014

Join the GeriPal & Pallimed party at the AAHPM/HPNA/SWHPN 2014 Annual Assembly

The 8th annual GeriPal / Pallimed party is back on for this year's AAHPM/HPNA/SWHPN 2014 Annual Assembly.   We are going to do a similar progressive party as we did at the 2013 annual meeting in New Orleans.  What does this mean? Basically we will start off at the Field Irish Pub at 9pm on Thursday March 13, and as the evening progresses we will be moving to different locations.  The only way to find out where we are is to use social media and follow on of the GeriPal/Pallimed feeds, or the #HPMparty hashtag.

Date: Thursday, March 13th.  Start time 9pm.  End time TBD

Where: Depends

Starting location: The Field Irish Pub

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Friday, March 7, 2014

Does citalopram help with agitation in Alzheimer disease?

Most patients with Alzheimer’s disease will develop neuropsychiatric symptoms, including agitation, at some point in their illness. These symptoms have a tremendous impact, as they have been associated with decreased quality of life of both patients and their families, and an increase caregiver burden, and decisions for nursing home placement.  Having dealt with many caregivers trying their best to manage these symptoms, I can attest to the frustration in the lack of any quick fix.

In the recent issue of JAMA, Porsteinsson and colleagues published a multicenter, double-blind, placebo-controlled randomized trial of what appears to be one potential fix, the use of the selective serotonin reuptake inhibitor (SSRI) citalopram.   In short, the conclusion of the article was that the addition of citalopram compared with placebo significantly reduced agitation and caregiver distress among patients with probable Alzheimer disease.   Let's take a closer look to see if we agree.

What they did:

The authors recruited 186 patients with probable Alzheimer disease, MMSE scores from 5 to 28, and clinically significant agitation/aggression. They were randomized to receive a psychosocial intervention plus either citalopram (n = 94) or placebo (n = 92) for 9 weeks. Dosage began at 10mg per day and increased to 30mg per day over 3 weeks. They had a variety of exclusions including major depression, psychosis, current treatments with antipsychotics, and unstable doses of Alzheimer disease (cholinesterase inhibitors and memantine). Prolonged QT interval was later added as an exclusion criterion after the FDA issued an advisory regarding dose-dependent risk of QT prolongation with citalopram therapy.

The main outcomes of interest focused on agitation. For those of you who want to know the details the measures, they were:
  1. An 18-point Neurobehavioral Rating Scale-Agitation (NBRS-A) subscale, 
  2. A 7-point modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change [ADCS-CGIC] score

In addition to these measures of agitation, the authors also looked at the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI). They also looked at a whole host of secondary measures including effects on function (ADLs), caregiver distress, cognition (through MMSE scores), and tolerability.

What they found:

Baseline characteristics between study groups were similar except that participants assigned to citalopram had better MMSE scores.

There was an improvement in agitation favoring citalopram as noted by an effect size of approximate 1-point on the NBRS-A, something that the authors state is clinically relevant. They also found that 40% of the patients receiving citalopram had moderate or marked improvement from baseline on one of the main agitation scores, the ADCS-CGIC, compared with 26% of the placebo-treated patients.

Citalopram treatment was associated with a significant increase in the QTc interval compared with placebo. Citalopram also worsened cognitive functioning compared with placebo as measured by the Mini-Mental State Examination (MMSE) with a mean between group differences of 1 point.

Three reasons why it is hard to change clinical practice based on these results:

1) Generalizability: we don't know how many individuals were screened to get the enrollment numbers for this study, as it was never reported. This is important to know as if they screened 2000 people to get 186 participants, it would suggest that this is a very select group that ended up in this study, and that the findings may not be generalizable to your patient. Given the number of exclusions in this study, this is highly possible.

2) Effectiveness of randomization: at the beginning of the study the placebo and the citalopram groups were not the same, as they had different baseline cognitive function. So if the randomization didn't work for MMSE, there may be some other unmeasured factors that were also unbalanced. Furthermore on safety, the placebo group got a little better in their MMSE and the citalopram got a little worse. Is this just regression to the mean for the citalopram group or is it that citalopram actually had a clinical effect on cognition (or is it that the MMSE is not a great tool for cognition)

3) Lorazepam use: use of rescue lorazepam was similar in the two groups. Since use of an as needed medication seems like it should be a good indicator of how someone’s behaviors are doing, this may lead some credence to the argument that there was really no difference between the two groups. However, only about one in five participants ever used a lorazepam for agitation, so it just may mean that the study was too small to see an effect here.


The idea of citalopram as an addition to non-pharmcological interventions seems like a better alternative than antipsychotics. Considering how few other medication options there are in our bag of tricks, I do think I would turn to citalopram if I was thinking about starting a medication.

