GeriPal - Geriatrics and Palliative Care Blog

Thank you so much for writing "from the field" and...

2010-07-29T15:28:26.019-07:00

Thank you so much for writing "from the field" and giving us a glimpse into what you are seeing and all that you can do with little- such a different vantage point; please share more with us and the residents when you return. You should submit this to 'piece of my mind'.

As usual, excellent reading from Dr Gawande. One ...

2010-07-29T15:18:35.964-07:00

As usual, excellent reading from Dr Gawande. One thing that struck me was how young patients were. The firefighter was 42. The primary character Sara was in her 30's. Ms Cox was the only one who was older at 72. Clearly not a representative sample of the dying folks in America.

I'm not sure what to think about this. It could be random, it could be Dr Gawande's practice. It could be that stories of dying young people are much more...poignant? compelling? But it seems important to note for this community.

OMG! the hospice staff was about to call 911 for m...

2010-07-29T14:02:02.467-07:00

OMG! the hospice staff was about to call 911 for me, I was laughing so hard! Yep, will send this on to cooworkers and my sister, who HATES any type of "therapy voice"

FYI this link is from NPR's Fresh Air: Dr Gawande....

2010-07-29T13:52:14.529-07:00

FYI this link is from NPR's Fresh Air: Dr Gawande.
http://www.npr.org/templates/story/story.php?storyId=128828629

Thanks Helen and Wendy. I would like to see more ...

2010-07-29T09:40:33.060-07:00

Thanks Helen and Wendy. I would like to see more about the role of the primary care physician. Would be great if the New Yorker picked a primary care doc next (Jerome Grupman is a neurologist, and Atul Gawande is a surgeon).

For those of you interested in hearing more from Atul Gawande on this subject, he will be interviewed by Terri Gross today (Thursday). For those in the Bay area listening to KQED, it will air at 1pm and 7pm.

Well said Brad, a fine example of how health, and ...

2010-07-29T09:38:25.410-07:00

Well said Brad, a fine example of how health, and particularly aging, suffering, and dying, are primarily processes that take place outside of biomedical medicine, in the psychosocialspiritual sphere. Being "present with suffering," and "comfortable with the notion that some things just can't be fixed." Very spiritual ideals. What is left unclear is how we get from here to there. Almost as though we need a phrophet for our times.

For those of you interested in hearing more from Atul Gawande on this subject, he will be interviewed by Terri Gross today (Thursday). For those in the Bay area listening to KQED, it will air at 1pm and 7pm.

Alex, this is just hilarious. I would love to see...

2010-07-28T21:32:29.309-07:00

Alex, this is just hilarious.

I would love to see a series of exaggerated communication techniques.

Alex, this is just hilarious. I would love to see...

2010-07-28T21:32:22.506-07:00

Alex, this is just hilarious.

I would love to see a series of exaggerated communication techniques.

Alex, this is just hilarious. I would love to see...

2010-07-28T21:32:22.204-07:00

Alex, this is just hilarious.

I would love to see a series of exaggerated communication techniques.

As a physician/survivor, I encourage everyone not ...

2010-07-28T08:41:14.088-07:00

As a physician/survivor, I encourage everyone not to let the length of Gawande's article dissuade them from reading it.

Dr. Gawande offers us useful insights on the highly complex and emotionally charged topic of end-of-life.

In one article, he brings together important truths, such as the notion that "doing everything" can - and often does - impair patients' quality of life in dramatic ways. And although it may nourish hope of lengthening life, in reality it often shortens life.

Gawande also helps us see why and how clinicians often encourage patients and their families to keep "fighting" death in ways that are not liken to help and are surely going to interfere with quality end-of-life care.

Here are links to short articles on (1) negotiating the difficult transition to hospice care and on (2) balancing hope and acceptance at the end-of-life. I hope your readers find them useful:

http://tinyurl.com/OT-071006

http://tinyurl.com/OT-122506

With hope, Wendy

Thank you for this beautifully written and thought...

2010-07-27T18:46:40.096-07:00

Thank you for this beautifully written and thought provoking post. I had the opportunity to live in Puebla for 6 weeks and observe home care. I won't share stories here, but I was constantly struck and pleased that the first thing anyone, particularly kids, asked me was "What is your name and how old are you?" It was such a natural acceptance and interest in aging, completely opposite of the US culture of fear and shame around aging and dying. We have much to learn from people who live with less detachment from our natural mortal life cycle.

