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Showing posts from August, 2009

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

A Rant on Terminology

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America. (See Chrissy Kistler’s tribute to Senator Kennedy .) How many times have we all heard that someone is “a fighter”, “a survivor”? The rest of us must be wusses. How often do we hear of use terminology that is (inadvertently) offensive to an individual or others? If we see advance illness as a ‘battle’, then there IS necessarily a loser. The implication is that we have full control over our disease process and even our survival if we just have the right attitude. This is a dangerous concept and one we shouldn’t perpetuate. T

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

The Cause of My Life: Ted Kennedy’s Healthcare Legacy

This morning, as I was riding to work on the bus, I was flanked by two older gentlemen with daily newspapers. We started to chat about current events and I mentioned that Ted Kennedy had passed away during the night. One of the older gentlemen says, “Yes, well, I hope at least this can help this whole health care mess.” As we three continued to talk, they discussed how happy they were with care at the VA, how they didn’t understand how Americans as a society could turn their backs on each other, how a few bad eggs were derailing the conversation, turning it into an anarchic free-for-all. Watching the media, I too have been troubled by the darkening tone towards any fundamental change in healthcare. I have been worried that we may have a whole lot of reform and not a lot of change. Perhaps, however, my bus companion is right; maybe we now have a rallying point. I sometimes find myself mired in doubt. Don’t Americans want fairness, equity, a just society? I sometimes wonder if I am jus

Educating the masses about Geriatrics and Palliative Care (aka Marketing)

Geriatrics and Palliative Care (and primary care) have a problem. We haven't learned how to make our work, our mission, "sexy." During yesterday's White House Health Reform open conference call with physicians (reportedly 2700 physicians connected to the call) , an astute participant asked why the White House health reform committee doesn't hold public education campaigns about end-of-life care to debunk the highly skewed Death Panel myth. The Health Reform representative moderating the call said that was a fabulous idea and that she'd bring it to the attention of the White House, but also encouraged physicians to do their own education and outreach campaigns locally. As has been noted on GeriPal in other posts and comments, we in geriatrics and palliative care are not the most savvy marketers. The fact that the forces behind the Death Panel--the money, marketing, personalities--can so easily create such a phenomenal stir on th

Despair not Progressives

With "Death Panels" dominating the healthcare reform debate, I was getting depressed. My hope had continued to rest with the House, that as long as the House remained committed to a strong public option, substantive reform this year may be possible. This article by Mike Lux on the Huffington Post lays out what needs to happen in more detail: 1) Hold the progressives in the House to only vote for a public option. So far, so good. They've signed multiple letters, taken multiple pledges, sent a very clear message about their determination. They need to stay strong. 2) Get the Democrats in the Senate to accept that this will have to be a Democrats-only bill. This seems to be moving in the right direction. Schumer sent exactly the right message over the weekend, and it's clear things are beginning to head that way. 3) Split the bill into two parts in the Senate, with the public option and the financing going through the reconciliation process. Democats are sending signa

A Health Care Glossary for Politically Charged Times

Now that we are in an Orwellian world in which words reflect corporate and politically motivated interests rather than reality, I thought that a glossary might helps many of us navigate the shark ridden waters of health reform. HOW TO USE THIS TOOL Whenever one of the target words or phrases is used, simply reply by citing the information included under “reality based term”. HEALTH CARE GLOSSARY Politically Motivated Term Death Panel : This term is used politically to scare us into thinking that if the “Obama” plan passes, Gestapo like panels of physicians will pull the plug on any patient (especially if they are old or disabled) with a poor prognosis. Reality Based Term Death Panel : Death panels exist now, but not in Medicare and not at the VA. The only “Death Panels” that exist in the current health care system are in private health insurance plans, where a reviewer might deny a life saving service if it is deemed to be too expensive. The so called “death panels” that are pro

Elder Self-Neglect: A Palliative Care Emergency?

There is a very important article in the Aug 5 JAMA by XinQi Dong of Rush University examing the relationship between elder self-neglect and abuse and mortality . There is an excellent editorial by Tom Gill from Yale University. The article examines the risk for mortality in older persons following a report of self-neglect to social service agencies. Self-neglect can be difficult to define. Dr. Dong's description is useful: "Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medications, and safety precautions." The key finding: A report of self-neglect was associated with a huge increase in mortality. During the year after a self-neglect report is filed, the risk of mortality is increased six fold. While the article does not provide specific death rates at 6 months and 1 year, it is clear from the data in the article that it must be quite high a

Adverse drug reactions in elders: looking for flubs in all the wrong places

A great deal of energy – and money - has been spent on preventing adverse drug reactions in elders. Many of these efforts have had limited success. Taking the next step to limit the harmful impacts of adverse drug reactions (ADRs) requires a fresh approach, and should focus on monitoring adverse effects of drugs after they are prescribed rather than preventing problem drugs from being prescribed in the first place. At first blush, this approach seems counter-intuitive – isn’t it better to prevent a problem rather than trying to catch it once it has already happened? Of course, the answer is yes, but primary prevention of ADRs is often difficult if not impossible. In large part, this is because most ADRs are not due to “bad” drugs, but are unfortunate complications of drugs that have a legitimate place in the therapeutic armamentarium. This was demonstrated in an important national study that evaluated causes of adverse drug reactions in elders that led to emergency room visits. Less

Learning something new

The aspect of geriatrics and palliative care which never ceases to amaze me is how much I learn from my patients and their families. In many ways I have 24/7 access to an endless 'university' of life lessons. I recently came upon a life lesson that, simple as it seems in words, opened a profoundly new perspective on the life-death journey for me. In so many palliative care teachings on communicating with patients and preparing them and their families for death, I have learned to ask patients what tasks/goals they feel they need to complete/accomplish before they die. The responses have run the breadth of possibilities: reconnecting with an estranged child, handling finances, seeing a wedding/graduation/birth, finishing a painting, finding a home for a beloved pet. I've come to always ask my patients this important question. Many of my patients have found comfort in the completion of these goals and tell me prior to their death that they have accomplished everything import


Colace is a problem at our hospital too . Both because there is not data that it works and because once people are on it, they believe their constipation problem is solved. Another problem is hydromorphine caused by a cognitive fallacy I have entitled the belief in small numbers. The view is "how dangerous can 1-2 mg of anything be...especially compared to 7-15 mg of anything else!" (I would love a psychological reference for this.) This is a big big problem - people start dilaudid rather than morphine, they go from morphine to dilaudid cause the former did not work, etc. Education works but slowly... What drug issues do others have?

Inappropriate Medications in the Hospice Setting

Supportive Care in Cancer recently published an article on the use of “futile” medications in patients with advanced and incurable cancer . It was a retrospective chart review of patients attending a palliative care clinic at the Princess Margaret Hospital in Toronto between November 2005 and July 2006. Futile medications were defined as either unnecessary (no benefit in terms of survival, quality of life, or symptom control for this particular population) or duplicate (drugs from the same pharmacological class). Long story made short is that about one fifth of these terminally ill patients were taking at least one futile medication, with 90% of these being medically unnecessary. Highest on the list: statins and multivitamins. Now, one can argue that there is a good level of subjectivity to the term “futility” used in this article, as it was the studies’ authors and, as luck may have it, the palliative medicine consultant who decided when a medication was futile (any medication that t