Judged by the Color of their Skin

I have an nonagenarian who is a racist. I don’t think you can use the words she uses to describe people of various ethnicities and not categorize her as such. She’s been my patient for about 3 years now and in this period of time I have been medically impotent in her care. Her severe heart failure goes untreated, she continues to drink, is likely depressed, and is losing weight, likely from the large mass recently found in her abdomen when she came to the hospital recently for a CHF exacerbation.

And yet, if any other provider asks her about my care, she will sing my praises. She tells everyone she can, that excepting one male physician she had many years ago, I am by far the best doctor she’s ever had. And I honestly can tell you that I’ve only managed to do two things for her: help her get the basal cell carcinoma that was slowly eating off her nose removed, and listen to her.

And listening to her isn’t easy. She has excuses for everything, why she can’t quit smoking, why she can’t keep his appointments, why she won’t take her meds, you name it. And you know what, I can tolerate that. I feel my job is to tell her she ought to stop smoking, drinking, etc, that she would likely feel better if we could get her to X, Y, or Z appointment, but it’s her job to actually do it. So I see her periodically and watch her wither away in front of my eyes.

Now I justify my actions to myself by saying this is part of a lifetime of behaviors, that she’s alienated her friends and family over the years, and that it would be foolhardy to think I might intervene in this trajectory. Yet on the other hand, I wonder, is this cognitive disability? Is this her lifelong alcohol abuse? Should I intervene against her will? Should I have intervened years ago? But that would no doubt threaten our rapport and I am uncertain that anyone could make her take her meds, or that it’s ethically acceptable to force her to do so.

But then she starts with the name calling, she talks about her grandchildren who are of mixed race and explains their failures in terms of their ancestry. She fires caregivers that I’ve worked hard to set up in her home because she thinks they can’t speak English and are “just a bunch of foreigners”, though she’s really deaf and sometimes has a hard time understanding ME. She’ll turn around on one hand and say, “You know I like you, Doc. I think we might be related.” And I respond, “I think we’re all brothers and sisters some way or another.” But I know the words don’t sink in. I try and reason with her, and when that fails, to set limits on her behavior. When she was in the hospital, she had some rather unpleasant words about some of the staff and I told her that she could think that but she needed to respect them and her behavior was unacceptable.

You know, part of me thinks that eventually this generation who lived during segregation will die, just like the generation of slave owners who lived on after the Civil War. I can only hope this will continue to diminish as an issue. But in the meantime I think, I am here to serve. I don’t chose my patients, they chose me. As long as she’s not hurting anyone (except maybe herself), I think: If I don’t care for the racists, who will? In our last days, don’t we all deserve someone to listen to us, even when we say or have done some pretty egregious things? I can only hope someone will listen to me someday, even if I refuse to take my meds, miss my appointments, and drink too much, and do me no harm.

NOTE: facts changed to protect the identity of the patient.

Read more »

Stocking Stuffers for Your Favorite Geriatrician

Don't know what to get your favorite geriatrician for the holidays? Out of ideas as you bought your geriatrician a snuggy last year and this year amazon.com is telling you that the healthcare reform package you ordered is unlikely to be delivered in time for Christmas? Well, good news! The BMJ Christmas edition is here and it is chock-full of articles that you and your Geriatrician will be sure to enjoy. Here are two samples:

• Perceived age as clinically useful biomarker of ageing. Your geriatrician is probably tired of looking up prognostic indexes to aid in complex decision making around age appropriate cancer screening. It turns out that there may be an easier way. A group from the University of Southern Denmark report that someone’s perceived age, or "how old you think someone looks", correlates with lifespan. The researchers photographed 1,826 Danish twins older than age 70. These photos were then shown to a panel of 20 geriatric nurses, 10 young male student teachers, and 11 older women, who evaluated the perceived age of each twin. Dannish Death records were subsequently used to track the survival of the twins over a seven year period. The results show that the member of each twin set who looked older was more likely to die first, even after adjusting for chronological age, sex, and other biomarkers of aging.

• Lying obliquely—a clinical sign of cognitive impairment.  Geriatricians will jump for joy once they are taught the “oblique sign”. A group of neurologists from Germany decided to determine if patients who fail to “spontaneously orient the body along the longitudinal axis of a hospital bed when asked to lie down” are more likely to have cognitive impairment. They tested 110 inpatients aged 60 or more by asking them to lie down from a sitting position on the side of the examination bed. The researchers then took a photograph of the patient in bed to determine the “obliqueness” of the patient. The results show that an “angular deviation” of at least 7° predicted cognitive impairment according to the three different cognitive tests. Their conclusion – “suspect cognitive impairment in mobile older inpatients with neurological disorders who spontaneously position themselves obliquely when asked to lie on a bed.”

Oh, but there is so much more.  Don't miss the articles on the use of "Nellie the Elephant" as a learning aid during CPR (and why its use should be discontinued), Ageism and the Economist, and how Santa Claus is a public health pariah. 

Read more »

My last few days with my grandmother

It was the a Monday morning in November when I got the first call from my uncle Gili - my last remaining grandmother, Savta Rina, was hospitalized. She had had diarrhea for a few weeks and got dehydrated and so was admitted to the hospital.

A few months before I took my family to Israel, mostly to visit Savta. She wanted to see my girls, her only great-grandchildren, before she died. She used this line a lot - “before I die” - having no compunction about addressing the inevitability directly or evoking guilt to hasten the desired visit. She always was a practical and smart woman; as a teenager she, along with her two sisters, survived the concentration camps, then immigrated to Israel and formed the backbone of their new family. Right before our last visit she had been hospitalized also, and seemed none the worse for wear, but this time Gili sounded a bit more worried. She had been eating much less and losing weight.

My grandmother was a poster child for smart decision making with very little education. In her 40’s she quit smoking and in her 50’s she lost weight and kept it off. A lifelong vasculopath and bad hypertensive, she walked her way out of bilateral claudication, survived a few silent MI’s and refused a bypass 10 years earlier, developing collaterals in her coronary circulation. A year ago she began to give her possessions away. Lately she had developed atrial fibrillation, nausea and decreased appetite. She had a bit of abdominal pain. She began having falls. She developed worsening renal failure. She refused a colonoscopy. She joined the Israeli equivalent of a “right to die” society.

On Tuesday Gili called from the hospital – Savta’s breathing was much worse and she needed oxygen to keep up her saturation. He asked if I wanted to speak to Savta. When I did she sounded bad – two to three words at a time and wheezy. I called my dad – who was on a Buddhist retreat in Arizona and left a message that he needs to go to Israel. I called my sister, who was planning a trip to Israel anyway and told her to think about moving the trip up. Then I spent the rest of the morning working in the hospital (I am a primary care doc in a county system). In the afternoon my sister called and said she had moved her trip up. It’s funny that I told everyone else to go but hadn’t yet decided if I would, but when my sister called I decided to go too. Before going to bed I got word that Savta said she would “wait for us.” Knowing this woman’s history of exerting her will on life I had no doubt that she would.

