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Showing posts from September, 2009

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 pa

Looking for Posts We Love - Palliative Care Grand Rounds Coming Soon

Don't forget that GeriPal is hosting Palliative Care Grand Rounds on Wednesday, October 7th! The goal of Palliative Care Grand Rounds is to put a spotlight on outstanding blog posts from any website with a focus on hospice, palliative care, death, or dying. So, let us know in the comment section of this post (or the previous post on this subject) if you come across a website with a good article. If you are a blogger, pick one of your favorite posts on your own blog and leave the link in the comment section (shameless self-promotion is ok – part of the goal is to spread the word about the great palliative care community out there on the web).

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...

Notes From the Field

I am in the emergency room with my 93 year old father-in-law. His colostomy bag has filled up with blood overnight, and the people who own the board and care home where he lives have called the ambulance because they are terrified that he might die. This will be his third admission this month; the first time, he had a DVT and was put on Coumadin. The second time, he had a fistula, and there was a lot of discussion about whether they should operate and how to manage it. He has atrial fibrillation, a bad knee, arthritis, and moderate/severe dementia. Each doctor he's encountered has treated a part of him, and has treated that part well. During his second hospitalization, I spoke with the hospitalist and said that we would like to focus on symptom management and comfort. I was told that the hospital had a palliative care service. I asked for a referral. Oh, the hospitalist said, it's too late; your father-in-law is being discharged. I wish I'd know you wanted that and we wo

Newsweek article on rethinking end of life care

The current issue of Newsweek includes an article titled "The Case for Killing Granny: Rethinking End of Life Care." It also seems to be titled "We Need to Talk About Death". Although the headline seems a bit sensationalist (it certainly caught my eye, as I was trolling through a database of popular media articles on aging), the piece itself is thoughtful and a decent read. Unsurprisingly, it has also generated a lot of reader comments. It will be interesting to see how this national conversation on end-of-life care evolves.

“Moribund Obesity”: Palliative care diagnosis or poorly chosen label?

I’ve always had a fascination with how certain phrases influence practice and how established terms frame and reinforce provider attitudes toward the individuals they care for. I recently began exploring the experience of nursing home life among obese residents, and in a literature search came across Deepak Gupta’s letter the editor “Moribund Obesity as a Palliative Care Diagnosis.” Now, add to my list of questionable palliative care related diagnoses (presently including: psychogenic mortality, failure to thrive, organic brain disease, et al.) the newly coined “moribund obesity.” At the risk of oversimplifying, a morbidly obese individual achieves moribund status when usual interventions to reduce or control obesity fail as a result of some insurmountable barrier or collection of barriers—physical, psychological, social or spiritual. Most distressing in the article, suggested spiritual barriers include “inadequate self-control and the spiritual pain that comes from feeling worthless

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 hosp

Overuse of Pain Medications in Hospice and Palliative Medicine

This week’s Lancet includes an article titled “The Death of Ivan Ilyich and pain relief at the end of life” authored by Guy Micco and GeriPal’s very own Alex Smith and Patrice Villars (it can be viewed for free if you register). This is a thought provoking article focused on the question of whether there is overuse of pharmaceuticals to treat various forms of suffering in hospice and palliative medicine. It also serves as a nice follow-up to Patrice’s post on the geriatric care of the hospice patient . The authors argue that a good death, as seen through their interpretation of The Death of Ivan Ilyich , may include physical and existential suffering. Tolstoy’s character finds redemption in his suffering; he remains conscious through the agony of a prolonged and painful death and ends up with a greater understanding of life. The authors further argue that such a moment of clarity may no longer occur if we rely on practices that promote complete freedom from suffering through the ov

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

The Rise of Social Media in Medical Education: Part 1 in a series

In the course of a typical year I generally take about 10-15 structured online mandatory training courses. I also have the opportunity to review many other types of online venues for medical education. Unfortunately, the vast majority of these experiences leave me disappointed and frustrated. These “virtual” classrooms seem to throw every word of a text book or syllabus into a PowerPoint presentation and then reformat it into a web browser accessible format. By slide number 10 I am usually drifting off into my imagination, wondering how best to make an application that presses the forward button for me so that I can take a quick nap. The problem with the use of technology in education is not the technology itself, but rather the inappropriate use of it in relation to the educational objectives of a course. For example, if I am going to give a ground rounds talk, I may want to use PowerPoint slides. PowerPoint presentations can effectively convey and reinforce information if slides ar

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 transl

Palliative Care Grand Rounds Coming to GeriPal

Leigh Kramer from the blog “ Confessions of a Young (Looking) Social Worker ” will be hosting Palliative Care Grand Rounds this Wednesday, September the 2nd. For those of you who don’t know, Palliative Care Grand Rounds is a great series that puts a spotlight on outstanding blog posts focused on hospice, palliative care, death, or dying. Stop by her site starting this Wednesday to see what great blog finds she has been able to dig up. Also of note, GeriPal is hosting Palliative Care Grand Rounds on Wednesday, October 7th! GeriPal hit close to 400 readers on Friday alone, so I have no doubt that the GeriPal community can uncover some great posts hiding out there in the blogosphere. If you see, hear, or smell anything over the next month that you think is worth passing on, please comment on this post with a link to the article.