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Showing posts from November, 2009

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 a…

How should costs fit into the conversation about end-of-life care?

Diane Meier just tweeted: "60 minutes misses the point- palliative care is about matching treatment to patient goals, NOT stopping it."

The central question raised by the 60 minute episode and subsequent discussion: how should costs fit into the conversation about end-of-life care? Various positions:

1. We should focus on reducing costs at the end of life. Costs of care at the end of life are outrageously high. We should limit spending on "unnecessary" expenditures that do little to prolong life. As a side effect, we will reduce suffering.

2. We should focus on reducing suffering. Many of the life-prolonging interventions at the end of life (e.g. mechanical ventilation, ICU stays, ED visits) cause suffering. As a side effect of reducing suffering, we will reduce costs.

3. We should focus on informed choices: matching patients care to their goals and values. Many patients do not realize alternatives exist to high intensity life-prolonging care, such as care focused on m…

Does Morphine Stimulate Cancer Growth?

Over the last week Reuters, ABC news, MSNBC, BBC News, and more than 75 other outlets reported on how two "two new studies add to growing evidence that morphine and other opiate-based painkillers may promote the growth and spread of cancer cells." What was most shocking were the headlines used to promote the stories:
Morphine 'might spread cancer' (BBC News)Morphine May Help Tumors Spread in Cancer Patients (US News and World Reports)Pain drug morphine may accelerate cancer growth (Reuters, ABC News)Common Pain Relief Medication May Encourage Cancer Growth (Science Daily)All these articles (most stemming from an initial Reuters report) discussed the recent presentation by a group from the University of Chicago on the mu-opioid antagonist methylnaltrexone (otherwise known as Relistor or “that new opioid induced constipation medication”). This work, as presented at a meeting in Boston, revealed that use methylnaltrexone prevented tumor-cell proliferation and migration i…

Dying in 14 Minutes of 60 Minutes

CBS did a segment entitled "The Cost Of Dying" on tonight's 60 Minutes.

Considering the title of the segment and the short amount of time alloted to it, CBS's coverage was accurate and thought provoking.

I'd have done some things differently.....for example:

Point made: Patients most often don't pay their medical bills out-of-pocket. In fact, they hardly look at their bill. My addendum: CBS should have provided actual price tags for costly EOL-in- ICU procedures, like CRRT, TPN, and mechanical ventilation, as well as data to show the percentage of time these procedures are in place but do not prolong life.

Point made: Most people want to die at home or in hospice, but instead die in hospitals. My addendum: Discuss the fact that patients have a choice; that a living will is easy to complete, does not require a lawyer/fees (in most states), and that patients have a right to make their own healthcare decisions, especially at EOL.

Point made: Technology is availa…

Hospice Upheaval

It never occurred to me until today that enrolling my patients in hospice could cause them harm and distress. What unfolded is what happens all the time but which I hadn't recognized could have such a negative effect. My patient had been receiving home health through one agency for chronic ulcers and short term home rehabilitation. She has been largely bed and chair-bound and I have seen her frequently on housecalls. Her condition had plateaued and with her strong desire not to ever return to the hospital and to live as comfortably as she could in her home until she died, we agreed it was time to transition to hospice. The previous home health agency did not have a 'sister'-hospice as part of their organization. So I enrolled her with one of the agencies I work closely with.


The intake by the hospice case manager was uneventful. All seemed well until I heard from her family that yesterday several men from several different DME (durable medical equipment) companies came in …

The Best Town to Die In

Palliative Care rooted in the community--this was the topic of a recent Kaiser Health News story which can be found at this link.

While the data on costs and advance directive completion are compelling, what strikes me as the most powerful message in this story is how one community has made a culture-shift toward end-of-life care. As we discuss national health care reform, it is a good reminder for all of us that the best innovations in patient-centered and cost-efficient care do not come from national legislation but come from grassroots (and not just 'academic' but community-based) efforts. Community health systems such as Gunderson Lutheran are an example of how care for populations in an entire community can be improved by the thoughtful, persistent efforts of individuals with organizational support. That this Wisconsin community achieves tremendous cost savings compared with other communities for individuals at end of life is noteworthy. That community members in this cit…

Healthy People 2020: Your input is needed

Healthy People 2020: Your input is needed!