However, the real take home is the fact that to meet the “standard of care” all study participants received a psychosocial intervention consisting of three components:
  • provision of educational materials 
  • 24-hour availability for crisis management 
  • and counseling sessions at each study visit that included the design and adjustment of a supportive care plan, emotional support and an opportunity to communicate feelings, counseling regarding specific caregivering skills, and assistance with problem solving of specific issues brought up by the caregiver or study participant.

We’ve previously discussed how healthcare systems have a duty to provide family caregivers information, skills, and support systems to help those caring for patients with dementia (see this article in JAMA Internal Medicine or this GeriPal post). I just wish that the standard of care used in this study was really the standard of care that is seen in the real world.  To quote Ken Covinsky about a recent study showing the benefits of counseling and psychological support for dementia caregivers:
"If this intervention were a drug, it would be on the fast track to approval and a pharmaceutical company would be on track to earn billions of dollars. But alas, it is not a drug. Therefore, this beneficial program will not be available to the vast majority of dementia caregivers in the US."

by: Eric Widera (@ewidera)
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Thursday, March 6, 2014

Dementia Village: Dignified Care in an Experimental Town

Tragedies at the end of life come in many shapes and sizes. For Betty, an elderly woman with end stage dementia, the last few years were comprised of minor, daily tragedies, finding herself staring out the window of her locked unit, wondering why she couldn’t get out the door to go for a walk. She would pack her bags with her belongings, excited about a day out with her friends to get coffee at the café and her hair done at the salon, only to find that she needed to stay in the white-walled unit. I remember her confusion and anger as the staff, dressed in white coats and nursing scrubs, would correct her on her age and the fact that the man next to her was indeed her husband. She would spend her days watching television and awaiting her meals and medications without pursuing any of her previous interests like baking and gardening. I wondered if there was a better way to do this, a place where she had a home to call her own and where she could safely and freely wander to the grocery store and gardens. A place where they used less medications and restraints and where there were readily available activities like art and music for her to develop a routine and spend her days. Imagine my surprise to learn that such a place exists, an idyllic community in the Netherlands where patients can safely roam to their hearts content.

Hogeway (literally, Dementia Village) is a state-run facility in the Netherlands on 4 acres, with 23 housing units only a few minutes drive from downtown Amsterdam. At first glance, it looks like any other village, but in actuality, it is an innovative approach to caring for patients with severe dementia and an attempt at giving residents a healthier and happier reality for the final years of their life. They care for 152 residents with severe dementia who are free to wander around a small community designed to resemble the lives the residents remember. Residents can visit a grocery store, a cafe, a hair salon, gardens, a pedestrian boulevard, a theatre and even a pub. They can join one of 25 clubs with interests from baking, music, painting and gardening. The cost is $6555 per month and they live 6-8 per apartment with 2 or more of the 240 staff members in street clothes there to assistant them with daily activities. Creative solutions, not medications or restraints, are used when residents become confused or aggressive. So far, advocates of the village have noted that the residents here participate in more exercise and walking, eat more healthfully, take fewer medications and perhaps even live longer.

The WHO estimates that the number of people living with dementia worldwide will double by 2030 to about 65 million and will likely triple by 2050. In fact, according to the Alzheimer’s Association one in three seniors will die with dementia. There has been a significant amount of interest other European countries like England and Germany to implement similar places, and anecdotally, news pieces about Hogeway have generated plenty of interest in the US-- we all can name a Betty or two who would benefit. We would certainly need a more dignified name, but I wonder if the rest of the concept would translate here? Stay tuned. Perhaps it is time to evaluate if a community like this could work in the United States.

by: Stephanie Rogers

Here is a video from "CNN's World's Untold Stories: Dementia Village" on Hogeway

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Wednesday, March 5, 2014

“Honoring Choices” in PACE programs

This is the way it went: a group of familiar faces, some family, some professional care providers, gathered around the man's bedside and talked about his preferences. Aspiration pneumonia or not, he didn't want the feeding tube, and was sick of going to the hospital, so for the next episode of pneumonia, could he please just be treated at home? Notes were made, the decision was repeated aloud to get everyone on the same page, and the preference became the plan. The decision became the default.

This is news because we know the usual defaults in health care run more like this: Panicked relative: "He's getting so sick - shouldn't he be in the hospital?" By-the-book emergency department physician, "Well, I can't send her home like this, can I?" Social worker in hospital, "With so many patient needs, you really ought to consider a nursing home."

Community Life, a Pittsburgh-area provider of comprehensive geriatric care under the Medicaid PACE model (Program for All-encompassing Care for the Elderly), is changing the default settings for their clients by "Honoring Choices."

“Honoring Choices” is the title of a Community Life quality improvement program that addressed a vexing problem that they encountered over and over again. The program’s success was recognized by The Fine Foundation, Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative with a bronze award at the recent Fine Award for Teamwork Excellence in Care at the End-of-Life.

