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Surrogate Decision Making in the ICU

Imagine your loved one is very sick in the ICU. So sick that the ICU doctor believes that there is only a very small chance of survival, and even if your loved one survived, he/she would have significant, permanent disability. If you were placed in this position, how would you want to make decisions about continued intensive medical treatments to support his/her life? Would you want to make it on your own? Would you want to share the responsibility for this decision with the ICU doctor? Would you just want the ICU doctor to make the decision for you with our without your opinion?

Now imagine we ask the same questions to surrogate decision makers of critically ill, incapacitated adults. How do you think they would answer? We now have some idea of how thanks to a study authored by Sara Johnson and her colleagues at UCSF and University of Pittsburgh.

The study, currently in press but accessible early online, presented two clinical vignettes to 230 surrogate decision-makers fo…

Outcomes of Surgery in Older Persons: How Could We Know So Little?

About half of all operations performed in the United States are performed on persons over the age of 65. So you would think that there would be tons of research to help us guide patients as they ask us questions about how their health will be impacted by an operation. But we know very little. As far as evidence-based medicine is concerned, surgery in the elderly is an evidence-based wasteland.

How will an 85 year old with severe knee arthritis do after a joint replacement? One reason that this question is so hard to answer is that 85 year olds are so different. This question can not be answered generically. Some are highly active, while others (even if they had good knees) are disabled physically and/or cognitively. We suspect functional factors like these are likely to have huge impacts on surgical outcomes, but there is almost no data to guide us.

And we even lack the most basic evidence to address the older patient's "How will I do after surgery" question. Most of th…

A Negative Palliative Care Trial?

There has been a lot of good news about palliative care in the last year. Most notably is one well designed randomized control trial (RTC) finding improved survival and quality of life for stage IV lung cancer patients receiving outpatient palliative care consultations. This line of evidence has been particularly important for those of us attempting to grow palliative care programs both in the inpatient and outpatient arena. But, what should we do when the results of a RTC of inpatient palliative care consultations come up negative? Should we ignore these findings, dispute them, or acquiesce? These are the questions that I am grappling with after reading a research letter in the Archives of Internal Medicine by Dr. Steven Pantilat and colleagues.

The study in question is a randomized, prospective, clinical trial meant to evaluate the impact of a proactive palliative medicine consultation on the care of hospitalized chronically ill elders. The study population included 107 patients a…

Are Most Published Studies Lies?

A couple of recent articles in the lay press expose the fallacy that publication in a scientific journal means "it must be true."  Thanks to Aunt Sue for noticing the first, published in the Atlantic by David Freedman, titled, "Lies, Damned Lies, and Medical Science," and the second published in the New Yorker by Jonah Lehnrer, titled, "The Truth Wears Off."  Both articles rely heavily on the work of John Ioannidis, an epidemiologist at Stanford.

Highlights (lowlights?) discussed in these articles:
Of the 49 most cited clinical research studies, only 34 have been replicated, and in 41% of cases where replication was attempted, the results contradicted the original findings or seriously downgraded the estimated effect size.One third of all studies are never cited, let alone repeatedOf 432 genetic studies examined, most had serious flaws, and only 1 study held up when others attempted to replicate itThe public is slowly starting to catch on.  Spectacular fai…

Singing to people who have dementia

This month’s American Journal of Alzheimer’s Disease & Other Dementias offers us something unusual but highly relevant . Chatterton, Baker and Morgan give a review of the literature on singing to people with dementia and they find that singing to people who have dementia improves quality of life for both the people with dementia and their caregivers.
Singing to people who have dementia improves quality of life for both the people with dementia and their caregivers.
Their finding bears repeating. It particularly bears repeating because of information that cannot be included in their exhaustive review of the gerontology and music therapy literature. When we drop below the altitude of the lit review, we find stories, images and songs. When we look closely at the men and women involved in relationships impacted by dementia we witness just how important, and beautiful, music can be in creating relationships in end-stage dementia.
In their systematic literature review, the author…

CAM Resources

The subject of complementary and alternative medicines (CAM) has a plethora of articles in the lay literature, read intensively by our patients, but may be only superficially covered by their medical practitioners.