Every 10 years, The US Government produces Healthy People, a statement of the Public Health Goals for the Nation. The Healty People document becomes very influential, and is considered by policy makers and funders. For the first time ever, there is a concerted effort to directly address Geriatric Issues in Healthy People. The Geriatrics and Palliative Care communities need to do all they can to assure that the final report of Healthy People 2020 fully bears the fruit of this effort.

A draft of Healthy People 2020 is now available for public comment. Your comments can influence the final Healthy People 2020 statement of US Public Health Goals. It is important Geriatrics and Palliative Care providers help shape Healthy People 2020.

In the past, health goals for the elderly played a minimal role in Healthy People. For the first time, Healthy People 2020 includes a section devoted to health objectives for older adults. Amy Berman, Program Officer …

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 delay…

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.

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.In discussing "code status" with patients I advised the fellow and intern I was working wit…

Bandwidth: An exceptional communications resource

There is a Fantastic resource available with wonderful tools that can help you communicate your message. Bandwidth was developed with support from the John A Hartford Foundation to help its grantees effectively communicate their findings and make the case to the opinion leaders and the public for Geriatrics. John Beilenson led the development of Bandwidth.

If you go to Bandwidth you will find a treasure trove of wonderful tools to help you best convey your message. For example, are you presenting a poster at a national meeting? If you go to the poster section, and you will find invaluable tips on how to make the most effective poster (Hint: LESS IS MORE!!!). Having seen posters at AGS that use these techniques, I can assure you the advice here will markedly increase the interest in your poster.

Are you going to talk to a reporter? Go here for some tips on how to get your message across. Bandwidth also has advice on how to give an effective "elevator speech," and how to give …

$50,000 for your favorite Palliative Care Leader in Idaho, Oregon, Utah, and Washington

Who can pass up the chance to give $50K to their favorite palliative care leader or organization if it turns out that it won't cost you a dime?  The Regence Foundation has established a new program, the Sojourns Award, aimed to promote palliative and end-of-life care in Idaho, Oregon, Utah, and Washington. It is meant to recognize individuals or non-profits that provide exemplary leadership and innovation in palliative care. One winner from each state will receive the Sojourns Award along with $50,000 (keep in mind before you go out and buy that new flat screen TV that individual awardees will need to give the money to a non-profit.)

The call for nominations is now out at the Regence Foundation website with a deadline of December 4th, 2009.  Anyone can nominate, however I would also be happy to put together a nomination for someone we think is deserving of $50K. Just comment on this post or email me with suggestions of people or non-profit organizations that inspire you.

Palliative Care Grand Rounds - And the Winner Is...

This month's Palliative Care Grand Rounds is now up at Pallimed: Arts and Humanities. Christian Sinclair gave out awards in his grand rounds to the great posts of September. The honors go out to the best and the brightest palliative care bloggers including our very own Dan Matlock for his now "award winning" investigative article on the ravages of S.O.D!!! I heard Dan was in the running for this year's Pulitzer Prize for this piece, although the video on Baxter the Therapy Dog will likely take the honors.

Christian did a great job of finding other fascinating posts ranging from the redesign of PubMed to an Oncologist describing the death of one of his patients. Check out Palliative Care Grand Rounds and check out the links – you'll be glad you did (just bring a box of Kleenex for Baxter's Video).

Traversing the Great Divide: Inpatient and Outpatient Care

As the health reform debates continue, I am struck by the lack of attention to what seems to be a critical issue in poor health care delivery. With the technologizing of medicine (and more recently the hospitalist "movement"), delivery of health care has come to be centralized around acute care hospitals. Over time, patient care has been divided into acute inpatient care and 'ambulatory' outpatient care. While transitions of care, hospital-at-home, and health reform measures such as Accountable Care Organizations attempt to address the divide between inpatient and outpatient care, I keep wondering when providers, change-makers, and policy advocates are going to discuss an inherent problem in the separation of inpatient and outpatient care. The current reimbursement system through Medicare provides a clear example of the problem in defining inpatient care as one thing and outpatient care on the other extreme--when we all know that patients are the same individual rega…

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…