Community Life provides a type of integrated care of which most patients can only dream, serving as PCP, insurer, pharmacy, physical and occupational therapy, home care provider and adult day care rolled into one. The integration even extends to the interdisciplinary team meetings, where the patient is at the table and essentially running the meeting. With this level of integration and patient-centeredness, high levels of satisfaction and consistency between patients' stated wishes and actual care delivered should be routine, right?

Unfortunately, the actual data didn't bear this out; pain management satisfaction scores, overall satisfaction and rates of patients dying in inpatient acute care were all falling short of stated goals. People who had made clear choices like the man in the first paragraph were ending up in the exact situation they had hoped to avoid. The last was a particular concern; if there is one wish that has been consistent across every end-of-life survey going back to the SUPPORT study in the 1990s, it is that people do not want to die in the hospital. Integrated care is supposed to help fix that problem - so what went wrong?

“Honoring Choices” was about Community Life trying to get to the bottom of this problem and set it right. What they discovered was that the loop of communication wasn't closing - the patients may have stated their wishes, and the Community Life physicians may have heard them and recorded them, but when a patient got sick after hours or a family member became acutely concerned about their health, they went to the emergency room. Once there, a series of physicians (emergency, "moonlighter" admitting patients to the hospital, hospitalist attending and occasionally even an intensivist) who were not around the table when that compact was made were making decisions, without benefit of knowing the "plan." The acute episode wasn't usually discussed by Community Life staff until the next morning, by which time the wheels were often turning in the hospital - often without anyone communicating with the Community Life physician about it first. At discharge, the instructions given to the patient and family often didn't make it into the hands of Community Life staff - setting up the patient to "bounce back" (to the hospital, not to their previous state of vigor).

“Honoring Choices” prioritized using alternative care settings - home care, nursing facility, hospice - wherever appropriate ‒ instead of the hospital. To quote Community Life medical director Emily Jaffe, "Good care and judicious use of resources are not mutually exclusive." Doing so meant codifying closed-loop communication into the way Community Life delivers care to every patient: immediate notification of Community Life MDs when one of their patients is admitted to the hospital; daily, direct doctor-to-doctor communication between Community Life and the hospital physician; daily conference calls between hospital staff and Community Life staff for the purposes of setting daily goals and goals for discharge; continual reassessment of the best location to provide care for that patient, including early Palliative Care and timely hospice referrals where appropriate; ordering of meds, DME and home care 24 hours before discharge; Community Life follow up within 24 hours after discharge; and integration of advance care planning, review of POLST documents and other related conversations as an express agenda item in the post-acute follow-up visit. The conversation in the opening paragraph grows out of this kind of follow-up meeting, which asks the question, "Well, that was awful - how do we keep that from happening again?"

This is a 21st century problem. Community Life addressed it using a 19th century instrument - the telephone - and an intervention as old as homo sapiens - conversation. Lots of it. Coupled with systematic, pro-active management, Community Life has managed to get their inpatient death rates down, hospice utilization up, and both overall satisfaction and specific satisfaction with pain management up compared with pre-intervention data.

by: Dr. Jonathan Weinkle, Squirrel Hill Health Center and a Jewish Healthcare Foundation (JHF) consultant,

Note: “Honoring Choices” is just one example of what this year’s Fine awards set out to demonstrate: namely, that if quality healthcare is marked by teamwork, attention to detail, and striving to deliver care that works to every patient, that quality should follow patients throughout their lives including during the days, weeks and months that make up the “last chapter” of their life story. Every other aspect of care – orthopedics, bariatrics, long-term care, and prevention – is today focused on helping patients live their best life, their way. This year’s awards are focused on those who are helping people live their final days the best they can, on their own terms.

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Wednesday, February 26, 2014

Surrogate Decision Making in the Hospital (Or, That Family Member By the Bed is Much More Than a Visitor)

An innovative study in JAMA Internal Medicine on surrogate decision making has profound implications for how we take care of older hospitalized patients.  The study, by Lexy Torke and colleagues at Indiana University, systematically described the involvement of surrogates in decision making for hospitalized patients.

Surrogate decision making refers to the phenomenon in which someone other than the patient is making or helping to make the key medical decisions.  In older patients, the surrogate decision maker is usually a family member, either a spouse or adult child.

Torke proves that surrogate involvement in decision making is much more common and extensive than previously described.  Most prior work has focused on surrogate decision making in the ICU and at the end of life.  But Torke shows that surrogates are extensively involved in decision making in less severely ill patients on the general medical wards.  Further, surrogates are involved in much more than end of life decision making.  They help make a wide spectrum of medical decisions ranging from whether to consider a medical procedure to discharge planning.