On Wed morning my wife Lori drove me to the airport and I got on a plane. It would be 22 hours or so later that I would land in Tel Aviv. Layover in Newark was short and my parents would be on the same second leg going to Israel.

When we got to Israel on Thursday afternoon I found my sister at the airport (she had landed the hour before). We got into the rental car and went straight to the hospital. Savta was there – in much better shape than I thought. Her breathing had gotten better. I later pieced together that when I had spoken to her 2 days before she had simply gotten fluid overloaded, and while I was in route had gotten fairly effective diuresis. She was tired but conversational and barely needed oxygen. She said she wanted to go home. I left thinking I had sounded a false alarm. I was exhausted from travel and went back to Savta’s apartment to sleep. Before leaving the hospital I found out that Israel does have a version of home hospice.

Twenty three years earlier, at 63, three years after being widowed, my grandmother entered a relationship with her downstairs neighbor, Ephraim, that was probably more satisfying than her marriage had ever been. Ephraim was an orthodox Jew, an intelligent, gentle man, still working as a Yeshiva principle into his 70’s. In the first, secret years of their relationship (my grandmother did not want to raise her widowed sisters’ jealousy) they would have coffee and chat in the evenings. Ephraim would drive Savta Rina to do her shopping. When he proposed marriage a few years later my grandmother declined (“why would I want to start keeping a kosher kitchen and cooking for a new man at my age”), but their friendship only strengthened. Now, two months out from his bypass surgery, Ephraim was staying at his daughter’s house but came to visit Savta Rina every day in the hospital. My sister and I would stay in his apartment for the next few days.

Having gotten good sleep, I woke up with delight on Friday morning. Knowing that Shabbat was coming, my sister and I went shopping to stock up. Family friends had filled the fridge with great home-cooked food but we were hankering for our favorite local comfort foods. I love shopping in my grandmother’s neighborhood – a lot like the outer Richmond district in San Francisco – you can walk to so many great places within a few blocks and enjoy the Russian delicatessens with amazing, fresh produce, diary products and good rye bread.

Shopping turned out to be our undoing. By the time we made it to the hospital at 11AM the doctor had already left. Friday, which used to be just a short work day when we left Israel 25 years prior had become a full weekend-type day in Israel. On-call physicians only. No one willing to discharge or have a family meeting. My sister and I had an agenda – get my grandmother home for hospice care. She had been so clear about her wishes – no intervention, die in peace. When we came in on Friday she told us that the worst decision she ever made was going into the hospital. Now we would be stuck there till the weekend was over on Sunday.

The hospital was pretty good actually. The nurses came on time to turn Savta – too weak to walk at this point and down to less than 80 pounds, she really was skin and bones. The staff was also not too pushy with meals or meds – which surprised me given my expectation of a “Jewish mother” type of institution. Best of all, they let one of us spend the night in the empty bed next to my grandmother, and didn’t seem to care about enforcing visiting hours. My grandmother had two roommates, both there for angina. They were both chatty and friendly, and didn’t mind me spending the night.

After a family dinner at my uncle’s house, where we clarified the fact that we all agreed that being back home is what Savta wants, I went back to the hospital Friday night to spend the night next to her. The Israeli family, without exception, knew no one who died at home and had no idea what to expect. They deferred to my sister and I almost entirely.

Until we could get a discharge, my reason for being in the hospital was to protect my grandmother from too much intervention that she didn’t want. My first task was to go and try to change her status to “no code”, which I was informed by the nursing staff was not possible without a courthouse-approved legal document. It was not a legally-protected option in Israel, and hospitals in general were very interventional. The nurses all understood what I was trying to do, and I was told the best thing to do would be to speak with the department head after the weekend and that my grandmother’s wishes would be “unofficially” honored. The theme was repeated on the next day when my grandmother asked to go outside for some fresh air – the on-call physician (an overwhelmed resident) refused us permission to take her off her monitor. Finally, when I pushed and asked who else I should talk to, he said to me “I will not give my permission, but what you do without telling me is none of my business.”

I tried to sleep next to my grandmother in the empty bed, but the hospital noise and lights, jet-lag and roommate snoring combined to allow me only a half-hour or so. My Savta had gotten a sleeper and slept soundly – her breathing at night so shallow that I worried she was about to die a few times. By morning she awoke and was alert, but too weak to speak more than 1-2 words at a time. In that state it was still interesting to see her shvitzing (bragging) instinct intact – when the weekend doctor came to round she pointed at me, smiled, and said simply said “doctor”. She consistently asked to leave the hospital. In the morning she asked for beer or coffee – I got her some coffee which she loved, drank 2 sips of, and barfed. She would consistently throw up anything substantial from there on out. When reinforcements came (with beer for Savta) in the morning I left to go back and sleep.

Saturday evening was more back and forth from the hospital. My youngest cousin Noa – who had cut short a U.S. trip would take the night shift. Savta would barf again and became less and less verbal.

By Sunday morning she would mostly point and blink, speaking when she had to only. She complained of back pain. We waited impatiently for the doctor. He came and did rounds, and when we spoke tried to impress us with medical jargon. He was middle-aged and had the look of a career government worker who was a little burnt out. The pinky finger on his right hand took a 90 degree lateral turn at the PIP joint. This fact reassured me more than anything else – a man who would tolerate imperfections in his own body clearly would be able to have some flexibility with regards to Savta’s wishes. This proved true - when I mentioned home hospice he said “no problem”. He had no trouble writing for a fentanyl patch and some ativan as needed for anxiety. He discharged her home within two hours of our request. The whole morning Savta kept pointing at her watch – now eerily sagging off of her wasted forearms all the way near her elbow – impatient to go home.

I rode home in an ambulance with her. In a quintessentially Israeli moment the ambulance driver pulled off to the side of the road where another car was waiting. He asked me to wait “just a few minutes” while he tried to get his GPS unit fixed. After 10 minutes I started to make a scene and we drove off. He was remarkable efficient getting my grandmother up the stairs. My grandmother would die in the same apartment she had lived in for the past 50 years.

The density of urban living in Israel creates an intimate sort of codependent dysfunction that I had been glad to escape as a teenager. Now I saw some benefit – within 2 blocks of my grandmother house was both her clinic (where the charge nurse knew her well and was happy to make house calls) and a place where we could borrow supplies for the house. Wheelchair, bed rails, a hospital bed, bedside commode – all were obtained within hours and essentially for free. Hospice per se was impossible (only available in Israel with a cancer diagnosis), but my sister, also a primary care physician, was able to set up a hospice equivalent. She had done a few palliative care rotations in med school and residency, and did a masterful job of anticipating, coordinating care, titrating meds and doing the day-to-day physical care. The biggest trouble was getting opiates out of her PCP – but a strong case of advocacy from the clinic charge nurse did the trick. My father, a computer scientist, was remarkably unsure of what to do or how to help.