Recently an article appeared in HemOnc today where David Rosenthal MD, of Harvard Medical School, discussed the relevance of CAM in oncology. He outlined the five primary domains of CAM;
1) Mind-body medicine; eg. meditation, yoga, acupuncture.
2) Biologically-based practices; eg. dietary products & herbal supplementation.
3) Manipulation & body-based practices; eg. spinal manipulation.
4) Energy medicine; eg. Qi gong, magnetic or light therapy.
5) Whole medical systems; eg. Ayurvedic & Traditional Chinese medicines.

Many of us who work in hospice and palliative medicine are familiar with at least some of these CAM agents. Our patients utilize some of the examples given, from acupuncture to St. John's Wort, for symptomatic care. In hospice we're aware…

Stimulating Interest in a Career in Geriatrics - The Scholarship Award Summit

When the clock strikes midnight on January 1st, the very oldest of the baby boomers will turn 65 years of age. Every hour thereafter another the equivalent of a Boeing 747 airplane full of baby boomers will be turning 65. By 2030, the US will have effectively doubled the population who are older than 65 to an estimated 71 million individuals.

It is imperative that we think about novel approaches to increase the numbers of practicing geriatricians given this dramatic change in our population demographics. The John A. Hartford Foundation has led the way in promoting models to increase recruitment in advanced fellowships by targeting a wide range of learners. Among these models include those focused on residents, such as the Geriatrics Is Your Future Program at Baylor College of Medicine, and the Annual Resident Award Summit at the Southeast Center of Excellence in Geriatric Medicine.
Building upon these programs, the UCSF Division of Geriatrics just announced the first annual Geriatri…

Singing while you walk and learning to communicate between the towers of academia

As a geriatrician and an ethnomusicologist, I have had ample opportunity to observe the impact of music upon gait among my patients. Whether singing “Tumbalalaika” in order to help a Parkinsonian patient avoid freezing on a threshold, or singing “Won’t You Come Home, Bill Bailey,” in order to help someone with dementia get up and walk to the dining hall, I have watched as halting, shuffling gaits develop a steady rhythm. In each case, the patient begins to walk in synchrony with the song and the caregiver.

It was with delight, therefore, that I read the article by Trombetti, et al., in the upcoming issue of the Archives of Internal Medicine. They have taken such anecdotal experiences and subjected them to the rigors of the randomized clinical trial. Powered to detect measurable differences in gait, they have demonstrated in medical parlance what many of us have seen, that gait can improve with music.

Trombetti and colleagues offer us an interesting piece of information: that community…

Telemonitoring: Sounds Great. But it doesn't work.

Telemonitoring is a novel disease management strategy that sounds wonderful. But just because something sounds wonderful does not mean it works. Sometimes new technologies are implemented into clinical practice just because we think they should work. But wishful thinking should not be good enough for our patients. New technologies should be subjected to rigorous evaluation before they are widely implemented
Telemonitoring in theory that should improve outcomes for patients with chronic illness. Patients are given devices for use at home that allow them to transmit information via the phone or internet to their providers. This often includes information about vital signs such as blood presssure and weight, symptoms, or other parameters such as blood sugar. The theory is that this information will allow providers to detect problems early, intervene, and prevent clinical deterioration. It sounds so good that many health systems have implemented telemonitoring for a number of conditions. F…

Older Adults and Quality of Life are New Topics in Healthy People 2020!

Healthy People 2020 has been released, and there is good news for GeriPals.  (See Ken's post soliciting suggestions from GeriPal readers for Healthy People 2020 back in November 2009.)

New topics for 2020 include: "Older Adults" and "Health-Related Quality of Life."  The objectives for care of older adults have been finalized and are searchable.  Objectives for quality of life are still under development.  This means they might still include the suggestion I submitted on behalf of GeriPal, suggesting greater training and access to palliative care services. 

Take a look at the new guidelines.  Some of my favorites from the Older Adults section
Increase the proportion of the health care workforce with geriatric certification by 10%Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supportsReduce the proportion of unpaid caregivers of older adults who report an unmet need for caregiver sup…

Sex and drugs (with or without rock and roll)

Annals of Internal Medicine published an interesting article today on sexual activity in 75 to 95 year-old men. Using data from a large cohort study in Australia, the authors identified several interesting findings:

