Saturday, November 22, 2014

6 tech innovations that will make you say "nifty!"

Generally at GeriPal we focus on low tech, high touch interventions.  Like talking to people.

But this week we had an inspiring visit this week from  David Atashroo, MD, from Stanford.  The title of his talk was "Innovation in Aging."  And some of the stuff he shared is really exciting, and worth sharing.  These are innovative technologies that can be used to help aging seniors.  Many of these are in the early stages of development or are at the startup level.

1.  Check out this wheelchair.  Who says wheelchairs have to be, well, ugly?  This thing looks cool!  Made by Whill.



2.  Now check out this car.  You can roll your cool wheelchair right into it.  And it's electric.  Brilliant!  Made by Kenguru.


3. Check out this spoon.  You know how noise canceling headphones block out background noise?  Well, this spoon, made for patients with essential tremor, cancels out the tremor, so the spoon stays steady.  Made by LiftLabs.


4. This is a dog avatar that for people with dementia.  It talks with them and reminds them to do things.  It's also fun.  Mad by GeriJoy (nice name).


5. A lot in the news recently about turning back the clock for older adults, particularly those with dementia.  Literally tricking the mind into thinking it's 1940, not 2014, by surrounding them with pictures, news, art, furniture from that time period.  A small step toward recreating that time-period is simply playing music from when someone was young.  But does your average young nursing home staff person know what music to play from the 1940s?  Probably not.  Music and Memory helps design those set list.


6. Another way to take you back is through the use of virtual reality, and no company is hotter in that space right now than Oculus.  Check out this awesome YouTube video called, "My 90 year old grandmother tries the Oculus Rift."





This post is rather risky - I worry about being bombarded with emails from new companies wanting me to write up their products.  Please send those requests to the GeriTech blog - that's the focus of that blog!  Also, I own no stock in these companies and don't plan to buy any.

During his talk, David Atashroo made an appeal to us (UCSF Division of Geriatrics), to become more involved with the start ups.  He pointed out that they need us to design good products.  We know what the problems are - they often have no idea.

Personally, as an academic, I worry about conflicts of interest.  While working with the start ups is not for me, some of us should be talking to these creative geniuses.  Our future depends on it!

by: Alex Smith, @AlexSmithMD

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Thursday, November 20, 2014

Lessons from the Stage: A Lesson About Patient Communication Learned in an Improv Class



My husband and I took a beginner’s improv class not long ago. Two of the most fundamental rules they taught about performing improv with a partner were: (1) never say “no”—it kills the storyline that you should be working with your partner to build. And (2) never say “yes, but...”…. because you might as well have just said “no.”

It plays out something like this: You and your partner get a prompt, such as pretending to be cops. Your partner has an idea for where the scene could go next. Little does your partner know that you have a brilliant idea for where you want to take the scene next. Your partner boldly proclaims, “Alright, partner, I just heard from the sheriff and there’s a murder to investigate.” Still holding to your own idea, you reply, “Yes, but before we get there, we first need to fulfill our assignment as undercover go-go dancers.” Yes, but… you just killed your partner’s storyline instead of building on it.

It sounds so simple. An easy two words to avoid. But once we were aware of it, we noticed that we were doing it every few lines, our own hidden tug-of-war over the storyline. Now, this is not to say that one can’t influence the storyline in improv. The primary building block of influence, however, is a different two words: “Yes, and…”

My husband and I started noticing “yes, but”s all over our lives. “Yes, but let’s do the dishes first.” “Yes, but I think this movie will be even funnier.” “Yes, but doing it this way might work better.” Countless hidden “no”s disguised under the cloak of “yes, but.”

One setting that is certainly not protected from the “yes, but” is the hospital. I was recently working with a resident, watching her interview a patient. The patient was an older gentleman with advanced hepatic disease. He had received a liver transplant many years ago, but subsequently relapsed on alcohol after the death of his wife. He had a history of poor engagement with care, and we were told had been quite stoic and closed-off during this hospitalization.

I watched with awe as the resident I was working with pulled a chair up to the bedside and really tried to get to know this gentleman. As the patient spoke about his 16 years with his wife before she died, of the way she brought meaning to his life, the tough exterior finally began to melt. For a moment, just a moment, water began to build in his eyes. The proud supervisor in me was rooting in my head, yes, let’s see if I we can keep him in this place. “That must have been so hard,” the resident began, “…but I’m glad that you were lucky to have sixteen good years together.” It was the “yes, but.” Coming from a place of good intentions, but a “yes, but” nonetheless.

As quickly as the door had opened, it had closed—the deep sorrow over a life without his wife closed behind it. His face was wiped, and we were back to business as expected. What would have happened, I wondered all afternoon, if the resident’s comment had stopped before the “but”: “That must have been so hard…” Had the patient transiently thrown us off of our storyline? Had my resident been attached to a plan of shifting this conversation towards positivity? Regardless of the cause, rather than building on the opening, we had reclaimed control of the reigns. Yes, but…

I began noticing the subtle messages embedded in so much of our wording in medicine. “I too hope your father will get better, but I’m also worried that he may not.” A phrase that I’ve said so many times from a place of kindness, but is there the subtle message: my worries and practicality are here to put a check on the hope you are so strongly clinging to. Changing the “but” to an “and”: “I too hope your father will get better, and I’m also worried that he may not.” A one-word change, possibly imperceptible, but perhaps with the subtle message: there is room for us to carry both—all the hope you may have, along with our worry.