I flew back just 5 days after I arrived. My grandmother – barely verbal when I left, looked disappointed when I told her I was flying back. Her last words to me before I left were to make sure I got some money out of her purse to help pay for the flight. As I checked in over the next few days, my sister reported Savta slowly went more and more inwards, eschewing speech or touch towards the end. She made a single effort to visit a little with the stream of well-wishers and family coming through the apartment, but then let that go too. One cousin wanted to call 911 as things advanced, but my family talked some sense into him. As I was going in to see a newborn in my primary care clinic, three days after my return, I checked my email and saw the message that she died.

Read more »

Primary Care Providers Are Challenged by Dementia Care

An excellent article in the Journal of the American Geriatrics Society provides insights into primary care physicians views of dementia care. Since the vast majority of patients with dementia are cared for by primary care providers, improving care makes it very important to understand the perspective of their providers. The paper is authored by Dr. Dorothy Harris of UCLA.

The authors surveyed 164 primary care providers (mostly family physicians and internists). The survey primarily compared the providers' views of caring for dementia, with that of caring for diabetes and heart disease. The key findings:

• Providers were much more likely to somewhat or strongly agree that dementia is difficult to manage (56%) than heart disease (22%) or diabetes (22%)
• Providers were much less likely to stronlgy agree that they could improve the quality of life for patients with dementia (31%) compared to heart disease (59%) or diabetes (62%)
• Providers were much less likely to strongly agree that their health care organization had the resources to manage dementia (21%) than for heart disease (52%) or diabetes (49%).

On the one hand, it is not surprising that clinicians lacked confidence that they could improve the quality of life for patients with dementia. For heart disease and diabetes, there are effective pharmacologic therapies that significantly alter the natural history of the disease and clearly improve outcomes and quality of life. For dementia, the ability to change the natural history of the disease is very limited, and existing pharmacologic treatments are of marginal benefit.

On the other hand, behavioral and psychosocial interventions are very effective at improving patient and caregiver quality of life and outcomes in dementia. (see Vickrey, Belle, and Callahan studies). However, these interventions take training to administer, and require team based approaches. They are not purely clinic based, but require collaboration with community-based service providers. Further, Medicare and other insurers do not pay for these approaches and support for services aimed at helping family caregivers is woefully inadequate. Bree Johnston and I previously noted that if these behavioral interventions were drugs, they would be on the fast track to approval.

The difficulty reported by clinicians likely reflects the reality that few health systems have the necessary systems in place to optimally care for patients with dementia. Improving care will require changes at the system level that enable primary care providers to coordinate optimal care. And as noted by Harris:

"The challange lies in instituting cultural changes in primary care practice and training---such as making the caregiver a focal point of care interventions--to elevate this type of care to the same status as practices for treating heart disease, diabetes mellitus, and other common conditions that rely more centrally on prescribing medications."

Read more »

How Will Pilot Programs Impact Geriatrics and Palliative Care?

In one of the most influential health policy journals of our time - the New Yorker - the surgeon Atul Gawande "calls out" our health care system for not supporting geriatrics:

[Our system] is neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

This is not an article about geriatrics - Dr. Gawande wrote that article already. This is an article comparing the pilot programs included in the proposed health care legislation aimed at reducing costs to the successful pilot programs that revolutionized agricultural in the early twentieth century. The pilot programs, as I read them, have two aims: improving quality, and reducing costs, maybe not in that order. My question: how will geriatrics and palliative care be impacted by these pilot programs?

Let's focus on bundled payments, of the most promising pieces of pilot legislation. In bundled payments, health systems receive a single payment for all services related to a procedure. Let's take hip fracture repair, for example, and talk about an older patient with Medicare insurance served in a hospital with both a geriatrics and palliative care consult service (rare I know, but it's an example). My understanding - and please comment if you think I'm mistaken - is that all providers and services related to the hip fracture repair would receive a lump sum payment for that service, including the surgeon, the anesthesiologist, the nursing staff, the hospital, and the rehabilitation care. The bundled payment would be the average payment for these services. High cost providers would have incentives to reduce costs, and low cost providers would make money. This pilot is in stark contrast to our current system - fee-for-service - whereby each provider would bill Medicare separately for their portion of care: the surgery, the hospital care, the rehabilitation.

So how might geriatrics and palliative care be impacted by bundled payments? Let's say the post-operative hip repair patient becomes delirious due to poorly controlled pain. As we know, delirium is associated with worse outcomes, including death. What incentives does the surgeon or hospital have for including geriatrics or palliative care? One might argue that paying for a geriatrics or palliative care consult would treat pain more effectively and reduce delirium and it's complications, thereby reducing costs. The system should then self-regulate, and those that consult geriatrics and palliative care appropriately would realize the benefits in terms of reduced overall costs. But the concern is that geriatrics or palliative care might simply be dropped completely in a myopic move to cut costs.

Furthermore, some of our "interventions" do not translate well into reduced costs by way of the bundled payments. For example, a family meeting that results in non-surgical management of hip fracture, obviating the need for surgery in the first place.

I do believe we need payment reform. Fee-for-service is nuts. But I also believe we should proactively consider the practical implications of the pilot legislation on our fields.

I'm interested in the thoughts of others. Am I being pessimistic? Does anyone have thoughts on how other pilot projects - such as accountable care organizations, patient centered medical homes, and reformed payment for home health and rehabilitation care - would impact geriatrics and palliative care? Finally, kudos to Dr. Gawande for supporting geriatrics!

Read more »

Should we screen for Abdominal Aortic Aneurysms?

Abdominal Aortic Aneurysms (AAA) pose one of the most interesting and difficult of dilemmas about disease screening. AAAs are dilitations of the aorta that are prone to rupture. AAA ruptures are catastrophic, and usually lethal (about 80% mortality). AAAs are pretty much a Geriatric disease, with almost all ruptures occurring after the age of 65. AAAs are much more common in men than women. (and most ruptures in women occur after the age of 80). There is a very strong association with smoking---those who ever or currently smoked are at least 3 times higher risk than never smokers.

Since repairing a AAA can prevent rupture, on the surface, this seems like a great disease for sceening. The problem is that surgical repair is a major operation, with substantial morbidity. About 5% of patients will not survive surgery. One way to think of this is as follows:

Among patients with AAAs, the patients who will benefit from surgery are those who will eventually have a rupture. However, all patients who will just live with the AAA, and eventually die of something else will be harmed by surgery, and sometimes this harm will be substantial. Obviously, there is no certain way to know in advance which group the patient sitting in front of you will end up in.

In 2002, a large RCT in the UK (Multicentre Aneurysm Screening Study--MASS) was published that supported screening 65-75 year old men for AAA. The investigators recently published the 10 year follow-up of MASS that further clarifies the role of AAA screening. This clever study randomized over 60,000 men 65-75 years old to two groups: One group received an invitation to receive a screening abdominal ultrasound (US). The other group got usual care. 80% of those invited attended the screening. If no AAA was detected, no further intervention was done. If a AAA between 3.0 to 4.4 cm was detected, the US was repeated yearly. If a AAA of 4.5-5.4 cm was detected (either initially, or on follow-up), the US was repeated every 3 months. If a AAA of 5.5 cm or greater was detected, the subject was referred for surgery. About 5% of subjects had a AAA detected on initial screening.