This study examined 1083 patients over age 65 admitted to the general medical wards and ICU at 2 Indianapolis hospitals.  These patients were identified by their physicians as needing to make at least one major medical decision.  The key findings were as follows:
  • Nearly half of patients (47%) required at least some surrogate involvement in major medical decisions.  About half of the time, the surrogate made all of the decisions.  The other half of the time, the surrogate and patient jointly made the decisions.
  • Surrogate decision making is not just for ICUs!  As expected, surrogate decision making was particularly common in the ICU, but even on the medical wards, surrogates were involved in over 40% of major decisions.
  • Surrogate decision making is not just about code status!  Surrogates were instrumental in many decisions that had profound short and long term consequences for the patient's care.  49% of surrogates participated in decisions about procedures about operations and 47% of surrogates helped make decisions about discharge planning.

As noted in an eloquent commentary by Yael Schenker and Amber Barnato, we need to start thinking much more "upstream" about surrogate decision making, preparing for surrogate involvement long before the end of life.  They note that the common question, "Who would you want to make decisions for you if you were no longer able to make them yourself?" fails to account for the complexity of decision making.  So, it is better to ask, "Who would you want to be involved in decisions about your care?" and "How would you like us to involve them?"

Torke's study has major implications for how we organize hospital care, which often completely fails to account for the HUGE role played by family members and friends of the patient in the decision making process.  As noted by Torke:
"The current hospital structures and routines of daily bedside rounds are built on the assumption that the patient can provide historical information and make decisions independently.  Perhaps because of this, there are substantial barriers to communication for surrogate decision makers.  In the hospital, family members are considered "visitors" rather than crucial participants in their family member's care."

We need hospital processes and structures that recognize families as much more than "visitors."

by: Ken Covinsky (@geri_doc)
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Tuesday, February 25, 2014

Tell CMS to protect appropriate palliative care prescribing

Attention all Geriatric, Palliative Medicine, and Primary Care Providers:

Act now to prevent the adoption of strict, punitive regulations impacting opioid prescribing.  The proposed Center for Medicare and Medicaid Services (CMS) regulations will significantly hamper our ability to provide individualized care for patients with serious or life-limiting illnesses. Porter Storey, Executive Vice President for the American Academy of Hospice and Palliative Medicine (AAHPM), recently highlighted this urgent need at a University of Colorado Palliative Medicine Grand Rounds, and AAHPM is currently drafting a letter of comment for CMS. We thought it important enough to share with the Geripal community because your stories matter. Time is of the essence.

This is a call to action to comment on CMS-4159-P. The proposed rule revises the Medicare Advantage program (Part C) regulations and prescription drug benefit program (Part D) regulations. As stated in the Executive Summary, one of the goals is to “strengthen our ability to identify strong applicants for Part C and Part D program participation and remove consistently poor performers.” While part of the intent of the revision is to identify inappropriate prescribing of opioid and other potentially harmful medications, these new guidelines may have significant unintended consequences, including limiting access to appropriate symptom management for patients with serious illnesses.

The proposed rule will 1) require a certification for Medicare Part D prescribing abilities, and 2) could result in suspension or revocation of all Medicare Part D privileges. The fine print is worrisome. The last 2 pages of the 678 page document describe prescribing practices that could result in revocation of Provider enrollment in the Medicare Part D program. Specifically,
424.535 (14) Improper prescribing practices. CMS determines that the physician or eligible professional has a pattern or practice of prescribing Part D drugs that falls into one of the following categories:
  • “Instance where necessary evaluation could not have occurred"
  • “Prescribed controlled substances in excessive doses, linked to overdoses”
  • “Prescribing drugs for indications not medically accepted"
  • “Malpractice suit where physician paid settlement to plaintiff” 

Here are a few scenarios to show why you should be worried:
1)  A rural primary care physician serving as medical director for the region’s only hospice misinterprets the new rule and decides she can’t prescribe for patients she hasn’t seen because they live 100 miles away and can’t come to the office. This results in an entire region without access to appropriate palliative care.
2) A coroner draws opioid levels on a decedent with cancer who was on stable, but high-dose opioids and mislabels the case an opioid-related death resulting in loss of prescribing capabilities for a palliative care doctor.
3) A pulmonologist raises concerns that a patient was inappropriately prescribed opioids for dyspnea because the pulmonologist is worried that opioids might raise the patient’s CO2 levels, causing harm. This results in a claim that the opioid indications are not medically accepted, despite increasing evidence of benefit.

AND, most importantly of all, you should be concerned because the proposed regulations lack a description of any form of due process by which providers would be able to describe the validity of their prescribing practice.