Needless to say, different clinical scenarios will call for different communication strategies, perhaps at times even the use of a “yes, but.” Deciphering what type of communication a patient or family may need is indeed a large part of the art of medicine. But let’s face it, strategies that allow us to take control of the storyline come far more naturally to most clinicians. Controlling, predicting, planning—they are traits that are selected for through the years and hoops of medical training. I can say from firsthand experience that the same temperament that has been serving me through medical training, made the act of relinquishing control in an improv class feel surprisingly unnatural. Amidst our standardized exams and linear templates, perhaps this is just the skill that we need to be training clinicians for: neither taking control nor quietly watching the show, but enough engaged flexibility to build on the story— a partner in the patient’s storyline. Yes, and…

by: Danielle Chammas, MD (@ChammasDani)
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Thursday, November 13, 2014

Time to act! Urge your senators to confirm Dr. Vivek Murthy for Surgeon General



by: Alex Smith @AlexSmithMD

Vivek Murthy was nominated for Surgeon General of the United States by President Obama in November of 2013.  A bipartisan group of Senators approved his nomination in February 2014 and pushed it forward for a full vote.

A (not so) funny thing happened on the way to the vote.

In his confirmation hearing, Dr. Murthy was asked by Senator Lamar Alexander about his tweet that gun control is a public health issue.

Senator Alexander noted that "Americans have a first amendment right to advocate the second amendment."

Daily Show commentator Jon Stewart responded on his show "Yes, Americans have a first amendment right to advocate the second amendment.  And apparently, you don't have a first amendment right to have a different opinion from that.  Everyone knows the first amendment only applies to saying positive things about the second amendment."


Vivek Murthy responded to Senator Alexander that he would not focus on gun control as surgeon general.  He would focus on obesity.

But it was too late - Murthy had touched the third rail of politics - gun control.  Senator Rand Paul of Kentucky wrote a letter to majority leader Harry Reid saying he would put Dr. Murthy's nomination on hold.  His office bragged that they had "put yet another hold on another qualified nominee."

The NRA attack machine went into full swing, opposing the confirmation. The Surgeon General is an office with no control over gun control legislation.  As editors at the New England Journal of Medicine wrote in support of Vivek Murthy for Surgeon General,

The critical question is this: Should a special-interest organization like the NRA have veto power over the appointment of the nation's top doctor? The very idea is unacceptable.

Unacceptable though it is, the Senate backed off.  Senators from red and purple states, worried about re-election, balked at confirmation.  The vote was put on hold.

Well now those Senators have lost.  And this presents a brief window of opportunity to push through the vote on Dr. Vivek Murthy.  Those senators that lost no longer have a political reason to oppose this nomination in their last month in office.  This is a brief window, folks.

And really, this is not about gun control, or the NRA - all of that is a (ridiculous) distraction.  This should really be about the candidate.   Here are some of Vivek Murthy's qualifications for becoming America's Top Doctor:
  • Harvard undergraduate
  • Yale medical school and MBA
  • Primary care residency at Brigham and Women's Hospital, Boston (where he now works)
  • Founded Doctors for America
  • Founded ePernicus, a social networking and collaboration site for health researchers
  • Co-founded Visions Worldwide, supporting HIV/AIDS education in India
  • Served on the U.S. Presidential Advisory Council on Prevention, Health Promotion, and Integrative and Public Health
  • Support from hundreds of public health organizations, including the Hospice and Palliative Nurses Association, American College of Physicians, Society of General Internal Medicine, American Academy of Family Physicians, the American Cancer Society, and the Gerontological Advance Practice Nurses Association.  
  • (I have contacted both the American Academy of Hospice and Palliative Medicine and the American Geriatrics Society about becoming involved in supporting Dr. Murthy's nomination)
I know Dr. Murthy.  We were in the same small primary care residency at the Brigham and Women's Hospital in Boston.  Vivek was one year below me, in a class of four residents per year.  We spent countless hours together in journal club, our patient-doctor course, and on the wards.  Vivek Murthy is one of the most humble, brilliant, innovative, and caring physicians I have ever met.  Vivek Murthy is a fresh face with new ideas for leadership in healthcare.

And this is not really about Republicans and Democrats, either.  Ask yourself this: at this time of healthcare crisis after crisis (think Ebola), can our nation afford to go without leadership from its top doctor, the Surgeon General?  We need thinking at the top that is steady, informed, and sharp, not a leadership vacuum imposed by a single issue special interest group enraged by a tweet.

Please take action.  In just 2 minutes you can email or call your Senator to support Vivek Murthy's confirmation in the Senate.  I did both in about 5 minutes.  Then I asked my wife do it and it took her even less time.  Ask your family and friends to do it.  It's easy - just follow this link.  You can tweet about the issue here.
I can say that as a resident, Vivek Murthy was a strong supporter of geriatrics and palliative care.  In terms of his published views on the internet, he responded to a NEJM perspective by Drs. Thomas Smith and Bruce Hillner on bending the cost curve in cancer.  One of the issues in this area are unnecessary tests for cancer in patients with a short life expectancy, like screening for cancer in those already diagnosed with advanced cancer.  We blogged about this subject in a post called "Dumb Medicine."  In reply to this issue, Dr. Murthy is quoted on Kaiser Health News:
Dr. Vivek Murthy, President of Doctors for America, e-mails that physicians spend less time with patients (not always for reasons of their own choosing) and are less likely to have important discussions with patients and families about priorities or tradeoffs in care. It takes less time to consent to an intervention or to prescribe a medication than it does to persuade a patient that an intervention or procedure is unwise. Murthy notes that one cumulative effect of millions of missed conversations is to reinforce the intervention mindset among patients. So, alongside efforts to alter physician incentives, medical schools and health care settings must equip physicians with the knowledge, the interpersonal skills and other supports to conduct these important conversations well.
Advocacy to train physicians with communication skills, and concern about millions of missed conversations and the "intervention mindset" - doesn't that sound like something GeriPal readers should support?