The primary outcome was a AAA related death, determined primarily with death certificates. A subject who died within 30 days of AAA surgery was also classified as having a AAA related death.

Over 10 years, about 1.6% of subjects in the screening group had elective surgery. The mortality rate from the AAA surgery was about 4%. Including these post-op deaths, approximately 0.5% of patients in the screening group died of AAA. In the control group, about 0.7% of subjects had elective surgery for AAA. About 0.9% of control subjects died of AAA. The cost analysis estimates that the screening program cost 7600 Pounds ($12,300) per year of life saved.

Another way to look at these results: For every 200 patients screened, one AAA death will be prevented, and two additional patients will have AAA surgery.

When we discussed this article at the UCSF Division of Geriatrics journal club this week, we debated whether this screening program should be routinely adopted in the US. Our group was split (5 in favor, 6 opposed). Those opposed noted that the improvement in AAA mortality might not necessarily translate into a benefit in terms of all cause mortality. They also felt that classifying 30 day post-surgical deaths as AAA deaths did not fully account for the downsides of the extra surgeries. Several noted that it is common for older patients to do poorly after major surgery, and some will have declines in functional status. These quality of life impacts may be substantial, and may causes long term decreases in survival.

Those in favor of screening, felt the survival benefit was substantial, and likely to outweigh the downsides of surgery. Because AAA rupture is so lethal, they felt it was unlikely this degree of AAA mortalty reduction would not translate to an all cause mortality reduction. It was also noted that a study powered to show an effect on all cause mortality would be impossibly large, and that demanding such evidence before we act sets the evidence bar unreasonably high.

Of note, in part based on the earlier results from MASS, the US Preventive Disease Task Force does recommend a one time screening ultrasound in men age 65-75 years who are current or past smokers. This is similar to the MASS protocol, except that the roughly 30% of men who never smoked would not be screened. The guideline and evidence report can be found on the Annals of Internal Medicine website.

Read more »

The need for Geriatrics

There is an excellent op-ed in the Boston Globe from Dr. Lewis Lipsitz that in clear yet eloquent language makes the case for training of more Geriatricians, and the survival of Geriatrics as a specialty. Dr. Lipsitz is a Professor at Harvard Medical School and chief of Gerontology at Beth Israel Deaconess Medical Center.

One of the nice things that were articulated in this op-ed is that one of the most of the important roles of the Geriatrician is to listen. While many older patients have a whole bunch of specialists, it is the role of the Geriatrician to put everything together, listening to the patient and caregiver at great length. There was one rather stunning statistic in the op-ed. In 2007 only 91 new Geriatricians were trainied in the US. As the need for Geriatrics is increasing, the number seeking training is falling.

Dr. Lipsitz notes a major problem recruiting Geriatricians is the poor compensation compared to other medical specialties. The key skills taught in Geriatrics are not lucrative procedural skills---and spending more time with patients is certainly not profitable.

An odd benefit of all these negative financial incentives for becoming a Geriatrician is that it ends up making it a lot of fun to play a role in training. This may seem like an odd statement, but our fellows are truly amazing, and I think one of the reasons is this anti-incentive. Our fellows certainly do not choose Geriatrics for the money--in fact, most of them have survived a gauntlet of attendings who have questioned their choice, noting that they are "good enough" to get a cardiology or GI fellowship. Our fellows join us because they are passionate about providing great care for the elderly, teaching others to provide this care, and doing research that will lead to care improvements. Working true believers who really believe in what they are doing is a lot of fun. However, training only a small number of true believers is not good for our health system, or our nation's elderly. It is really important the disincentives Dr. Lipsitz discusses be addressed.

Dr. Chris Langston, program director at the John A. Hartford Foundation, has an excellent discussion of this article on the health AGEnda blog. He calls on all of us to step up to the plate and make the case to the public for better care for older patients, and the workforce issues that are needed to make this happen.

Read more »

Nelson Mandela and Imagery of Aging

There is a wonderful article in the New York Times, written by Celia Dugger, that discusses the aging of Nelson Mandela. I found something really appealing about this article. It discusses the frailties Mr. Mandela is facing, frailties that are common in 91 year olds. Yet rather than portraying the disabilities of aging in a negative light, the article seems to convey a certain reverence for aging---The while hair, frail body, trouble walking, hearing impairment, and short term memory problems only add to Mandela's iconic status.



I found the public reverence for the aging Mandela, grounded in his epic struggle and courage, to be analogous to the more personal reverence we and our patients' families feel for parents and grandparents as they age---reverence that is not diminished, but enhanced, when they develop these frailties.



I wonder if Geriatricians need to do more as a discipline to convey this reverence. Much of the science of Geriatrics is focused on preventing and delaying these fraities, and this is as it should be. But I sometimes wonder if we talk too much about so-called, "successful aging," holding up as the ideal the 91 year tennis player doing their daily jog. No doubt this is a wonderful thing, as rare as it is. But perhaps the better ideal for our discipline is the 91 year old with trouble walking, lots of medical problems, and in need of caregiver assistance, yet revered by their family and living a great quality of life.

Read more »

Potpourri from clinical work

I've been attending on our hospital's palliative care service. Several things have been on my mind, and although I don't have time to flesh them out in a full post, I would appreciate the thoughts of the GeriPal community on these issues.

1. An elderly man with mild cognitive impairment made several racist remarks in an initial meeting last week. How should I have responded? Confronting him about the inappropriate and offensive nature of these statements may have jeopardized our new relationship, compromising my ability to help him in the long term. Not saying anything may have tacitly transmitted the message that racist statements are OK. These issues were compounded by: 1) the patient's advanced age and likelihood that these were long held attitudes; 2) mild cognitive impairment; and 3) the patient's short life expectancy and the need to work on other pressing issues.


2. In discussing "code status" with patients I advised the fellow and intern I was working with last week not to use the phrase "if you are dead." In my experience patients who we may code are rarely dead, more likely they would die if we did not otherwise intervene. Later in the week, however, I found myself uttering these same words in a family meeting. What do you think about the use of this term...is the distinction between "dying" and "dead" important to these discussions? Is it just important to clinicians, or to patients and family members? (see similar controversy over the term "allow natural death" in the comments to this post).


3. Palliative - from the latin palliare "to cloak." Is that what we're doing, cloaking? Covering...what? Symptoms maybe. But as Patrice Villars said yesterday, "I think we're trying to look under the cloak."


4. A patient fired me again last week. I've written about being fired previously. No one has ever empirically studied being fired in the practice of geriatrics or palliative care. This leaves those of us who have been fired to wonder...are we alone??? There is an uncomfortable silence around this issue.

