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Showing posts from December, 2009

Death and Taxes: It's Shaping Up to be a Busy Year

The Wall Street Journal published an article today entitled "Rich Cling to Life to Beat Tax Man." The article describes a new wrinkle in advance care planning: "families are struggling with whether to continue heroic measures for a few more days" in order to take advantage of the ostensible temporary one year lapse in the estate tax that will begin on January 1st (experts say it is not likely that Congress will leave this lapse issue alone for long; a fix could even be retroactive if put in place soon enough). It also describes patients placing provisions into the advance directives allowing proxies to make end-of-life decisions based partially on changes in the estate tax law.

How big of a problem is this? Can financial incentives postpone or accelerate death? Do changes in the estate tax code really affect whether people live or die? In 2001, Joel Slemrod and Wojciech Kopczuk won the IgNobel prize for their paper called "Dying to Save Taxes". In their p…

Tarenflurbil for Alzheimer Disease: A novel agent meets with great disappointment

The current issue of JAMA reports on the largest trial ever conducted for a drug designed to slow the progression of Alzheimer Disease (AD). The study examined the impact of Tarenflurbil, a novel secretase modulator that reduces the concentration of toxic forms of B-amyloid. B-amyloid is more likely to be present in the brains of persons with AD, and most believe amyloid deposition plays a central role in the pathogenesis of AD. (Though there are some who question the amyloid hypothesis.)

Tarenflurbil showed great promise in mouse models and in a phase 2 study in humans. This very well powered study randomized 1684 patients with mild AD (MMSE 20-26) to Tarenflurbil or placebo, and compared a number of outcomes over 18 months. The key findings:

Tarenflurbil had no impact in terms of delaying the decline in cognitive functionTarenflurbil had no impact in terms of delaying declines in physical functionTarenflurbil had no impact in terms of improving quality of lifeTanenflurbil had no impa…

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 …

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…

Cheating Death: A Book Lost in Definitions

"Death is not a single event, but a process that may be interrupted, even reversed. And here's the exciting part – at any point during this process, the course of what seems inevitable can be changed. That is precisely what we are going to explore in this book: the possibility of cheating death."
These are the words of Dr. Sanjay Gupta, a practicing neurosurgeon, the chief medical correspondent to CNN, an almost Surgeon General, and now author of the book Cheating Death. Cheating Death is, in Dr. Gupta's own words, a "medical thriller". This is an apt description considering the dramatic prose that the author infuses into this book. Dr. Gupta lavishly uses inspirational and exceptional real life stories to make his point that medical science is blurring the distinction between life and death. His tale weaves the science of hypothermia protocols, CPR resuscitation techniques, hibernation and suspended animation research, near death experiences, and fetal surg…

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 …

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 h…

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 AtulGawande "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 pi…

Destination Therapy and Reversing Frailty

For those geriatric and palliative care practitioners who glossed over the recent NEJM publication of the Heartmate II trial as yet another esoteric, hyper-specialized trial should think twice. This trial could have significant implications for many geriatric and palliative care patients.

Issue #1 – disconnecting the Left Ventricular Assist Device (LVAD): On our palliative care service, I recently assisted with the care of a 74 year-old gentleman with one of these continuous flow LVADs. It was one of the most complicated goals-of-care discussions I have ever been involved with. From a cardiac standpoint, his heart/LVAD were doing extremely well. He did not have any signs of infection and his LVAD was maintaining great cardiac output. That said, He kept getting admitted with mild flare-ups of acute pancreatitis of unknown etiology, he didn’t want to get out of bed, and had an albumin of 2.8. Ultimately, he refused SNF, went home, failed rehab at home, stopped performing his ADLs, and t…

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 patie…

Will Rogers Phenomenon and the Cost of Healthcare

"When the Okies left Oklahoma and moved to California, they raised the average intelligence in both states." - Will Rogers

In medical terms this is called Stage Migration bias, because it was first observed in cancer. If there are more intensive efforts to detect or stage cancer, patients who would have been classified as Stage 2 before the more intensive effort, may be classifed as Stage 3. This has the effect of taking the sickest Stage 2 patients (those whose cancers had spread more widely but that spread can only be found with the more intensive workup) and moving them to Stage 3, where they are the healthiest Stage 3 patients (since other Stage 3 patients are those whose cancer spread was more obvious and did not need the more intensive work up to detect). Because the patients moving out of Stage 2 are sicker than those that remain, Stage 2 patients will average be healthier and will appear to do better. Because the patients moving into Stage 3 are healthier than those t…

The downside of the growth of palliative care

As palliative care matures, I become increasingly concerned about the downside of our growth.

Let me say more.

A couple of stories from the last few months: One of my faculty told me that she got a consult for patient who was made "comfort measures only" and did not have any issues but "they thought we would be mad if we were not consulted". Conversely, I have had many consults for patients where the primary team feels like the patient is dying so they should be transferred to our service. And consults by medical house staff to give bad news or talk about resuscitation preferences (cause we are better and more experienced at it).

My worry: We may be deskilling other doctors. Unfortunately, if the patient is viewed as dying, the primary teams feel that they should back off and ask palliative care to "take over". So house staff and junior internal medicine house staff do not have the opportunity to have these conversations and receive feedback. And as concerni…

Overwhelming Relief

I've been thinking about this analogy for a while (I may be stealing this from someone, but I don't recall, so my apologies in advance) and was reminded of it again with the latest brouhaha about the "new" USPSTF mammography guidelines.

Scenario 1:
A fireman who is also an arsonist, who comes to your house and sets it on fire. You desperately work to try to contain it and you're not sure you're going to be able to save the house. Thankfully, the fireman/arsonist comes back w/the rest of the fire department and they put out the fire. How do you feel? Are you grateful? Are you relieved? Are you angry?

Scenario 2:
A doctor recommends a mammogram. It is abnormal, making you worried that you have cancer. You can't sleep for 2 wks, and ultimately get an invasive biopsy, which turns out to be normal. How do you feel? Are you grateful? Are you relieved? Are you angry?

The times I've been the doctor in scenario 2, patients are invariably so relieved when they find …

December's Palliative Care Grand Rouds

Palliative Care Grand Rounds is a great series that puts a spotlight on outstanding blog posts focused on hospice, palliative care, death, or dying (and some geriatrics back when we hosted it in October). December’s edition of Palliative Care Grand Rounds is up at Death Club for Cuties (a site that I enjoy visiting thanks to the Jerry’s unique perspectives as a nurse practicing in neuro ICU).

The great thing about these grand rounds is that I always find new websites that I fall in love with. This month’s favorite: the New Health Dialogue Blog. This site is a great source for news and commentary on health policy. Don’t trust me? Just check out Dying Well Beats Dying Badly. And Expensively or OK. So McAllen Has Some Company.

Lastly, I just want to thank Jerry for listing Geripal as one of the "The Usual Suspects".  Keyser Soze would be proud...

Penalizing Hospitals for Readmissions: Unintended Consequences?

Medicare recently started publicly reporting hospital readmission rates as a measure of quality, and there are proposals to financially penalize hospitals with high rates of readmission. A recent article in the Annals of Internal Medicine makes a compelling case that an unintended consequence of such a proposal could be to worsen health inequalities by inappropriately penalizing hospitals that care for our most vulnerable underserved patients. I found the article convincing. I don't think Medicare should implement any plans to penalize hospitals based on readmission rates without answering the concerns of this article. Further, the article raises serious questions about viewing readmission rates as a measure of quality. The authors of the article were Drs. Rohit Bhalla and Gary Kalkut of Montefiore Medical Center in the Bronx, NY and the Albert Einstein College of Medicine.

It is certainly true that encouraging hospitals to reduce readmission rates in older patients is a good thing…

Thoughts on Preventive Medicine

You can prevent Heart Attacks
You can prevent Strokes
You can prevent Colon Cancer
You can prevent Cervical Cancer
You can prevent Breast Cancer
You can prevent Prostate Cancer
Really? Well perhaps
You can prevent Syphilis
You can prevent the Friends of Syphilis
You can prevent smallpox, polio, measles, mumps, rubella, tetanus, chicken pox, meningitis, influenza, hepatitis, diphtheria, whooping cough
You can prevent Diabetes
You can prevent Complications of Diabetes
You can prevent Hip fractures
You can prevent Diarrheal Illness
You can prevent Nosocomial Infections
Really? Really, just wash your hands

But you cannot prevent death.
Saying that we can prevent death is preposterous.
Indeed, the word “prevention” doesn’t even apply to death
You can delay death
You can stall death
You can prolong life

But it just doesn’t make sense to say that you can prevent death.