This window of opportunity will soon pass.  The current Senate breaks for the Holidays soon.  After that, the new Senate with new leadership takes hold.

The time is now.






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Wednesday, November 12, 2014

Some say Geriatrics is not glamorous, but I say it is.


Tonight I was having a discussion with some close friends.  I’ve got to brag here, I have some very smart, passionate physician friends from residency.    One of the hospitalists asked for our collective advice about a recent difficult clinical encounter: 

“How would you handle a 90 year-old patient in the hospital who refuses to let the nurses change her until we let her go home?  She’s been sitting there in her own urine for 24 hours, and I just don’t know how to help.”

Five months into my geriatrics fellowship, I thought maybe I could handle this one.  I suggested that likely she’s likely very frustrated about her declining health and her ability to care for herself.  She recognizes that her independence and freedoms are slowly being taken away from her.  She’s probably trying to exert control the only way she can. 

The other comments from the group were very different.  “More colace,” one said jokingly (from the friend who thinks that’s all I prescribe).  “Oh that’s ‘failure to thrive,’ she should be conserved,” another weighed in.   “I’d just put her in long-term care, there’s nothing TO do,” said another. 

I realized then how much these five months had already changed me.  My viewpoint had shifted, and I wasn’t seeing things the way my colleagues were anymore.  I still knew the complex physiology and I still got excited about the mystery diagnosis, but now I was managing patients way more challenging than I ever had in residency.  They had multiple medical problems combined with frail cognitive and functional issues, sometimes complicated by loneliness and a loss of dignity.

This was not doctoring I read about in books or learned from writing orders on the wards.  This was an art of balancing the social with the emotional, the physical with the existential.

“I just wanted to brag about my glamorous life,” my hospitalist friend said jokingly about the case she presented me. 

Glamorous.  I looked up the meaning.   One definition was “full of excitement, adventure and unusual activity.”   Well, I’d have to say taking care of older adults IS very glamorous.

I’m still excited every time Mrs. S, a lively 96 year-old lady, tells me how she met her husband.  (Her dementia has progressed, she doesn’t remember she has already told me this many times.)  “It was 1934, and I was on a 3-day train trip from Texas to San Francisco.  There were 250 military men on the train and 8 ladies.  I had my pick of the litter and we had a ball,” she laughs until tears fill her eyes.  We giggle until our stomachs hurt, but after a while, we decide to talk seriously about her blood pressure.  It has been low lately, and the dizziness it causes may be the reason for her recent falls.  Although she may need the medication for her heart failure and to prevent a future heart attack, I have the difficult decision of weighing the risks and benefits of the medication. 

There are no studies to guide my clinical decision-making.   (In fact, there are very few studies that include any 96 year-old patients at all).  There is no review of the literature I can do to determine what the “best” answer is.  Instead, I have the glamorous job really listening to what’s important to her, what gets her up in the morning, and what sacrifices or risks she is willing to take so that she can have the life that she wants. 

My job is so exciting, adventurous, and unusual that I get to individualize the care I provide for every person I see.  Its scary territory when there is no case like another in which to guide my decisions.

My patients’ lives are filled with amazing stories and memories.  They have survived decades of experiences, with peaks of joy and valleys of suffering.  They continue to have dreams and wishes.  They still have many tear-filled fits of laughter left.   My job IS glamorous because I get to do my best to get them there.  And I’m loving every minute of it. 


by: Stephanie Rogers @SERogersMD
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Monday, November 10, 2014

Geriatrics and Palliative Medicine: Partners in a Common Mission



Over the past decade, the disciplines of Geriatrics and Palliative Medicine have become intellectual cousins. 

Within Palliative Medicine, the recognition that Palliative Medicine is not just about end of life care has been a paradigm shift.   There is now recognition that core skills of Palliative Medicine, including symptom management, communication, and caregiver support are needed throughout the course of serious illness.  While these needs of seriously ill patients transcend age, it is a demographic fact that older persons will be the bulk of persons with these chronic palliative care needs.  So, the population that has long been of interest to Geriatrics is now of great interest to Palliative Medicine. 

Within Geriatrics, we have become consumed with the recognition that most frail older persons have multiple illnesses.  We realize that treating each illness separately, rather than treating the whole patient leads to considerable harm.   Geriatricians strongly advocate for a focus on whole person health outcomes such quality of life and functional status rather than traditional disease metrics.  Geriatricians have been increasingly concerned that traditional treatments focused on each individual diagnosis leads to dangerous levels of overtreatment that can harm patients. 

On the other hand, care that is grounded in an understanding of the patient’s goals, focused on quality of life, functional, and supportive needs of the patient and caregiver is of great benefit.  Kind of sounds like we are getting pretty close to palliative care, doesn’t it?  So a basic competency of Geriatrics is the ability to attend to the palliative needs of frail patients throughout the full course of serious illness

So, given this overlap between the two fields, shouldn’t the next step for each field be to aggressively define and defend its turf?

Two wonderful perspectives, by Jim Pacala and Diane Meier in the Journal of the American Geriatrics Society, eloquently argue that the answer to this question is an emphatic NO!  These thoughtful perspectives are great reading for those in both fields.

Pacala and Meier implore us to put a laser focus on the needs of seriously ill patients, rather than worry about who has what turf.   Both fields focus on the most vulnerable patients, the 5% of patients who consume 50% of health costs.  Yet for all that money, our health system is utterly failing these vulnerable patients, delivering disjointed, dysfunctional care that does not meet their needs and goals, and often causes harm rather than benefit.   We should of course embrace what is unique about each discipline and value the specialized skills each discipline may bring to the table.  But, Pacala and Meier tell us that we have so much more to gain by collaborating and working together than worrying about turf.

Perhaps the most important feature that unites those in Geriatrics and Palliative Medicine is the passionate belief that we need to change how health care is delivered to seriously ill patients.  With needs so great, we do not need to worry about turf.  There is more than enough work to go around.  By working together, we can offer hope to seriously ill patients and their caregivers who feel that their voices are not being heard. 
by: Ken Covinsky @geri_doc
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Friday, November 7, 2014

Family caregivers give up $522 billion in income per year to care for seniors



by: Alex Smith @AlexSmithMD

You don't get something for nothing.

We've blogged previously about the silent long term care system of informal caregivers in the US.  These are the families and friends who provide the bulk of care for older adults in the US.  The National Caregiving Alliance estimates that nearly 1/3 of US aldults are caregivers.  This caregiving is seemingly "free" - it appears to cost the US Healthcare System nothing.  Often, however, this work comes at great cost to the caregivers, including higher rates of depression and other health effects.  It also means the caregiver is providing care, and not earning an income for themselves or their family.

Today we have more information about the economic costs of informal caregiving in the US.
Amalavoyal V. Chari and colleagues published a national study of the costs of caregiving for elders in the US in the journal Health Services Research (link to an interview with Dr. Chari here).  They focused on how much these caregivers would have earned had they been working instead of providing informal care for older adults.  What they found:
  • They estimate the cost of informal elder care at $522 billion annually.  That is, had these caregivers been working instead of providing care for "free", they would have made $522 billion. 
  • The costs of formal long term care (e.g. nursing home care) are less than half the costs of informal care - $221 billion annually vs. $522 billion annually.
  • The estimated costs of replacing informal caregivers with paid unskilled caregivers is $221 billion, and replacing informal caregivers with skilled caregivers is $642 billion.  Conclusion: the informal caregiving system is more affordable than replacing this system with a skilled care system.
  • These estimates may be underestimates because they do not include the cost impacts of caregiving on the emotional and physical health of the caregiver.
Why is this information important?  Policy initiatives are just starting to recognize the importance of informal care.  Many states offer Medicaid's Cash and Counseling Program to reimburse caregivers for low income and/or Medicaid eligible seniors.  This program is in an early, pilot phase, however, and risks budget cuts at the State and Federal level.  We need more support for this program.  And the  monetary recognition of the sacrifices made by informal family caregivers addresses just one small aspect of the problem.  Better training for this work is essential.  Informal family caregivers are often untrained and unprepared, working in isolation for years on end.

Time our country started listening.

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Tuesday, November 4, 2014

December's Consumer Reports: Gadgets, Gear, and Hospice & Palliative Care


The December issue of Consumer reports is truly amazing. It’s filled with articles to help consumers find the right headphones, smart phones, and smart watches. One hot new piece of gear that is rated quite highly by consumer reports in this issue is something you may have heard about once or twice before, Hospice and Palliative Care.

You can access the for free all of the articles on their website at this link. This is a really well thought out webpage that is written by consumers, for consumers and includes the following resources:
  1. The story of Paul Scheier's life and death: The website includes a 17 minute long video that discusses the importance of hospice and palliative medicine, addresses myths often connected to these programs, and includes a tear shedding journey of Paul’s life and death.
  2. A guide on how to pick a hospice 
  3. Advice about advance directives including a link to an app by the American Bar Association called My Health Care Wishes (Android and iOS) that lets you store advance directives and related legal documents on your mobile device.
  4. A section on "when things go wrong" that includes a link to the American Geriatrics Society's Health in Aging Foundation to help consumers find a geriatrician!

by: Eric Widera (@ewidera)
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Monday, November 3, 2014

Advance care planning cold calls, crowdfunding palliative care, and pocket card decision aids

by: Alex Smith @AlexSmithMD

Every once and a while, a new innovation comes along that makes you go, "Wow!" or, "I never would have thought of that" or, "Not sure if it will work, but I'm sure interested to find out."

The following three are interesting not only because of the ideas themselves, but also because of the different ways they are going about funding: for-profit (Vital Decisions), both for-profit and not-for-profit (ResolutionCare), and non-profit (Caring Advocates).

1.  Cold calling patients with serious illness and engaging them in advance care planning conversations.  Vital Decisions, a large and growing for profit company, obtains lists of patients with serious illness from insurance companies.  Counselors working at Vital Decisions call patients and engage them in advance care planning conversations.  NPR did an interesting story on this company in August.  As Bob Arnold said at the end (to paraphrase), "would it be better if the patient's doctor, nurse practitioner, or social worker did this? Yes.  But this is better than what patients have currently been getting."  Major outstanding question: can you conduct advance care planning conversations effectively over the phone with someone you don't know?

Source - Wikimedia Commons
2.  Crowdfunding palliative care.  ResolutionCare based out of Humboldt county in Northern California has launched a crowdfunding campaign on indiegogo to raise $100,000 in November.  The money will go toward building a palliative care service for patients with serious illness, particularly those living in rural areas.  The care model is based on Project Echo, a remarkably successful program that started at the University of New Mexico to improve care for rural patients with Hepatitis C.  The central idea is that expert palliative care specialists on the ResolutionCare team will use video technology to conduct video consults with doctors and other providers at outlying practices.  This will increase the reach and impact of the the ResolutionCare team, and hopefully, increase the quality of palliative care delivered by the providers who consult.  Major outstanding questions: is palliative care similar enough to hepatitis C treatment that the Project Echo method will be effective? Do video palliative care consults to healthcare providers improve the quality of care for patients living with serious illness? Will people give money to crowdfund palliative care?




3.  Pocket card decision aids.  Dr. Stan Terman in Southern California is on a mission.  His mission is to ensure that patients who later develop advanced dementia will not be forced to endure treatments they would not have wanted.  His nonprofit company, Caring Advocates, has created a series of pocket cards to help people plan and make choices about the type of care they would prefer in various states of health.  An example is below.  He has also produced some provocative videos that might be used for teaching.  For example, he made a YouTube video version of his talk at the American Society of Bioethics and Humanities titled, "Must we all die with forced hand feeding in advanced dementia?"  Hard to not click on that, isn't it?  Compelling story of a woman in Canada with a clear advance directive who is being hand fed despite her directive and her daughter's wishes - he has video of the patient and her distraught daughter. Major outstanding questions: do pocket cards work as decision aids?  Will they be widely used?


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Sunday, November 2, 2014

Advance care planning tool PREPARE, now in Spanish!

by: Alex Smith @AlexSmithMD and Rebecca Sudore @PrepareForCare

Do you have Spanish-speaking patients?  If you do, then point them toward PREPARE in Spanish

The rising tide of palliative care has not lifted all boats equally.  For example, hospice use among African Americans decedents increased from 5% in 1992 to 34% in 2010.  However, hospice use among white decedents increased even more, from 10% to 46%, over the same time period.  Hospice use increased at a faster rate among whites than African Americans.  The gap actually got bigger.

We haven't paid enough attention to disparities.  There is a real risk that many of the services, tools, and skills of palliative care may benefit majority patients more than minority.  The explosion of palliative care may have the unintended effect of increasing ethnic disparities rather than reducing them. 

That's just one of the reasons that work like Prepare in Spanish is so important.
We previously blogged about the launch of PREPARE (prepareforyourcare.org), an innovative online advance care planning tool.  The central idea behind Prepare is to move advance care planning upstream, to help patients and surrogate decision makers prepare for in-the-moment decision making. Advance directives are not enough.

PREPARE is a program that uses videos and personal stories to help people identify what matters most in life, communicate with loved ones and clinicians, and make informed medical decisions based on their values. PREPARE is appropriate for any person at any stage in their life and at any stage of readiness to engage in advance care planning.

Prepare was launched to the public in 2013. Since then it has received close to 50,000 unique visitors from over 115 countries.

Through generous support from the California Healthcare Foundation, PREPARE has been “transcreated” into Spanish after careful pilot testing within the Spanish-speaking community. (espanol.Prepareforyourcare.org)





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Friday, October 31, 2014

Addressing Unmet Palliative and Geriatric Needs of Zombies



Considerable evidence indicates that zombies do not receive optimal palliative or geriatric care.  High prevalence of untreated pain, depression, decreased socialization, and impaired sleep and mobility, as well as lack of access to proper medical care are universal issues facing this population of undead. It is therefore not surprising that zombies and their loved ones often express dissatisfaction with after-life care, which may play a role in zombies' seeming unquenchable desire to eat the brains of the living. In the following post we will address some of the most common issues facing zombies, and some potential palliative and geriatric solutions to providing truly Zombie Centered Health Care (ZCHC).

Hospice Care
One of the most surprising issues facing zombies is the lack of coordinated health care focused on the care of the dead. Many zombies may benefit from an interprofessional team based service like hospice. However, the hospice benefit is limited to those with less than 6 months to live, effectively ruling out zombies as they are already dead. One proposal by some zombie advocates is to create an open access policy for hospice that includes the undead to ensure that they receive the same type of care that has been shown to improve care and family satisfaction in the living.

Pain
A growing amount of evidence is revealing that opioid use in zombies is quiet uncommon despite high rates of traumatic injuries. There are several possible reasons why zombies may be at risk for the under-treatment of pain. A common belief is that zombies feel and experience less pain as they generally do not report pain to their health care providers. A similar situation arises for those with dementia, however current evidence reveals that pain sensitivity and the perceptual processing of pain remain largely intact even with advanced dementia. It is therefore likely that in zombies, it is not a reduction in the actual experience of pain that leads to underreporting but, rather, an inadequate assessment of pain due to poor patient recall and communication of painful symptoms. We therefore recommend an adaption of the faces of pain scale as shown below:

Faces of Pain - Zombie Version

Gait Issues 
While the gait speed of zombies has not previously been estimated, we can use the speed of the Grim Reaper as a rough estimate for the maximum speed of a zombie. In a BMJ article, Death’s maximum speed was estimated to be less than 3 km/hour, which is around the speed I have estimated zombies to shuffle at in most of the publicly available films. This speed in older adults is associated an elevated mortality risk, which remains true for zombies, as they have a 100% mortality rate. Interestingly, zombies pose a paradox as they have a slow and shuffling gait reminiscent of a Parkinsonian gait, but an exceeding low risk of falls as revealed through an informal yet systematic review of all available zombie clips available to the public viewing.

Delirium 
Zombies are clearly delirious as evident by an acute change in mental status, inattention, decreased level of consciousness, and disorganized thinking. In addition, day/night reversal and perseveration (for braaiiins) is virtually pathognomonic for their condition. However, after researching hours of zombie behavior, another clear finding is that insomnia is a very large issue for zombies. I have yet to see a film of zombie behavior that shows one in sleep. While this is merely a hypothesis generating finding, there is a strong correlation between insomnia and the delirium seen in zombies (a 1:1 ratio). Given this, it may be reasonable during any zombie apocalypse to attempt interventions that produce a phase-shifting effect on circadian rhythms, such as the use of bright light therapy or melatonin, to decrease the rate of zombie related behaviors.