While sexual activity decreases with advancing age, it is still common: approximately 40% of men age 75-79, 30% of men age 80-84, and 20% of men age 85-90 are sexually activeRoughly half of participants reported that sex was at least somewhat important. Many stated that sex was moderately or very importantAmong men who were not sexually active, only 40% stated it was because of lack of interest. Reasons commonly cited for not being sexually active included lack of a partner, physical limitations of oneself or of the partner, and lack of interest by the partner.Several reversable risk factors were associated with lack of sexual activity, including use of beta blockers and antidepressants (thus the title of this post).These findings should not be surprising - news flash, men …

AND orders: A Confusing Conjuction that Attempts to Allow a Natural Death

Paula Span has an excellent article out today in the NY Times titled "D.N.R. by Another Name." In it, she describes the use of the term AND that we have discussed previously on GeriPal (see here for Patrice Villars post on terminology). AND stands for "Allow Natural Death" and was born out of a movement to rethink how we approach end of life discussions and decisions. Both Christian Sinclair (of Pallimed fame) and I were interviewed for the story. Here are a couple thoughts of mine that didn’t make the cut but I felt were important reasons why I'm not a big fan of AND.

First, DNR is only a medical order and should not be used as a way of bringing up end-of-life discussions. DNR only means “if the patient has a cardiac arrest, do not attempt cardiopulmonary resuscitation". DNR orders do not attempt to specify what medical care should be provided to DNR patients before they experience arrest. This care, which some may argue is more important care than the l…

"Allow Natural Death"???

I want to alert readers of a fantastic debate that just started at the New York Times New Old Age Blog about changing the term "Do Not Resuscitate" to "Allow Natural Death", or changing DNR to AND.  Please post comments there!  NYT blogger Paula Span interviewed GeriPal co-founder Eric Widera for this piece.  This is the second time Eric's been in the NYT in the last 2 months, go Eric!  Christian Sinclair of Pallimed was also interviewed.  We had a terrific debate about this issue in response to an early post by Patrice Villars (see here).

Most people who comment are in favor of "AND."  And what does that mean, anyway?

by: Alex Smith

New Dementia Performance Measures: Opportunity for Public Comment

The AMA Physician Consortium For Performance Improvement has released a draft set of performance measures for persons with dementia. The draft is now open for public comments. It is likely that these performance measures will be influential. For example, I would not be surprised to see the VA implement many of these measures. The measures would benefit from comments by the GeriPal community. The multidisciplinary perspectives many of you can offer are likely to have a positive impact on the care of patients with dementia.

My initial overall impression of these performance measures is quite positive. They propose reasonable approaches that will improve the assessment and management of persons with dementia. The proposed performance measures encompass the following concerns:

Encouraging providers to stage the severity of dementia
Encouraging the use of standardized measures of cognitive assessment
Encouraging assessment of functional status
Encouraging better assessment and management …

Substance Abuse in Late Life

The house next to mine was busted for running a meth lab yesterday.    Scary - our whole neighborhood could have blow up.  I was interviewed about it for local TV here.  In retrospect, when we smelled something this summer like someone had left something on the bunsen burner too long?  Well, someone had left something on the bunsen burner too long.  Now we know why our neighbor always stepped outside to smoke.  Thanks for that, at least.

Some people asked me tongue-in-cheek if I would post this to GeriPal.  I said "no" to the first few, but then a family physician friend said that he's cared for at least two patients in their 70's who have been using meth, and denying it.  Then another friend described caring for several patients at the county hospital who tried meth or crack cocaine for the first time in their 60's and 70's.  "Why now?" She asked?  The sad answer, "We have nothing to live for, so we thought we had nothing to lose by trying it.…

The Legacy of SUPPORT: 15 years later

November 2010 marks the 15th anniversary of the publication of the SUPPORT Project, the largest study of end of life care ever conducted. This study that shook the medical world. SUPPORT was an ambitious effort sponsored by the Robert Wood Johnson Foundation to improve the quality of care towards the end of life in patients with serious illness. The finding that this $29 million effort had absolutely no impact on improving the quality of end of life care was stunning.

The failure of the intervention to improve end of life care and the strikingly poor quality of end of life care documented by SUPPORT led to calls for action in the lay media and by advocates of better end of life care. SUPPORT remains the most influential study of end of life care ever published, and with over 1300 citations in the peer-reviewed literature, by far the most cited.