Read more »

On teaching EKG's and family meetings

On my last day of ward attending, I handed out an EKG that resembled the Dow Jones industrial average over the last 10 years (not pictured). The normal pattern of an EKG was completely disrupted: ST segments were markedly elevated, P waves were hidden, and beats were grouped in odd patterns. My medical team laughed and shook their heads. I asked why. A brave intern responded that he was completely at a loss. Over the previous two weeks, our teaching rounds began with an EKG every day. We had developed a structured approach to reading EKG’s, albeit with simpler tracings. Someone finally said, “OK, let’s start with the first step – what is the rate: normal, fast, or slow?” Immediately, the focus shifted, from fear and doubt to problem solving. Patterns emerged. Small details contributed to a cohesive understanding. And the students and house officers realized that they could do this. By breaking a seemingly insoluble problem into smaller, more manageable steps, these trainees succeeded in interpreting an EKG that would have challenged a cardiology fellow.

We moved on to discuss a challenging conflict that occurred during a recent family meeting. The patient was in her 80’s, had advanced dementia, and had experienced a precipitous decline in her health status since suffering a compression fracture one month prior to admission. She no longer walked due to back pain. She had developed bedsores. She was admitted to our service with urosepsis, her third admission in the last month. In the family meeting, the patient’s husband agreed to the suggestion that she not be resuscitated in the event of a cardiac arrest. The patient’s son and daughter, however, strongly opposed a “Do-Not-Resuscitate Order,” saying, “We want everything done for our mother.” I asked the intern, who ran the family meeting, how he felt when this conflict came up. He said that while he wanted to support the husband, he didn’t know what to say to the adult children. He felt he had lost control, as family members had begun talking over each other and the medical team, and tensions were rising. I passed out an article published in the Annals of Internal Medicine by Quill et al., “Discussing Treatment Preferences With Patients Who Want ‘Everything.’” This terrific article describes a structured approach to addressing these issues with patients and families, beginning with an examination of the underlying reasons and emotions behind the request, an exploration of the benefits and burdens of treatment options and their alternatives, and culminating with a recommendation for care that encompasses what is known about the patient’s values and preferences. We role-played the family meeting, with the other house officers playing the part of family members. The intern used the suggested structure and his own words. He still struggled, and we had to rewind a few times to play parts over, but ultimately he learned, and felt more prepared to run a “real world” family meeting.

Before rounds were over, we compared the two experiences: the EKG and the family meeting. In each case, my trainees had felt at a loss, inadequate to the task, not knowing where to begin. In each case, a structured approach had helped them work through the problem. In the case of the EKG, however, a structured approach was more familiar to the trainees, whereas a structured approach to communication challenges was novel. The contrast to them was striking. It was the juxtaposition that brought the message home to my trainees: fundamentally, communication is a skill that can be learned, in the same structured way that performing a lumbar puncture, or interpreting an ABG, or reading an EKG can be learned.

Read more »

End Stage Dementia: A Terminal Disease Needing Palliative Care

There is an important article in the current issue of the New England Journal of Medicine authored by Dr. Susan Mitchell, a Geriatrician at Harvard Medical School and Hebrew Senior Life. The article has important implications for how we approach and treat advanced dementia in the nursing home and hopefully will spur providers to provide care that reduces and avoids suffering and improves the quality of life of their patients.

The context and importance of the Mitchell study is wonderfully illustrated in the accompanying editorial from Dr. Greg Sachs of Indiana University. Dr. Sach's tells the poignant story of his Grandmother's decline from dementia, who he notes "had little in the way of comfort or company towards the end." He notes, "now some 30 years after my grandmother's death, end-of-life care for dementia does not look all that different from the treatment she received."

Dr. Mitchell followed 323 patients with severe dementia in various Boston nursing homes. Generally, these patients could not recognize family members, were highly dependent, and had an average MMSE score of 6. These findings apply to very advanced dementia, which is very common in nursing homes. The key points of the study are as follows:

---Advanced dementia is a terminal diagnosis. 55% of patients died over 18 months
---Pneumonia, febrile episodes, and eating disorders often precede death. For example, 6 month mortality after pneumonia in these patients approached 50%.
---The symptom burden was high, especially as the end of life approached. For example, 46% had dyspnea, and 39% had pain in the last 18 months. (These were almost certainly underestimates as they are based on provider reports).
---Potentially burdensome treatments (hospitalization, ER visits, IV therapy, or tube feeding) in the last 3 months were very common--41% had at least one of these
----When family members understood that the prognosis was poor and understood the types of complications that could occur, the use of burdensome treatments decreased dramatically.
---Hospice was underutilized. Only 30% of those who died were referred, and about a quarter of these a week or less before death.

Hopefully, recognizing that end stage dementia is a terminal condition will result in improved care---care focused on the quality of life of patients and the needs of their families. Mitchell's findings suggest that communication with families is often poor---It is likely that many families would choose to avoid burdensome hospitalizations and "treatments" such as tube feeding if they understood the burdens and marginal potential for benefit. Even when such therapies are continued, palliative care should generally be offered simultaneously. The difficulty estimating prognosis has often prevented hospice referral in patients with dementia. This study helps by showing that pneumonia seems to signal an average 6 month survival in advanced dementia.

Unfortunately, some aspects of Medicare hospice policy in practice can have the effect of obstructing good care for patients with advanced dementia. This includes (1) the difficulty obtaining hospice when the family wants both palliative care and traditional disease focused care and (2) the limitation of hospice to patients with a six month prognosis---Mitchell's findings clearly show patients need palliative care long before the final six months. The availability of hospice does not relieve nursing homes of the responsibility for providing effective palliative care.

Read more »

Some Other Disease: A call to action.

This blog is a warning. “Some other disease” or SOD will soon become the leading killer of elderly patients in the United States. SOD arose insidiously and seems to be killing patients who would otherwise not have died.

I have heard about this growing pandemic of SOD in many settings. An oncologist recently warned of this crisis, “we are getting so good at slowing the growth of tumors with targeted therapies that patients will end up dying of some other disease.” Likewise, a heart failure physician recently cautioned, “we are getting so good with these new generation left ventricular assist devices that patients end up dying of some other disease.” Infectious disease specialists have been concerned about SOD for years: “we have turned HIV into a chronic disease where patients generally die of some other disease.” Even geriatricians are talking about it, “if we could get a drug to slow the progression of Alzheimer’s disease then elderly patients would end up dying of some other disease.”

What is this SOD?

In the near future, the single organ doctors (another type of SOD) will be so successful at single organ conditions that there may not even be 10 leading causes of death, but simply one - SOD. We need to reallocate a large portion of the nation’s research agenda to discover the cause and cure of SOD.

When patients choose to have many of these innovative medical therapies, do they realize that they are staring down the barrel of a death by SOD? Perhaps one day we will live in a world where we can say “we have gotten so good at treating SOD that people don’t actually die.” Only then will our health care agenda will be fully realized.