Thank you for the post, Alex. Gawande’s article is...

2010-07-27T16:30:26.016-07:00

Thank you for the post, Alex. Gawande’s article is truly remarkable and richly expands the discussion re: dying in America.(We have a hard time with 'death' but we sure know a lot of euphemisms for it: http://community.nytimes.com/comments/schott.blogs.nytimes.com/2010/07/09/weekend-competition-kicking-the-bucket/?sort=oldest&offset=2&scp=2&sq=euphemisms%20for%20death&st=cse).

Isn’t it ironic that what people seem to want is what we often find difficult to give: the time, attention, and ability to have meaningful conversations about what really matters to them during critical stages of their lives? And it isn’t just the geripal community that needs to read this, learn this, and do this difficult and sometimes heartbreaking work-- I was so encouraged to read that one of the heroes of the piece was the primary care physician. First of all, he was willing to be there. (How many of us ‘primaries’ let the service attendings or the hospitalists handle these challenging conversations?) But most of all, he had the concern, the ability, and the courage to help the family face the fact that no amount of tertiary care was going to stop the cancer. Isn’t that the kind of physician we want in our room, irrespective of “specialty”, when our own time comes?

Wow! What an amazing story. I have not thought ...

2010-07-27T16:23:26.906-07:00

Wow! What an amazing story.

I have not thought much about the value and relevance of Geriatrics in developing regions. Your statistic that half of the over 65 population lives in developing countries is really striking---and it is great to see how relevant your Geriatrics training was to improving care in Chiapis.

It is also enlightening to hear your stories about how some patients did not have access to kinds of invasive care they might get in the US, and how they were probably all the better for it.

It does point out that for all the access we have in the US to high technology care, we really have yet to learn how to use it wisely, saving such care for patients who will benefit, and avoiding it when it will do more harm than good.

I am glad you are asking an important question and...

2010-07-27T14:01:58.373-07:00

I am glad you are asking an important question and I have some very good advice. I have read the nine previous comments, and as a former patient, I had tried them all and can say that with the exception of the lidocaine cocktail and narcotics, none of them did much help.

I found the following OTC lifesavers and have written up an article detailing them at http://azam.org/archives/chemo.html. Please read and share.

In brief, I found great relief from:

*Gelclair (oral mucositis)
*Slippery Elm Bark Lozenges (oral mucositis)
*Carafate (gastritis)
*Aloe Vera Juice (colitis)
*Belladonna (colitis)

Haha! In your defense, you have never been as bad...

2010-07-26T10:20:04.023-07:00

Haha! In your defense, you have never been as bad as the bear in the video.

It often helps to hope for the best but plan for t...

2010-07-25T13:22:38.936-07:00

It often helps to hope for the best but plan for the worst. I too hope that the trash will be taken out, but let's think about what happens if this doesn't happen. What would you want done in this case?

Sometimes just meeting someone's request is the be...

2010-07-25T12:15:21.233-07:00

Sometimes just meeting someone's request is the best "technique." Have you taken out the trash yet Alex?

Alex, These are AWESOME! I am LOL so hard I am c...

2010-07-25T12:11:51.583-07:00

Alex,
These are AWESOME! I am LOL so hard I am crying. Can't wait to share these with my geriatrics and PC colleagues! Thanks so much for sharing!

Very funny Alex. The best communication technique...

2010-07-25T09:42:24.428-07:00

Very funny Alex. The best communication techniques will not rescue anyone when they are simply a jerk!

This post wins for THE FUNNIEST post ever!! I wond...

2010-07-25T09:31:29.375-07:00

This post wins for THE FUNNIEST post ever!! I wonder if families feel as frustrated with us sometimes as the wife in the video who just wants him to shut up and take out the trash! Hilarious. Thanks, Alex.

Thank you thank you thank you for these Alex. You...

2010-07-25T06:38:09.836-07:00

Thank you thank you thank you for these Alex. You forgot to mention 'therapeutic silence' in yours as well.
I will say that there have been many techniques that I have picked up/been taught in palliative care which are helpful at home; but they're most team dynamics ones. The most useful by far has been informing my wife: I am going to tell you this because I need to vent or think out loud not because I am asking you to fix this for me. This helps to prevent 'why don't you do this...why don't you do this...' responses to my venting. Heck, this is a bedside technique that I was taught: meet emotion with emotion.