Depression
Diagnosing depression is as difficult a task in zombies as it is for those with advance illnesses. DSM V criteria for the diagnosis of depression exclude symptoms like psychomotor retardation that are due to the direct physiological effects of a general medical condition, like death.   Furthermore, symptoms like guilt may be a normal reaction to lifestyle choices, such as eating your family members brains.

Prognosis
The median life expectancy for zombies is zero days.  This grim statistic underscores the importance of discussing prognosis with zombies, as it is for anyone with a serious illness.  A study by Smith and colleagues revealed that most zombies want to know their prognosis.  Unfortunately, upon my review, no zombie movie has ever demonstrated a health care provider, or for that matter any of the living, telling a zombie his or her prognosis.

Advance Care Planning 
The subject of advance care planning pertains to end-of-life decisions, which may seem unimportant for zombies as they are past the end of life. However, understanding the values and preferences of zombies around “dead-decisions” is just as important as asking the living about end-of-life decisions. Given the high rates of traumatic injuries, having stated values of what is most important to zombies in their deaths, what brings them enjoyment while being dead, and what are the biggest worries and concerns would appear to be just as important to the undead as to the living.

by: Eric Widera (@ewidera)
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Tuesday, October 28, 2014

Don't just do something, stand there... why it's too soon for talk of physician aid in dying



by Laura Petrillo (@lpetrillz)

When Brittany Maynard announced her plans to end her life on November 1st, the news rippled through social and national media like the foreshocks of an earthquake.  Ms. Maynard is a beautiful, relatable 29 year-old woman with a fatal brain tumor, who went public earlier this month with her decision to move to Oregon in order to obtain barbiturates via the Death with Dignity Act.  She has partnered with the organization Compassion and Choices to create a campaign to advocate for increased access to aid in dying legislation.  As bioethicist Arthur Caplan said on NBC News, "there are no new arguments in anything Brittany has to say," and yet, she has captured the attention of a new generation, and sparked a conversation about the amount of control patients should have over their own deaths. 

In this post I will not opine about whether patients should have access to physician aid in dying. But I will share my concern that like Brittany's death, the timing of this conversation is simply too soon, and threatens to curb the groundswell of interest in palliative care and hospice that stands to benefit many more people than physician aid in dying ever will.

There is increasing appreciation that Americans don't die well.  Patients receive chemotherapy and intensive care up until the last weeks of their lives, rather than spending time with loved ones.  They infrequently die at home, as most people would prefer to do, often because they seek aggressive care in hopes that extra treatments will give them more time.  There are many factors that contribute to this avalanche of medical care at the end of life, among them the reluctance of physicians to discuss prognosis with patients and to plan for what to do if the third line chemotherapy for metastatic cancer does not go as hoped, as well as our cultural narrative about "fighting" illness, a narrative with no room for vulnerability, future planning, or asking for help.

In addition to the fear of honest conversation, there is a fear of inaction on the part of physicians.  I noticed this firsthand this week  when I was teaching ethics to medical students who were fresh off their first clinical rotations. One student struggled with the idea of withholding CPR from an elderly woman with a previous do-not-resuscitate order who suffered an unexpected cardiac arrest.  The patient's advance directive was not readily available, so the medical team attempted to resuscitate the patient until they were able to track down the physical advance directive and confirm her preference.

"It seemed so logical to give her CPR in that situation, since there was a chance of saving her life," he said.  "What were we supposed to do, just put her in a body bag?"  He was not alone; other students told me about situations in which they wanted to encourage patients with poor prognoses to "be full code" with the assumption that this would give them more time with their families, or to offer patients procedures or treatments that might have any slight chance of increasing survival, even when there was a greater overall likelihood of harm.  The students had only been practicing medicine for a few months, yet already felt an obligation to act in any way that prolonged life, no matter the risks or alternatives.

There is also increasing appreciation that we can do better by patients at the end of their lives.  Dying patients who receive attention to their symptoms, as well as their psychosocial and spiritual needs in coping with advanced illness, not only rate that they have better quality of life, but actually live longer than patients who receive our current standard of care.  A recent Institute of Medicine report recommended an increase in advance care planning, shared decision making and access to palliative care to improve care of the dying.  Atul Gawande's book Being Mortal has rocketed to the top of the bestseller list and generated an incredible amount of positive attention to palliative care and its promise in ameliorating the crisis state of end-of-life care in America.

The recent buzz about physician aid in dying jeopardizes that momentum, by steering the conversation toward the extreme rather than focusing on a solution for the broad middle ground.  Patients and families are already wary of morphine, and suspect that it is used not only to palliate but also to hasten death.  I suspect that if physicians were also given the power to prescribe barbiturates for aid in dying, that patients may fear that shifting gears from curative intent treatment to comfort-focused care at the end of life care might mean consenting to euthanasia, and shy away.  And if conservatives erupted in "death panel" cries over physician reimbursement for advance care planning, imagine the backlash against aid-in-dying legislation.  Even though they are distinct, opponents won't hesitate to bundle these together and alienate patients from palliative care and hospice out of fear.

Moreover, I worry that physician aid in dying is yet another way to "do something," rather than simply being present with patients through the uncomfortable, unseemly dying process. I was surprised to see an overwhelming amount of support in the comments responding to Brittany's video, but on closer examination, many comments are simply anti-death: "Brittany, I salute you…. I have seen the most heinous of deaths and deaths prolonged because of guilt of the family, keeping people alive who are suffering" said one People.com commenter.  A twitter post read: " If a woman wants to die on her own terms & not suffer a horrendous death by cancer, let her."