Read more »

Palliative Care Grand Rounds

Welcome to Palliative Care Grand Rounds! This monthly blog carnival highlights some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. As this month's host of Palliative Care Grand Rounds, we will give our own "GeriPal spin," incorporating posts that feature the intersection between geriatrics and palliative care. Topics are sorted by heading. Thanks to our readers for suggesting posts. Have fun reading!

Death Panels and Health Care Reform
The saddest part of September came when the Advance Care Planning Consultation proposal (section 1233 from the house bill) was dropped due to concerns about "Death Panels." This was despite hard work from many members of our community including:

• The AARP, which had a great article on the politics of advance care planning and how section 1233 was falsely portrayed by fear-mongering. A quote from the article says it all - "Medicare pays doctors for procedures and treatments, but a physician who spends an hour explaining the ins and outs of medical directives cannot currently bill for that time and effort."
• Gail Austin Cooney, President of the American Academy of Hospice and Palliative Medicine, who blogged at the Huffington Post about her experience being newly diagnosed with ovarian cancer with a copy of "5 Wishes" on her lap never having filled an advance directive before this crisis. The goal of the article was to reframe the death panel debate and highlight the importance of encouraging physicians and patients to discuss end-of-life preferences when they are "healthy, clear headed and not in the midst of a medical crisis."
• Christine Cassel, President of the American Board of Internal Medicine, Diane Meier, Director of Center to Advance Palliative Care, Mount Sinai School of Medicine, and Jerald Winakur, Center for Medical Humanities and Ethics at University of Texas, who were interviewed by the journal Health Affairs. Dr. Cassel summed up the debate on section 1233, stating that keeping the advance care planning provision was not worth risking the overall success of health reform. Such is life…
• Evan Falchuk at SeeFirstBlog, who has a nice post about the reasons 73% of Americans think death panels might be real. The reasons: 1) It’s almost impossible to prove something doesn’t exist; 2) No one is reading the legislative proposals; and 3) Not talking about difficult trade-offs, while still making them. Further comments at DB’s Medical Rants.
• Terminally ill patients and palliative medicine physicians interviewed for the online magazine FLYP. FLYP (pronounced "flip") is the absolute pinnacle of online multimedia - video, text, sound, click everywhere. Slick! Thanks to Pallimed and one of their readers (utzgrrl) for bringing this to our attention.
  
• Will Ferrell (OK, Will Ferrell is not officially a member of our community, but we would like to welcome him as an honorary member. And this wasn't as much a defense of the advance care planning legislation as of the public option.). Thanks to the Health Culture for bringing this hilarious video to our attention. In the video, Will Ferrell and other superstars defend the rights of health care executives. Here's a snippet:
  

  Insurance company CEO's have a right to their American dream: five houses, a private plane, $500 million in your pocket. And a mini-zoo in your backyard for exotic animals, like a white tiger and pygmy horses.

• Finally, Tim Cousounis at Palliative Care Success blogs about Accountable Palliative Care Organizations. We need his sort of innovative thinking about how palliative care fits into - and can be a model for - health care finance reform.
  

Futility

• Medical Futility Blog by Thaddeus Pope: one of the best websites covering medical futility issues highlights an important case working itself through the court system - Betancourt v. Trinitas. This is a case of an elderly man in persistent vegetative state dependent upon dialysis, a ventilator, and a feeding tube. His family sued a hospital that was attempting to unilaterally withdraw extensive life support. If you are interested in ethics or end-of-life care, Pope's blog and his amicus curiae brief is a must see.
• The Hospice Physician's Blog posted a communication between the blog's author and an oncologist from the blog cancerdoc. The post focuses around the question, "Why don't they stop chemo?" It does a nice job of bringing home the challenges seen in end-of-life care from the viewpoints of two different medical disciplines. Well worth the read.

The Power of Pain & Distress

• Dana Jennings from The Well had a great essay on the power of severe pain. Favorite quote: "I’ve found that the deepest pain holds no meaning. It is not purifying. It is not enobling. It does not make you a better human being. It just is." (For different perspectives on the relationship between physical suffering and meaning, read Eric Widera's posts/comments on GeriPal and KevinMD about this Lancet article, co-authored by GeriPal's Alex Smith and Patrice Villars.)
  
• Also from The Well, Theresa Brown wrote about the moral distress health care providers feel when our interventions result in increased patient suffering.
  

Forgiveness & Healing

• Risa's Pieces recently had a post on "Kol Nidre," a prayer recited on the Jewish holiday Yom Kippur, asking for forgiveness for unfulfilled promises. This post came at the perfect time as one of us (Eric) recently promised a patient he would come back to visit him, but unfortunately the patient died before he fulfilled his promise. Risa acknowledges that her "list of small promises not kept is quite lengthy. In my work-life, people often die before I can do what I hope to do, offer to do, vow to do to make their life a little sweeter." Further on Risa helps us cope with the line "I will go to shul tomorrow to hear Kol Nidre chanted as it has been done for centuries, bringing past into present, absolving me for being human, imperfect, less than my promises suggest."
• Confessions of a Young (Looking) Social Worker has a touching story of forgiveness that emphasizes the importance of caregivers.
• Jim deMaine from the End of Life Blog wrote about the death of his mother and the role that an "Ethical Will" played in leaving a positive legacy after her death.
  
• Death Club for Cuties (love the name!) recounted a story with a very simple message – "that sometimes it's so important to sit next to somebody in order to actually be with them." Well said, Jerry.

Care of Complex Older Adults

• Chris Langston blogging for The Hartford Foundation wrote about the Guided Care Project, a nurse-driven primary care intervention with the objective of providing "whole person care" for older adults with chronic conditions and complex health needs. Physicians Langston interviewed were unable or unwilling to acknowledge that the guided care nurse improved care. Sounds like the project needs to be reframed around teamwork. What did Bal Mount say - something like, "You say you've worked on a multidisciplinary team? Show me your scars." The lesson here is that teamwork can be hard, ego-bruising work, but the end result is unquestionably improved care for patients.
  
• Great quote from this post at ChangingAging about what it's like to live with dementia:

  After living with dementia for six years Dr. Richard Taylor (2007) shared his experience: “Sometimes, when I am alone with my thoughts, I wander aimlessly around the corridors of my mind. I open various doors to see if they are still full of the memories I stored there years ago. To my pleasant surprise, most of them seem to contain all that I remember putting in the room. However, as I move from the past toward the present, I find more and more empty rooms. Not only are they empty, they are dark. They offer no clue, other than the label on the door, as to what they once contained.”

Closing Thoughts: The Art of Medicine and Nursing

• Pallimed has a tasty review of posts from the blogosphere about all things health, focused on the art of medicine and nursing.

There was so much great material this month! Apologies to those bloggers we missed - post a comment below mentioning your site. Please check the archive website to see who will host next month edition. Thanks to Pallimed for including us and organizing Palliative Care Grand Rounds!