The SUPPORT intervention study randomized over 4000 patients hospital at 5 US hospitals to usual care or the SUPPORT intervention. Patients had …

Palliative Care and Accountable Care Organizations – A Call for Comments

Accountable care organizations (ACO’s) are coming with a goal of creating a health care system that delivers higher quality care more efficiently. Important to both the palliative care community and the geriatrics community is whether our voice will be heard in developing the standards required of these organizations.  Don Berwick and his crew at CMS is now giving us the chance.

There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.

The dealine for comments is December 3rd, so there is little time to act. Lucky for us, Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: H…

Desktop Medicine: Here to Stay

I want to draw readers attention to a brilliant essay in JAMA by Jason Karlawish. He describes a new concept of medical practice that he calls “desktop medicine.”

Historically, we have used “bedside medicine” to diagnose pathological diseases. Bedside medicine incorporates the standard elements of the history and physical: the chief complaint, the history, review of systems, physical exam, and diagnostic studies. Bedside medicine is focused on diagnosing the presence or absence of disease: does this patient with dyspnea have heart failure or COPD? Is this pain due to cancer or osteoarthritis? Answers to these questions inform treatment decisions (e.g. lasix or albuterol, opioids or nsaids).

Desktop medicine, in contrast, uses different tools for different ends. The focus of desktop medicine is management of risk. Clinicians gather evidence from the patient and laboratory values, and use these to generate risk estimates, often with the help of a desktop computer. These risk estimates …

KUDOS to the Palliators who took the ABMS Boards on 11-16-2010

Geripal Readers, please join us in congratulating all the Palliators who took the ABMS Hospice and Palliative Medicine Boards yesterday.

The US currently has only one Palliative Care doctor for every 30,000 seriously ill Americans who are struggling with distressing symptoms and desperately need access to quality palliative care.

Palliators who took the boards yesterday: Your actions yesterday in taking the Board Exam helped greatly in the larger national effort to increase access to palliative care for all patients with serious life limiting illness and their families.

Thank you and strong work!
VJ Periyakoil
Stanford University School of Medicine

A novel therapeutic intervention: More time with patients

What would happen to the quality of patient care in the United States if we had more time to spend with our patients? Would we train better doctors if our residents spent more time with fewer patients? An essay in the Annals of Internal Medicine by Dr. Stanley Shi-Dan Liu, a resident at Johns Hopkins Bayview Medical Center suggests the answer to these questions is an emphatic YES!

Dr. Liu reports on his experience on the Bayview Aliki Service. Residents on the Aliki Service admit half the number of patients as other medical service teams. By having more time with each patient, they are charged with getting to know their patients as people, both in and out of the hospital. Residents spend much more time preparing their patients for discharge, call all their patients after discharge, and conduct post-discharge home visits on many of their patients.

Dr. Liu eloquently reports how having more time with patients transformed his ability to provide good care, noting:

"My patients, their…

Sex and Aging

It’s time to get comfortable with the notion that older Americans have satisfying sexual relationships. Studies on sex and aging confirm that most older adults retain sexual interest and ability. The problem is, as nicely summarized by Mark Lachs in this weekend's Wall Street Journal, that sex in the elderly remains a taboo subject, even among health care professionals.

A landmark study in 2007 by Lindau and colleagues helped disprove the myth that sex is no longer important as we age. They performed survey of 3005 older adults to evaluate the prevalence of sexual activity, behaviors, and problems in this population. The prevalence of sexual activity did decline with age – from 73% among respondents who were 57 to 64 years of age, to 53% among those 65 to 74 years of age, to 26% among those 75 to 85 years of age.

The authors of this study also found that among respondents who were sexually active, about half of both men and women reported at least one bothersome sexual proble…

Autonomy for Frail Elders

What does autonomy mean to a 95 year old woman with disability, dementia, and heart failure residing in a nursing home?  Beauchamp and Childress's classic text "Principles of Biomedical Ethics" devotes 41 pages to the principle of respect for autonomy; 34  pages are devoted to informed consent.  When we consider informed consent, we classically think of a major medical decision, such as writing an advance directive, deciding about major surgery, or withdrawing life-sustaining treatment.  How much relevance do these major life-altering decisions have for the frail elderly woman in the nursing home? 

As Holstein and co-authors note in their new book "Ethics, Aging, and Society: The Critical Turn," while bioethics is focused on these major medical decisions, most elders in long-term care facilities care less about these major decisions, and are far more concerned about everyday choices: the ability to make private phone calls, having a private space for visitors,…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …