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Showing posts from October, 2009

Are Drug Labels Missing Information That Patients and Clinicians Need?

In a perspective in this week’s New England Journal of Medicine, Drs. Lisa Schwartz and Steven Woloshin , faculty at Dartmouth University , persuasively argue that the answer to question posed in the title is YES. Schwartz and Woloshin note that when the FDA reviews a drug, expert reviewers consider a wealth of data about the benefits and side effects of the drug. They also raise questions, make judgments, and make statements about their degree of certainty that the benefits of the drug outweigh the risks. However, effectiveness and harm data that patients and their providers might want to see often do not make it to the drug label. Opinions of the expert reviewer, including their degree of uncertainty about the drug, would be of great interest but these virtually never make it to the label. This information is contained in FDA documents, but these voluminous documents are not practically accessible. This article is a quick and fascinating read that has 3 fascinating examples t

How should we counsel frail nursing home residents about dialysis?

Last weeks New England Journal of Medicine was a treasure trove of geriatrics and palliative care. In addition to the article on outcomes of advanced dementia discussed previously , a second paper examined functional outcomes of nursing home patients who initiated dialysis . This paper, by Manjula Kurella Tamura ( pictured ), and co-authored by GeriPal's Ken Covinsky , linked dialysis registry data to activities of daily living measures reported by nursing homes in 3,702 patients . There were several important findings: 1 year after initiating dialysis, 58% of these nursing home residents had died, 29% of subjects had a decline in functional status, and only 13% of residents had functional status that was maintained at the pre-dialysis level. Functional decline was greatest in the three months prior to and one month after initiation of dialysis. As noted in the excellent accompanying editorial (first author GeriPal's Bob Arnold ), these death rates resemble those of an adva

The Price of Hospice Rate Cuts

It goes without saying one can’t put a price on the last months, weeks and days of a life shared with a loved one. But in addition to improving the quality of the lives of millions of terminally ill individuals and their families each year, hospice care has also been proven to save the government money. Sounds like a win-win situation, right? Well, not judging by Congress’ proposed rate cuts. The high-quality, compassionate end-of-life care Americans depend upon is threatened by not one but two devastating rate cuts. Already bracing for a 3 percent regulatory rate cut starting this month (the Budget Neutrality Adjustment Factor or BNAF), hospice, along with most other Medicare providers, is also facing additional cuts through a “productivity adjustment” to help finance health care reform. These new reductions would slash rates by a damaging 11.8 percent throughout the next 10 years to fund new health care initiatives written into the bill. Combined, the impact of these two cuts wo

Can We Agree To Disagree

JAMA published an essay this week about a conversation I had with my grandparents entitled "Can We Agree to Disagree". This conversation changed the way that I practice medicine and changed the way that I discuss goals of care with my patients and their surrogates. In the essay, I describe a gut wrenching, although thought provoking, end-of-life conversation that I had with my grandfather and his surrogate decision maker— my grandmother. The essay describes how my grandfather was more concerned about my grandmother’s well being, feelings, perceived burden, and her preferences (to have my grandfather receive full aggressive measures) than he was about having his own treatment preferences honored (comfort care). What was even more eye-opening, however, is that neither of my grandparents knew that they disagreed with each other about these treatment preferences. Had we not discussed my grandmother’s needs and desires, and specifically addressed the fact that my grandparents

How Is it Going?

Hello GeriPal Community! I have certainly enjoyed reading many of the posts and comments since the launch of GeriPal 4 months ago. While I think that the website is adding value to my life and my practice in Geriatrics, we (Eric Widera, Alex Smith, and I) would love to know what all of you think of our site! We are hoping to take a step back to see if we are meeting your needs and whether there are any areas for improvement. For those of you who have not yet filled out the surgey we sent through email (or if you dont get emails from us), we are asking for 3 minutes of your time to fill out a very brief survey. Here is a link to the survey: Your continued support in building GeriPal is greatly appreciated. Thanks!

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 B

Death Panel Redux: Palliative Care Strikes Back

The hysteria around “death panels” has largely died down (no pun intended). This largely coincided with the removal of the provision to reimburse doctors for discussing end of life planning from the health care reform bill. So it was a shock to see PBS use the title “Life Panel? Death Panel?” in its most recent PBS Now series (for a quick review of the episode check out pallimed's review ). I can’t recite the exact adjective-laden prose I yelled at the TV but it went something like this: “For heaven’s sake, let the death panel rumor die a natural news cycle death.  It was on its way out - why are we keeping it alive? Pull the plug on it already!!!” Since watching the episode I have been wondering why the only time I hear the term "death panel" nowadays is in the context of blogs, advocacy groups, and news sites promoting end-of-life decision making. It turns out that the term death panel has become somewhat of a rallying call in the field of hospice and palliative care

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 d

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 - &quo

An Attempt to Balance the Signal-Noise Ratio Surrounding Palliative Care

While it has taken years to popularize the word "palliative" (I have to confess that the word still does not roll nicely off my accented tongue), it is remarkable how the recent negative press related to the issues addressed in the Newsweek article on rethinking end of life care have managed to gain significant traction swiftly. I worry that all this sensationalism will distract from real and important discourse on sensitive topics like exploring the underlying suffering beneath patients' requests for hastening death. On a related note, Dr. Susan Block from Harvard Medical School has authored a very timely video module entitled : P atient Requests to Manage Life's Final Chapter: Assessment and Palliation. The module is hosted on a Stanford curricular LMS , please note that you have to register and sign up to get access to it (takes 2 business days) . On a positive note, the module is free full text and has a interactive video case study intertwined into the module, p

What if palliative care doesn't save money?

15 years ago, Drs. Zeke and Linda Emanuel wrote an article in the New England Journal of Medicine titled, " The Economics of Dying - The Illusion of Cost Savings at the End of Life ." They present the potential cost savings if all persons who died in a particular year executed an advance directive, chose hospice, and refused in-hospital treatment at the end of life. Savings? 3% of health care spending, max. Max. Their conclusion: The unlikeliness of substantial savings in health care costs does not mean, however, that there are no good reasons to use advance directives, fund hospice care, and employ less aggressive life-sustaining treatments for dying patients. Respecting patients' wishes, reducing pain and suffering, and providing compassionate and dignified care at the end of life have overwhelming merit. But the hope of cutting the amount of money spent on life-sustaining interventions for the dying in order to reduce overall health care costs is probably vai