-Alex Smith and Eric Widera

Read more »

GeriPal Taste Test Part I: Liquid Bowel Medications

GeriPal has put together a taste test on "Liquid Bowel Medications" (see attached video) which was inspired from a great selection of comments from our previous posts on medications that should never be prescribed to hospice patients. We have a fine selection of medications including sorbitol, lactulose, and liquid (and crushed!) docusate.
The conclusions are pretty clear. First, one should never give liquid docusate (colace) by mouth. Second, one should never, never, never ever crush docusate and mix it with applesauce.
This really begs the question whether colace should be prescribed in the hospice setting or in frail elderly patients, as both groups are at risk for losing their ability to swallow large pills. There is also very little evidence that docusate works. In a 2008 nonrandomized cohort study done in hospitalized patients with cancer, a senna only protocol was more effective than a senna+colace protocol. Even though this study was small, with only 30 patients in each group, it should make us question the continued use of this medication.
*to view a higher quality video on youtube click here.

Read more »

Mary Tinetti Wins MacArthur "Genius" Grant!

Great news for Geriatrics! For the second consecutive year, a geriatrician has been awarded a MacArthur "genius" grant. Last year, Dr. Diane Meier of Mount Sinai Medical Center and the Center to Advance Palliative Care won for her pioneering work in developing palliative care programs in US hospitals. This year, Dr. Mary Tinetti of Yale won for her work in understanding and preventing falls in the elderly. Congratulations! This is well deserved attention to the stars of our field; great press for geriatrics and palliative care; and for the winners $500,000 isn't bad either...

Read more »

Bedrest as a danger of hospitalization

There is an important study in the current issue of the Journal of the American Geriatrics Society. This study addresses a rather fundamental question: How do older people spend their time when they are hospitalized? The answer is rather disturbing. They spend the vast majority of time bedbound. The study was led by Cynthia Brown from the Division of Geriatrics at the University of Alabama, Birmingham.

It is well known that hospitalization is a very vulnerable period for older persons. Many elders who are hospitalized for seemingly routine illnesses leave the hospital with a major new disabilty that threatens their ability to live independently. This happens even though the medical problem that resulted in hospitalization is resolved. Most studies suggest that about 1/3 of medical hospitalizations in persons over the age of 70 will result in a major new disability---this risk is over 50% in patients over age 85. Many Geriatricians believe that the type of care provided in the hospital contributes to the development of disability. A chief concern is bedrest. Older people seem to weaken quickly when confined to bed, and a number of studies show rapid loss of muscle mass in elders confined to bed.

Dr. Brown's elegant study asked how older persons spend their time when hospitalized for a medical illness. She attached wireless accelerometers to 45 older patients shortly after their admission. This allowed her to determine how often patients were lying down, sitting, and standing or walking. The subject selection for this study was notable because Dr. Brown only included subjects who should have been mobile. All subjects were walking prior to hospitalization. Even at the time of admission, 78% of subjects were able and willing to walk without assistance. None of the subjects had severe cognitive impairment or delirium.

So, how did subjects spend their time? On an average day elders spent:

• 83% of their time in bed (20 hours!)
• 13% sitting (3.1 hours)
• 4% standing or walking ( 55 minutes)

Again, recall that this study targeted the older patients who were most able to be out of bed.

This study raises fundamental issues about the quality and processes of care for older patients hospitalized with medical illnesses. It seems quite probable that this degree of immobility contributes to the very high rates of disability we see following medical hospitalization in older persons. While this study was done at one hospital, I strongly suspect this pattern is typical of most US hospitals. I believe the results would be similar at my hospital.

As clinicians, we need to think about what we can do to prevent immobility in our older patients. No patient who is capable of sitting should be lying in bed all day. At a minimum, we need to get our patients out of bed and into a chair. We need to think about the restraining effect of devices such as IV poles and urinary catheters, which we know are kept in too long. It is time to make mobilization a key quality of care indicator for hospitals. Accrediting organizations like JCAHO can play a positive role in this. Wouldn't it be great if JCAHO inspectors walked around medical wards and asked why patients were lying in bed?

We also need to be sure that other policies, such as penalizing hospitals for inpatient falls, does not have the unintended consequence of reducing mobility. We also need to accelerate efforts such as Acute Care for Elders Units to redesign the processes of hospital care in older persons.

Read more »

Sometimes You're Paranoid, but Sometimes They Really Are Out To Get You

With the endless news cycle surrounding health care reform lately, it’s easy to have missed some other breaking and troubling news. In the past two weeks, we have Pfizer paying $2.3 Billion in reparations for faulty marketing; we have a smoking gun with CME being used as blatant drug advertising by Forest labs (the makers of “Lexapro”, the wonder drug)- you can actually read the words themselves in a lovely pdf, I love Part IV. Promotional Objectives:

Maintain SRI category leadership in total number of medical education events
(including CME symposia, speaker programs, teleconferences, and peer selling
programs)

and now we have the invisible hand that pulls all the triggers: Ghost writing in Medical Journals . Unfortunately this last piece of research has not been peer-reviewed or published yet, but prior work by the same authors has shown worrisome rates of ghost authorship previously.

When I think about the drugs I use for my patients, the journals and lectures I rely on for my ongoing education, I am becoming more and more troubled. If the drug companies fund the studies, write the papers, market the drugs, provide my education surrounding them, and fund the guidelines I use to guide my decisions, how can I avoid giving my patients drugs that do them harm?

This is why we have government, when markets fail to self-regulate, when they are too opaque for any one human to suss out the truth, this is where the government should step in. And yet, even here we see failure. I remember learning about the Clinical Trials registry in an ethics class, as a way that drug companies could be kept honest. They register their studies, their outcomes, their plan, and we can see if they keep their word. And it sounds like a great idea. At least this way, someone would know who’s doing what research out there, but what do we find? Drug companies don’t use it. Why should they? A new study last week in JAMA revealed that drug companies don’t register their studies half the time; that even when they do, they report only selective outcomes, not necessarily the ones they indicated in the database. We all know the equation: sponsorship + research = positive outcome, but why can’t the Journals, the physicians, the public, someone, anyone, do something about it?

I like clinical research, I find it rewarding to have a clinical question and find an answer for it, with the hope that it may help some other physician or patient out there. With the comparative dearth of clinical research in older adults and palliative care being such a new relatively new field, I worry that the drug company influence in our lives may be even greater because there is less alternate competition. I don’t want to hurt my patients and when someone wants to hammer down my patient’s HgbA1c below 7, I cringe. Isn’t chasing the HgbA1C just another drug company ploy for my 80 year old patient? But how can anyone keep a clear head when we’re flooded with information that these are good things to do, that I'm a bad doc if I don't. I honestly have no solutions to this problem, only a nagging concern that fills me with worry and dread and keeps me up at night. Maybe I need some Lexapro?

-Chrissy Kistler

*This blog-post was sponsored and ghost-written and edited for content and posted by Geripal.