In summary, the proposed rule, CMS-4159-P, has the potential to severely limit the ability of providers who care for patients with serious or life-limiting illnesses to provide patient-centered care. This aspect of the regulation needs to be withdrawn or significantly revised to recognize that so-called “improper prescribing practices” is a nebulous concept without a solid scientific definition. There are examples of non-FDA approved uses of medications that are considered best practice or standard of care in certain medical specialties. As currently written, the regulations fail to describe how improper prescribing practices will be identified and adjudicated. For primary care physicians, who currently fill much of the need for symptom management in advanced illnesses, the vague terms in this regulation jeopardize their long-term ability to prescribe medications for any Medicare beneficiary enrolled in the Part D program.

So, dear reader, please contact CMS. Tell a story of a patient you care for, and how your goals are patient-centered care. Describe how your patient wouldn’t be eligible for a clinical trial and thus, you are using your medical judgment as you prescribe medications and make dose adjustments based on treatment responses, like pain relief, quality of life, and improved function. Describe how you do a significant amount of follow up and care coordination with caregivers and your clinic team because your patient is too ill to travel to your office. Describe your efforts to monitor for misuse or abuse, and how you prescribe the lowest effective doses, which still may be much higher than average doses that work for other patients outside of palliative care.

Take Action Now – Comments are due by March 7, 2014.
Please submit electronic comments on this proposed rule to CMS. They read these comments! They note, “A single, well-supported comment may carry more weight than a thousand form letters.”
You can read the PDF of the proposed rule here, but for time’s sake skip to the last 2 pages.

Suggestions for preparing your comments:
Consider commenting specifically on PART 424--CONDITIONS FOR MEDICARE PAYMENT, Section 424.535 - Revocation of enrollment in the Medicare program. (pg 675-6)
  •  Describe how this regulation will impact your patients
  • Be concise but support your claims
  • Base your justification on sound reasoning, scientific evidence, and/or how you will be impacted
  • Address trade-offs and opposing views in your comment
  • There is no minimum or maximum length for an effective comment 

By: Hillary Lum and Paul Tatum. Special thanks to Porter Storey for raising our awareness, and members of the AAHPM policy committee for quick review.

If you’ve read this far, take a few more minutes and submit a comment to CMS. March 7 will be here soon!
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Sunday, February 23, 2014

Ramelteon for the prevention of delirium in the hospital

About half of the patients that I saw on or palliative care consult service last week were delirious. This is in line with reported incidence of delirium in the medical wards (30-50%) and in the ICU (up to 80%). One aspect that many of these individuals had was a disruption of their circadian rhythm with sleep-wake reversals, so much of what we recommended was good sleep hygiene. This though is tough in the hospital where infections, medications, and environmental factors all wreck havoc on a good night's sleep.

It's thought that melatonin synchronizes the circadian rhythm that regulates the sleep-wake cycle, so maybe prophylactic use of this medication may help prevent delirium from occurring in these hospitalized older adults?  Hatta and colleagues published a study that reportedly showed that it indeed did.  In the JAMA Psychiatry publication, the conclusion was that ramelteon, a melatonin receptor agonist, significantly decreased the incidence of delirium in elderly medical and ICU patents.  Let's take a closer look and see if we agree.

What they did:

The authors conducted a multicenter, single blinded (patients and their doctors were not blinded), randomized placebo-controlled trial of ramelteon (8 mg/d) or placebo every night for 7 days. Participants were included if they were 65 to 89 years age and were newly admitted to medical wards and intensive care units. Patients were excluded from the study if they were delirious, had an expected stay or life expectancy of less than 48 hours, if they had other diseases that presented like delirium (severe liver disease and Lewy Body Dementia), were taking fluvoxamine, had alcohol dependency, drug abuse, or psychotic or mood disorders.

The main outcome they were measuring was presence of delirium based on a diagnoses by psychiatrists using DSM-IV criteria during twice a day rounds.

What they found:

  • The individuals who received ramelteon has a lower risk of delirium (3% vs 32%; P = .003)
  • Ramelteon remained associated with a lower incidence of delirium (P = .01; odds ratio, 0.07 [95% CI, 0.008-0.54]) after controlling for risk factors such as age, diagnosis of dementia, and admission diagnosis of infection. 
  • There were no differences in various sleep parameters between the two groups

Limitations of this study:

1) GENERALIZABILTY: Of those assessed for eligibility, 94% were excluded. Furthermore, the authors’ exclusion criteria are far from clear (actually they way they were written was a mess). But in the end, I’m let with the question of who would be eligible for the study as none of my patients would seem to fit the bill. Furthermore, I’m confused why they only mentioned one of the exclusion criteria in the abstract, as the long list seems relatively important to the generalizability of the study.

2) BLINDING: For some reason that I still don't understand they only blinded the rater but not patients or their physicians.  The authors state they did this because they were worried about participation rates. They also said that other staff like nurses were blinded, but patients knew and could easily tell everyone they interacted with (even the raters) that they took the study drug and not the placebo.