What's most hilarious about the ortho-anesthesia one is the computer-language mispronunciation of asystole. Initially I thought it was a deliberate joke to have the orthopedic surgeon pronounce it that way. Works really well.

This is an excellent discussion of a complicated i...

2010-07-24T08:15:36.838-07:00

This is an excellent discussion of a complicated issue.

As a palliative care NP when working with patients in similar states, I find that when the patients are still receiving chemo or radiation, they often have not been told (or heard) that this is palliative and not curative. These treatments are also not covered by the Medicare hospice benefit, which means that the patient and family are not receiving the support and care that hospice can provide. In many instances, I have seen the patient decline while undergoing these treatments and this can lead to a last minute hospice referral which can frustrate our hospice colleagues and really strains the patient and family as they both with developing trust with yet another new health-care team (hospice) and they struggle with end- stage symptom management. Until open access hospice is available, I think these issues will continue.

The cost of these treatments in the setting of our rapidly rising healthcare costs in America was not been mentioned. Who gets these treatments and who doesn't often depends on their insurance coverage and this is sure to evolve when more are required to be covered- is this a sustainable use of resources? No one knows but the implications are immense.

At a more basic level, we must remember that the more treatments and appointments that we schedule, these cost our patients and their families to spend hours, days and weeks in our facilities instead of spending their precious time doing the very important things that they might prefer in their limited remaining time.

Certainly, involvement of palliative care early would help to facilitate conversations (at diagnosis, in a perfect world).

Just my thoughts...

Thanks for a really interesting post. It is forci...

2010-07-23T17:52:17.095-07:00

Thanks for a really interesting post. It is forcing me to rethink some of my perceptions about this issue.

During this and past medicine attending months, we have had a number of patients who were described as receiving "palliative chemotherapy." My usual initial reaction is a doubletake, as if the very term is an oxymoron. I have sometimes felt like asking, "so exactly what is that we are palliating?"

Dr. Killeen eloquently describes a number of situations where chemotherapy and radiation can truly be palliative, and help the patient symptomatically, and improve their quality of life.

But I also wonder if the term "palliative chemotherapy" is sometimes used too generically, to denote a situation in which we are giving chemotherapy we know to be non curative, but without a specific symptomatic targets in mind, hoping the chemotherapy will help the patient in some way.

It seems that a decision to give palliative chemotherapy should be accompanied by a clear statement of exactly what symptoms we are palliating. That way, we could have a way of assessing whether the chemotherapy meets the goals of palliation. Along these lines, if the chemotherapy is truly palliative, it seems there should be some explicit approach in which we decide if the palliative benefits of chemo are outweighing the side effects, with better criteria for continuing or stopping therapy.

I wonder how much palliative chemotherapy is based on actual evidence. Since the use of palliative chemotherapy seems to quite common, it would be nice to have more clinical trials that recognize this potential use and have end points focused on palliative goals.

Thank you for a great post! I've been "preaching" ...

2010-07-23T16:19:18.846-07:00

Thank you for a great post! I've been "preaching" this for years...
But I'd also like to add that there are a number of patients on drugs to prolong their lives a bit longer that should still be considered Palliative Care Patients.

I'm thinking of drugs like Avastin that aren't necessarily curing diseases like Lung Cancer, but are giving these patients more time--with quality!

I agree, too often these conversations are not done well. Too many cancer patients think that they are being cured when that is not the goal (short of that rare miracle--and they do happen--but they are few & far between.

That's why palliative care trained professionals are important members of the team--to have those "difficult conversations"...

Enjoyed reading this post - very informative as we...

2010-07-23T12:30:23.975-07:00

Enjoyed reading this post - very informative as well as thought provoking. I agree palliative treatments may involve expensive and high tech treatments usually associated with life-prolonging treatment, such as radiation or chemotherapy. The concern I have is that some treatments that are labled "palliative" are sometimes not explained as such to patients - in my experience many patients receiving palliative chemotherapy believe the purpose of the chemo is to prolong their lives, not control disease or reduce symptom burden. This communication breakdown is sometimes due to patient factors (e.g don't want to hear it) and sometimes due to cliniican factors (lack of informed disclosure). This distinction between chemo or radiation with the intent to cure vs. intent to palliate is important, because in my clinical experience, some patients decide against further chemotherapy when they understand that the chemo is targeted at reduction of tumor and symptom burden, not life-extension.