Read more »

Rational vs rationing medicine

This morning on NPR's Morning Edition, Atul Gawande was interviewed to explain the difference between Rationing Care and Rational Care. He gave a nice, clear, straightforward explanation that Health Reform will never be about rationing. Rather, providers and patients need to make educated, joint decisions (the art of medicine) regarding rational care. He proceeded to explain that Health Reform is necessary. That continuing 'as is' will lead us to an essential meltdown with Medicare going bankrupt very shortly. He also spoke of our country's need for more Geriatricians and Gerontologic Nurses--that regardless of the 4-5 year expected time to transition our current uninsured patients into the new health system, that our elderly population (most of whom will have Medicare) is expected to double and we don't have the existing capacity in workforce to accomodate everyone.
What I always find remarkable about Gawande's writing and interviews is his ability to translate issues into easily-understood language. He helps to clear the air of the voluminous mis-applied, mis-defined, mis-used language that is out in the public and press.

Read more »

Interview with Seth Landefeld about Geriatrics and Palliative Medicine Leadership Summit

The John Hartford Foundation supported the inaugural summit of leaders from geriatrics and palliative medicine in July to encourage opportunities, challenges, and next steps for the field. I interviewed Seth Landefeld, chief of Geriatrics at UCSF and San Francisco VAMC, about his experience. Seth Landefeld, Sean Morrison, and Bob Arnold previewed and approved of this post.

On the impetus for the meeting: "The genesis for the meeting occurred 2-3 years ago when we realized that geriatrics and palliative medicine were competing for the same pool of internal medicine residents for fellowship training and that our training should be collaborative, not competitive. In subsequent discussions, we realized that the common ground between the two fields is so much greater than the issue of collaboration in fellowship training. I and several other board members of the American Geriatric Society, including Wayne McCormick, Greg Sachs, and Linda Fried, took this issue to the John Hartford Foundation, which has supported the academic development of both geriatrics and palliative medicine. We asked Chris Langston and Gavin Hougham at the Foundation whether they could help us build the geriatrics-palliative medicine common ground on a national level."

On the structure of the meeting: "Christine Ritchie chaired the planning committee, which included Jean Kutner, Greg Sachs, Bob Arnold, Wayne McCormick, and me. The meeting included the President-elect and key staffers of each organization (Sharon Brangman and Nancy Lundebjerg for American Geriatrics Society and Sean Morrison, Dale Lupu, and Sally Weir for American Association of Hospice and Palliative Medicine), the current President of AAHPM (Gail Cooney), leaders of the Hartford Foundation (Cory Rieder, Chris Langston, and Gavin Hougham) as well as leaders in both fields. We were divided into working groups around education, research, clinical models, leadership, and public policy."

On what was accomplished: "We asked, what is important, and what are the low hanging fruit? Where are the opportunities for collaboration? We created a statement that will be taken to each organization for feedback and support, with the idea of issuing a joint statement in the future. Something along the lines of: both AGS and AAHPM are committed to developing systems that will provide care for patients with advanced illness and their families. We saw opportunities for collaboration in joint fellowships between the two fields. One area of obvious overlap is the care of patients in nursing homes. As we try to conceptualize palliative care as more than just care at the very end of life, one can think of nearly all patients living in nursing homes as being persons who need good palliative care as well as good geriatrics, and yet almost no palliative care programs currently exist in nursing homes. "

On challenges: "One of the challenges will be getting more non-geriatrician palliative care providers interested in and actively committed to working on these issues. It was good that we had people like Janet Abrahm (oncologist and palliative medicine physician), Gail Cooney (neurologist and current AAHPM President) and a few other non-geriatricians from the palliative care field present. We need to reach out to other organizations, such as the American Medical Directors Association (AMDA). We need to make sure we have institutional memory about the work we've accomplished. The turnover of board members of these professional organizations is rapid, whereas the staff of the organizations stays relatively constant. It was important that high level staff members from each organization played leading roles at the meeting."

I'll leave it open to others to comment, only to say I think this idea of a collaborative approach is terrific, and this sort of energy and direction was exactly what led us to create GeriPal in the first place. What do you think about finding common ground between geriatrics and palliative care? What are the tensions and opportunities? What do you consider important, and what are the low hanging fruit?

Read more »

Trying to Integrate Advance Care Planning Into Clinic

As a geriatrician who primarily sees patients in clinic, I find myself often wondering how best to apply what I’ve learned on the inpatient Palliative Care service to my outpatient setting. Addressing advance care planning sounds so sensible, yet somehow it often ends up being much more challenging than expected.

The other day in my outpatient geriatrics clinic, I addressed advance care planning with two different patients. One ended up being easy, the other…not so easy. In both cases I had already brought up advance care planning during the previous visit. (Although the policy wonks seem to think that just one paid visit every 5 years can do the trick.)

The easy situation was completing a POLST (Physician Orders for Life-Sustaining Care) for Mr. T, a 94-year old man with moderate dementia. As usual, Mr. T came to his visit accompanied by his son John*, who is his DPOA and used to be the primary daily caregiver as well (Mr. T eventually was placed in a board & care). Although in previous visits both the patient and his son had confirmed Mr. T’s preference to be DNR and allowed to die when his time comes, now that we were signing a POLST, I asked Mr. T again what he would want people to do if he were found down without a heartbeat.

“I’d want ‘em to get the shovel!” he said, cackling. His son chuckled as well. “Oh, Dad,” he said as he patted his father’s shoulder fondly. Together, we completed the POLST, indicating that Mr. T should be allowed a natural death, yet wants to be transferred to the hospital for treatable illnesses. Easy, but it all did take 25 minutes.

The next patient was Mr. N, accompanied as always by his partner & DPOA, Tom. Mr. N, who has Parkinson’s, is only 80, but over the past year has developed some definite cognitive impairment; his physical condition remains otherwise good. His partner, who has struggled with the caregiving, had recently left me a voicemail saying he was looking into hospice but hadn’t yet brought this up with his spouse.

As I was saying, not so easy. I tried to start off by eliciting Mr. N’s understanding of his condition and trajectory. It was hard to hear him well, since he speaks slowly and haltingly. He told me that he has Parkinson’s but thought things were going pretty well, and thought that the new medicine will make him better.

Hmm. I had hoped he’d have more insight and memory. We had discussed Mr. N’s declining cognitive abilities and diminishing function in several previous visits. And no new medicine had recently been started. What to do? How does one engage in advance care planning when: a) patient, proxy, and doctor have different visions of reality; b) you think perhaps the patient doesn’t have capacity but you’re not 100% sure; c) it takes a long time for patient to speak clearly; d) you’re now running 10 minutes late for the next appointment; and e) you have no slots available in clinic next week (this is hardly the kind of thing that can be addressed during an overbook)?

The truth is that in clinic somehow I muddle through these situations, as best I can. I believe in advance care planning, in understanding goals, and in helping people figure out what is the right care for them, given their values and medical condition. But often, it seems so much harder than doing inpatient palliative care consults.

*Names and certain details have been changed to protect identities.

Read more »