These posts present a false dichotomy of choices: suffer a horrendous death by illness, or choose death by fatal ingestion.  This is not the case.  In the vast majority of cases, hospice care can bring relief and comfort to patients and their loved ones, and facilitate peaceful dying without the need to resort to a pill to speed things along.  Patients need to know that they will not be abandoned when treatments fail, and there are more ways to preserve dignity in the dying process.  They also need to be free of any possibility of coercion-- the greatest fear that most people have about the end of life is being a burden to their families.  How terrible to contemplate patients choosing aid-in-dying to save money, or because they are out of options for compassionate home or residential hospice care, or worse, because they feel pressure to end the situation quickly.

We live in a society where we are never content to be still, or feel like there is a situation we can't do something about.  But when it comes to matters of death and dying, we owe it to ourselves to slow down.  Talk with our patients and our own families about what is important.  Learn what is making a dying person suffer, and either help her through it, or be present with her in her suffering.  We need to ditch the fighter narrative, which empowers some but leads others down a fruitlessly aggressive path, and leaves them feeling stranded when the battle is lost.  And as physicians, we need to let go of our need to be the hero, and recognize when to shift gears and help patients find the resources they need to feel comfortable and safe.  Until everyone has access to comprehensive care, and information to make good choices about death and dying, it is too soon to talk about another "something" we can do to make the situation go away. 
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Monday, October 20, 2014

It's on! SF Giants and GeriPal vs. KC Royals and Pallimed

KC BBQ meal we look forward to receiving from Pallimed
Christian Sinclair of Pallimed and Kansas City has challenged us to a friendly wager.  As many of you know, many of the bloggers at GeriPal (including me and Eric) are based in San Francisco.

The world series is the San Francisco Giants vs. the Kansas City Royals.  What an opportunity!

The basic rules are simple:

  1. For each loss in the series, the losing blog must write a post for the opposing blog.  So, for example, after the Giants win Game 1 Tuesday night, a Pallimed blogger will owe GeriPal a post, to be published on GeriPal.
  2. Timing doesn't have to be the same night, so if the Giants win the series 4 to 1, then Pallimed owes GeriPal 4 posts, and GeriPal owes Pallimed 1 post, to be written in a reasonable time frame.  If it's the same night, that's fine too. 
  3. At the end of the series, the losing blog must send a dinner themed from their city.  So for example, in the unlikely event that the Royals steal the series, we at GeriPal will send Pallimed a dinner of something like sourdough bread, Mt. Tam Cheese, and It's Its.  When the Giants win, we look forward to eating a fine BBQ meal from Joe's Kansas City.

We may negotiate the finer details, but those are the basics.

We accept your challenge...and can't wait for your 4 blog posts and barbecue!  Just don't be Bum(garner)ed when you lose!

Alex and Eric


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GeriPal Hits 2 Million Pageviews


The Places Where GeriPal is Read

Last week GeriPal hit 2 million pageviews.  We celebrated quietly when the counter showed a whole line of 0's, but I thought it would be worth creating a list of the top 25 most read posts to commemorate the occasion.  Enjoy!
  1. The Dangers of Fleet Enemas
  2. Length of Stay in Nursing Homes at the End of Life
  3. End Stage Dementia: A Terminal Disease Needing Palliative Care 
  4. What to give Uncle Ernie, Grandma Mabel and Great Aunt Rose? 
  5. Dying without Dialysis 
  6. Beers Criteria Contest: Submit the Craziest Medication Combinations 
  7. When Surrogates Override the DNR: A Terrific Geriatrics and Palliative Care Teaching Video 
  8. MMSE and Copyrights Part II: Is the MMSE Derivative of Some Other Work? 
  9. Atul Gawande New Yorker Article "Letting Go" 
  10. Coffee Is Bad For You. Coffee is Good For You. Why Am I So Confused? 
  11. Survival from severe sepsis: The infection is cured but all is not well 
  12. Why is Forest Laboratories discontinuing Namenda? 
  13. TAVR: Life-prolonging and palliative or risky and costly?
  14. A New Treatment For Atrial Fibrillation in the Elderly?: The (IR)relevance of Clincial Resarch to Geriatric Populations 
  15. Death of the Gerontological Nurse Practitioner: Part 1 of 2 
  16. Loneliness 
  17. Watchful Waiting or Surgery for Prostate Cancer? 
  18. “Elders?” “Older Adults?” “Seniors?” Language Matters 
  19. A Call for Hospice Reform: Nurse Practitioners Lead the Way 
  20. A Study of Dignity Therapy on Distress and the End-of-Life Experience 
  21. 3 Issues of Hospice 
  22. How do you explain hospice? 
  23. Being Accused of Murder 
  24. Inappropriate Medications in the Hospice Setting
  25. Copyrights and Copylefts in Medicine: The Case of the Wayward MMSE

by: Eric Widera (@ewidera)


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Friday, October 10, 2014

A Call for Maternalism in Medicine



by: Laura Petrillo @lpetrillz

After a recent family meeting, I received a piece of feedback from a social worker that took me by surprise:  "You were very maternalistic in there, but it worked," she said.

I reflected on the conversation we just stepped away from.  Our palliative care inpatient consult team had been asked to talk with the family of a patient who had been in the intensive care unit for weeks.  Mr. B* had severe vascular disease and a systemic infection that had caused his organs to shut down, and he was now being kept alive by a ventilator, vasopressors, dialysis, transfusions and artificial nutrition.  His legs had turned purple and cold the day before, so the surgeons had amputated both of them in an attempt to save his life.  Now the purple was beginning to creep up his abdomen, and the surgeons did not have any more procedures to offer.