3) SIZE: this is a tiny study with only 67 patients actually included. My biggest issue here is whether the groups were really that balanced despite looking so in table 1. For instance, they didn't report whether the two groups were balanced in regards to environmental factors even as basic as whether they were in the ICU or not.  If more patients in the ramelteon ended up in a ward that was much better designed and trained to prevent delirium, this would significantly impact the study results.

4) HYDROXYZINE: Although it didn't seem to affect the study results, I’m still working hard to understand why they chose hydroxyzine as the alternative sleeping agent if individuals couldn't go to sleep. Yes, hydroxyzine. The same drug that is on the Beers list for… wait for it…. high anticholinergic activity causing delirium (strength of recommendation = strong).

Take Home Point:

I’m going to leave this study as a promising addition to medications we could potentially use to prevent delirium, but clearly not ready for primetime for delirium prophylaxis in all older adults being admitted to the hospital.

by: Eric Widera (@ewidera)

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Thursday, February 20, 2014

Why is Forest Laboratories discontinuing Namenda?

Why is Forest Laboratories discontinuing Namenda (memantine HCl) 5 mg and 10 mg tablets on August 15, 2014? Is it because there were no significant benefits of the combination of donepezil and memantine over donepezil alone in a study published in the NEJM in 2012?  Maybe, just maybe, Forest Labs is discontinuing Namdena because even the most positive trials of Namenda show only a very small statistically significant benefit that may very well be clinically insignificant?  Wait, I know.  Can it be that Forest is discontinuing Namenda 5mg and 10mg tablets because they are worried that individuals are being prescribed this medication earlier in the course of Alzheimers despite the fact that memantine is only approved for moderate to severe disease and despite a growing body of evidence that it provides no benefit in this population of patients?

Sadly, Forest Laboratories is discontinuing Namenda mg and 10mg tablets for none of these reasons.  They are discontinuing it because Namenda is going off patent in April 2015.  This means that a host of low cost generic memantine will flood the market and replace non-generic Namenda in a year's time.

So how does a pharmaceutical company maintain market share when competing against low cost generics? Well the good folks at Forest have decided that if they can just move everyone who is currently taking Namenda to Namenda XR (the extended release version of the drug), they won’t have to compete at all, since there is no generic version of Namenda XR.

So what will patients experience? When they try to fill their prescription for Namenda 10mg BID come August 15th, they will be told that their twice a day pill is no longer made and will need to get a new prescription for Namenda XR.  Brilliant!

This tactic is called a “forced switch” and has been attempted with other drugs in the past that were going off patent.  There is a catch though.  The little wrinkle in Forest's plan is that someone needs to write that prescription.  My recommendation is that we should use this time to reconsider the merits of continuing to prescribe Namenda in any of its formulations. For those with mild dementia, the evidence is clear that we should just stop it.  For those with more severe dementia, it definitely warrants a talk with the patient and their family members about whether there is really any benefit from continuing a medication that at best has shown to have only marginal benefits.

by: Eric Widera (@ewidera)

Note: a big thanks to Bruce Scott (@skipbidder) for the lead on this story.  Also, check out this previous post on Aricept 23 to see how Forest isn't alone when in comes to deploying cheap tricks to increase revenue streams
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Sunday, February 9, 2014

An Older Pedestrian Fights Back

Older pedestrians are more likely to be killed while walking than those under 65 years of age.  A lot has been said about reasons why (for a good read check out "Dangerous by Design") including factors such as the timing of traffic lights.

However, for a good laugh, check out this way to combat these high mortality rates:

by: Eric Widera (@ewidera)

Note: a big thanks to Paul Tatum for the link!
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Tuesday, February 4, 2014

The Long Term Care Insurance Con Game

"The Conjurer," painted by Hieronymus Bosch.  Can you find the "con" in this game?

Consider this scenario:

You are getting older, and are concerned about the costs of nursing homes and long term care.  So, you decide to get expensive long term care insurance to protect your family from these costs.  The policy will pay some of the cost of long term care if you develop cognitive or physical disability.  All you have to do is keep making payments on the policy until you have a need for services.  But make sure you make the payments.  If you don't, your policy gets cancelled, you lose all the money you put into premiums, and you get nothing when you need the services you thought you were paying for.

But wait, there is a catch.  One of the first problems that happens in persons who are developing the very cognitive problems that lead to the need for long term care services is trouble managing finances.  One of the first signs that someone needs their long term care insurance is that they can't keep track of bills, forget to make payments, and make bad financial decisions.

But guess what?  Since you were having memory problems, you forgot to pay your long term care insurance premium.  Since you missed payments, the insurance company will claim your policy is lapsed.

Ain't that a nice deal for the insurer!  The very fact that you have developed a need for their services becomes an excuse to keep all your premiums and never pay you a dime.

In a compelling post that will make your blood boil with anger, Paula Span describes such a horrendous situation on the New Old Age Blog.  A Virginia couple, David and Anne Pirron, diligently planned for their needs by purchasing a long term care policy from John Hancock.  Over 10 years, they paid $50,000 to John Hancock.  But then they developed cognitive problems.  These cognitive problems should have triggered payment from Hancock for long term care services.  But, because of their cognitive problems, they forgot to pay their premiums.  So, instead, Hancock cancelled their policy, paid them nothing, and kept the Pirron's premiums.

The irony is that if the Pirron's had filed a claim when they were developing memory problems, Hancock probably would have had to pay up.  But like most people developing these type of problems, it took them time to ask for the help they needed.  So, instead, Hancock used their need for help as a way to get out of paying.

A good deal for the insurers, but an awful deal for those who think they are paying to protect themselves and their families.

by: Ken Covinsky
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Thursday, January 30, 2014

“Can't go home, can't be admitted” – the emergency room purgatory

A 92-year-old woman with a history of stroke comes to an emergency department and is found to have fractures of her cervical spine. Neurosurgery sees her but doesn't think she needs surgery. The emergency department physician tries to admit her to the hospital as she has a new functional disability due to the fall but the hospitalist refuses as the patient doesn’t meet criteria for inpatient admission. And there she sits for another 23 hours while her fate is being decided… She has now entered a new state in modern medicine: purgatory.

"Purgatory" can be defined as "a place or state of temporary suffering or misery."   This is a very apt description, used in a recent JAGS article by Timothy Platts-Mills, Scott Owens, and Marvin McBride, for what happens when patients are seen in the emergency room for an non-surgical injury but don't meet standard hospital admission criteria (as detailed in the InterQual guidelines) and can’t safely return home because of new functional difficulties from their injury.   I'll lay out a brief summery of some of the options in these situations, although you should really go to the paper (here in JAGS) as it does a really wonderful job describing many of the issues for each type of placement.


1) Admit the patient to the hospital: the problem lies in the fact that many of these older adults with non-operative injuries may not meet inpatient criteria despite having new functional limitations that prevent them from going home safely. Some doctors may try to build a case for an admission, but this may require a lot more testing and interventions than the injured older adult actually needs. Even if they do get admitted, they run all the risks of inpatient admission including hospital associated disability, poly-pharmacy, delirium, and hospital associated infections.

2) Place them under "Observation": the goal is to create a short-stay, observation status (not quite inpatient, not quite outpatient) to evaluate an outpatient's condition or determine the need of an admission to the hospital as an inpatient. However, Sheehy and colleagues found that 17% of observation patients stayed more than 48 hours, and 1 in 4 stayed longer than 48 hours for those admitted to the hospital under "observation status".   Older adults with a new non-surgical injury are likely going to be in the hospital longer than just 24 hours because of new functional limitations due to the injury, as well as lack of good discharge options as observation doesn't count for as part of the 3-day qualifying stay for Medicare paid skilled nursing facility.  Furthermore patients don't like it because of a high copay with observation stays (see this New Old Age post) and hospitals don't like it as reimbursement for observation patients generally falls below the costs of a stay.

3) Skilled nursing facility (SNF): this may be a good option as it is focused on regaining function, the problem is that it just takes too long to get individuals into SNF care and for most elderly, the cost of skilled nursing facility care isn’t covered without 3-day qualifying inpatient stay (which doesn't include observation status days).  So it is only the rare occasion when a patient is placed in a SNF directly from the emergency room.

4) Discharge home with additional support: this option is probably where most older adults want to be but the challenge is to get the right care into someone’s home takes some time and also takes money, something that is often in short supply in the emergency department.


The authors of the article though give some possible ways out of purgatory. The most viable options they discuss include 1) expediting access to skilled nursing facilities by changing policy to allow for coverage of short-term access to skilled nursing care directly from the emergency department, and 2) developing ways to get rapid access to home health care. ACO’s are touted as one way to make the changes happen through the Shared Savings Program.  Here is a quote from the article:
“If holding open a few SNF beds for direct admissions from the ED results in Medicare savings by avoiding unnecessary hospital stays, then some portion of those savings might be given back to the facility to cover the cost of keeping the beds available.”

by: Eric Widera (@ewidera)
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Wednesday, January 29, 2014

Still Needed: Guidance for the “GeriPal” Patient with Heart Failure

As a (geriatric) primary care provider and (palliative medicine) specialist who cares for patients with heart failure (HF), the 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for Management of HF should be directly relevant to my clinical practice, right?