We met the patient's surrogate decision maker, a young woman named Devon. She was working and in school through Mr. B's illness, and was exhausted and overwhelmed.  She told us that Mr. B owned a sailboat that he loved, and that he was independent and stubborn, still smoking up until he was admitted to the hospital, despite his atherosclerosis.  She told us that he was a fighter, and she hoped he was going to make a full recovery.  However, she realized his condition was very serious, and she said that if he were not going to ever get better, she did not want him to suffer. 

We listened.  And examined the patient.  And talked to the surgeons, who were also struggling-- they did not feel good about continuing aggressive measures since Mr. B's chance of recovery was getting slimmer by the day.  They worried he was suffering and that they were doing him harm, but they did not know how or when to stop, since every time they asked, Devon opted to keep doing "everything."

The surgeons brought us all together as a group to talk, the family and the medical teams.  We offered Devon our support, and acknowledged her hope that Mr. B would get better.  We gauged her understanding of his critical condition, and provided an update on the dearth of options.  We gently told her how sorry we were that Mr. B was dying.  We echoed her goal that he not suffer, and recommended that we shift our focus to measures to make him comfortable.  We did not provide a menu of options, but rather one course of action that reflected the patient and family's goals, the patient's condition, and a realistic assessment of what our medical interventions could achieve in his situation.

When the social worker told me I was "maternalistic" after the meeting, I initially chafed. I had been trained to scorn paternalism, the old school attitude in medicine that "doctor knows best," and that patients don't get a voice.  Over the past few decades, there has been a pendulum swing in American medicine toward patient autonomy, the idea that patients have a right to choose what happens to their bodies.  Ironically, the first instances of this were patients who did not want the resuscitation that their physicians were bent on providing, and wanted the right to die naturally or at least not be sustained on life support that prolonged death rather than extended life. Now, it seems the challenge is much more often that extraordinary measures are routine practice and patients have come to expect them, and physicians continue to offer "everything" until the patients, or their families on their behalf, decide when to stop. 

I thought that the social worker was gender-izing the concept of paternalism to be politically correct because I'm a woman, the way you would say "mailwoman" or "congressperson," and casting me in the paternalist lineage. But the more that I thought about it, the more I wondered whether maternalism might be something different and new, and in fact might be just what is needed sometimes-- a place for the pendulum to rest when all options are not equal, and physicians want to communicate a recommendation while also taking the values of the patient and family into account.

To be maternal is to listen, support, protect, guide.  Sometimes it can be just too hard for families to say "enough."  They fear feeling like they gave up, or brought about their loved one's death, even though it was the illness that robbed them.  A maternalistic doctor might relieve that burden, by recommending a specific course of action rather than providing options and staying on the sidelines, agnostic.  But a maternalistic doctor can only make recommendations because she has first listened, and gotten to know the goals and values of her patient, and then added to those to her medical knowledge and experience, much as Sulmasy recommends in his "substituted interests" model of surrogate decision making.  Of course, male physicians could be maternalistic too.  We rejected the paternalistic doctors of yore not because of their gender, but because they left patient input out of their decisions.

The transition to comfort-focused care went smoothly for Mr. B, and he died a few hours later, his loved ones holding his hands, and a nicotine patch on his arm.  When Devon hugged me and thanked us for caring for him until the end, I decided to take the maternalism comment as a compliment. 

* potentially identifying details have been altered to protect patient confidentiality
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Tuesday, October 7, 2014

Atul Gawande, just what the doctor ordered

by: Stephanie Rogers @SERogersMD

Atul Gawande is expanding the conversation about care at the end of life with his new book, Being Mortal. Will people take notice?



The introduction to his book came a few days ago in his opinion piece “The Best Possible Day,” in the New York Times. It fueled a series of emotions for me and I reread his 2010 New Yorker article “Letting Go: What should medicine do when it can’t save your life?

As a doctor who recently finished training in internal medicine, I had many stories like his from my time in the hospital. I saw patients and families who would go to great lengths to try to extend their life in spite of an exceedingly poor prognosis.

They continued to plea, “What else can we do?” and “What other therapies exist?“ Many aggressive treatment options were offered, despite the fact that it was unclear how much these interventions would extend their life, and many times they produced complications including pain, infections, and the inability to interact with their families.

It seemed to me that we were doing something wrong. Perhaps we were answering their questions incorrectly. Or maybe we, as physicians, weren’t asking the right ones.

I was particularly affected by what I saw in the intensive care units: numbers of frail, older adults who spent their final days on mechanical ventilation, with uncomfortable tubes and lines in their bodies. Their families kept asking for more options, more treatments, just anything that could give them a chance to live longer. We, as physicians, fumbled through discussing the more appropriate questions during these difficult times:
         • How did their loved one want to spend his final days?
         • What sorts of treatments were worth pain and suffering, and which interfered with things that                       were important to him?
         • If the patient knew he would die in one day, a week, a month or six months, how would he want to spend that time?


Now that I am in my specialty training in Geriatrics, the care for older adults, I know that the culture has to change. We have to become better at these conversations.

Not all decisions are weighted equally at the end of life. Some interventions offer no benefit and yet we use them, just to feel as if we are trying something. As a trainee, I am often nervous to not offer everything we have in our toolbox because I have learned from a scientifically-advanced medical culture that this is how we do things.

How does a cultural shift happen? Perhaps, it just takes one person who people respect to speak up- maybe a physician, who specializes in cancer surgery, who had his own struggles with the way his father died.

What if that person, who began speaking to us about this in The New Yorker years ago, was able to inspire a wider audience by being on The Daily Show with Jon Stewart, and writing one of this week’s most viewed articles on The New York Times website? Maybe, with Atul Gawande’s encouragement and his new book released today, we can begin to reframe our goals for dying and allow our patients to choose the way they live.

I’ve downloaded his book today on my kindle, and I welcome your comments as you read along beside me.
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