Well, as recently stated by Dr. Fred Masoudi in Journal Watch, these guidelines are an important comprehensive revision and reflect a growing evidence base. He notes that the guidelines provide a concrete definition of guideline-directed medical therapy (GDMT) and place substantially greater emphasis on care transitions, patient engagement, and quality improvement. In particular, Table 34 (Plan of Care for Patients with Chronic HF) may be a helpful resource, though pragmatic interventions for older HF patients with palliative care needs remain largely absent. While the 2009 guidelines had a brief section titled “End-of-Life Considerations,” these updated guidelines highlight recommendations for coordination of care for patients with chronic HF, including a Class I recommendation that palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life. This is obviously good and reflects contemporary work by HF, geriatric, and palliative care specialists.

However, while the recommendations are helpful, the guidelines note several important evidence gaps. Geriatric and palliative medicine providers will certainly agree. As GeriPal readers are well-aware, the majority of clinical trials that inform GDMT were designed around the primary endpoint of mortality. For most GDMT, there is less certainty about the impact on quality of life, which is often a concurrent, if not the main goal of our patients and their families. Our patients are also often not included in the majority of trials, which didn’t include sufficient numbers of elderly, women, underrepresented minorities, or the sickest sick. As a geriatric and palliative medicine provider, I agree with the critical need for an evidence base that clearly identifies best processes of care, especially in the transition from hospital to home. There is clearly an opportunity for geriatric and palliative medicine researchers to continue to assist with the development, evaluation, dissemination and implementation of effective patient and family-centered interventions. As Dr. Masoudi notes, “Most of the recommendations… require functional systems of care in both the inpatient and outpatient settings and cannot be achieved by an individual practitioner in isolation.” This is what geriatric and palliative medicine specializes in!

So, where are we in terms of best palliative and supportive care for the older adult with HF and multiple medical conditions? It has been 10 years since Goodlin and others published the “Consensus statement: Palliative and supportive care in advanced HF”, which has driven the framework for research and clinical practices to improve the needs of this patient population. Gadoud and her colleagues recently summarized the current evidence and future direction for palliative care for people with HF. Abete and colleagues also summarized treatment for chronic HF in the elderly: current practice and problems. Hopefully, the next ACC/AHA HF guidelines update will be able to incorporate results from high-quality pragmatic interventions that focus on the comprehensive needs of older patients with chronic HF, especially related to the significant symptom burden, impact of depression, cognitive impairment, functional limitations, and caregiver and support needs that GeriPal readers see every day.

In your practice, what needs or successes do you see in the care of the “GeriPal” patient with HF?

By Hillary Lum (@hdaylum)

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Wednesday, January 15, 2014

Antibiotics in hospice

by: Alex Smith @AlexSmithMD

Case 1: You have a 94 year old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum.  Her daughter asks if she can be treated with antibiotics "to make her feel better."  The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also hoping to live until her first great grandchild is born.  Should you treat with antibiotics?

Case 2: You have an 84 year old man in the hospital being treated for a fungal infection of the heart.  The condition is non-operable and he decides to focus on comfort. The plan is to discharge to hospice.  The infectious disease team recommends a 12 week course of IV antifungals, or at the every least oral anti-fungals.  The patient, who has already had one stroke from a fungal clot in his heart that shot up to his brain, is willing to take the medication.  Should you follow these recommendations?

Case 3: You have a 98 year old woman with advanced dementia on hospice in the nursing home.  She is unable to speak and is fed by hand.  She develops a fever, is urinating more frequently, grimacing and moaning.  Should you send a UA?  Should you treat with antibiotics?

Though loosly based on real world expereinces, these cases are all made up.

The role of antibiotics in hospice is far from clear-cut.  A recent paper by a group from the Oregan Health Sciences University led by Jennifer Albrecht, PhD, used a national dataset of hospice agencies to investigate use of antibiotics in hospice.  They found that 27% of patients received at least one antibiotic in the last week of life.  These numbers, they note, are lower than previous estimates.  That is still a lot of antibiotics!

The data from other studies seem to suggest that antibiotics are beneficial in terms of symptom relief only for urinary tract infections, as in Case 3.  The data are retrospective, and by no means definitive (see citations in Albrecht's paper). 

In my experience there are a lot of gray areas where the decision of whether or not to prescribe an antibiotic is far from clear.  How much is the antibiotic directed at symptom relief?  At prolonging life?  As the Jennifer Albrecht notes, the goals of patients in hospice are also often mixed, and many patients have some mixture of goals oriented toward quality of life and extending life, as in Case 1.  They also note that while preferences for CPR are commonly documented, preferences for antibiotic use are not. 

Patient, caregiver, and provider beliefs about the effectiveness of antibiotics vary widely.  If we struggle to constrain antibiotic prescribing for upper respiratory tract infections with healthy ambulatory patients in primary care, think of how much more charged these conversations can be at the end of life. 

We need more clarity in this area.  It's a rich area, involving symptom relief and communication, topics at the heart of hospice and palliative care.  Hopefully there are some researchers out there willing to take this on!
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