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Showing posts from February, 2010

Potpourri from Clinical Work II

I've been on the palliative care service these last two weeks. Some interesting and challenging issues came up.  I don't have time to flesh them out into individual posts.  I would love some feedback from the GeriPal commmunity.
I was consulted about a 62 year old woman with an unusual form of memory disorder: she couldn't form new memories (all cases completely altered to protect patient identity).  She was stuck in a past that existed 8 years ago.  She had end stage renal disease and was on dialysis.  She knew that she needed dialysis to survive, because that was also true 8 years ago, and would agree to start each dialysis session.  Shortly after starting a dialysis run, however, she'd stand up, forgetting why she was there, and try to go for a walk.  The frequent need to re-orient her proved too much for the dialysis providers.  They refused to continue dialysis.  This case raised a number of issues.  First, if she understands the risks and benefits of dialysis, bu…

An invitation from Elise Carey and Laura Morrison... Please join us

Do you want to learn more about how your colleagues are teaching learners about hospice and palliative medicine?

Then, don’t miss this great new session at the 2010 Annual Assembly of Hospice and Palliative Medicine (AAHPM):


Interactive Educational Exchange: Sharing Innovative Teaching Materials and Methods
March 5th 3:15-4:15pm


For this interdisciplinary session, five educators were chosen through a highly- competitive review process to share their innovative curricula. The session will include a hands-on, interactive exploration of each of the educational materials at individual tables. Our hope is that participants will get ideas and materials to enhance their own educational programs at home.

The five innovations that will be presented are:

1) Amy Holthouser, MD - Palliative Care Clinical Teaching Vignette
2) Susan Kristiniak, MSN, RN - Pain Improvement with Nursing Knowledge

3) Gordon Wood, MD - Pain Theater

4) Susan Gerbino, PhD, MSW - Zelda Foster Studies in Palliative and End-of…

More on dementia and mammograms

We recently discussed a study that described the common practice of obtaining screening mammograms in women with dementia. We considered how mammograms are very unlikely to benefit these patients, but have a substantial possibility of doing harm.

Paula Span, on her New Old Age Blog at the NY Times has a wonderful post on this article. She imagines what it would be like to be a frail older woman with cognitive impairment, being undressed for a mammogram, for reasons she does not understand.

But what is most instructive about this post are the poignant comments from adult children of persons with dementia. A number express the sentiment that they had to protect their loved ones from a health care system that seemed to insist on performing all tests and ignoring goals of care such as the desire to focus the care of their parent on comfort and quality of life. Several reported having to fight to not have screening mammograms done.

I am sure the health providers who tried to order these pr…

A Call for Hospice Reform: Nurse Practitioners Lead the Way

Last week a physician colleague expressed her concern about signing routine hospice admission orders for her elderly patient with end stage heart failure. The routine ‘as needed’ (PRN) orders included phenobarbital, pentobarbital, haloperidol, lorazepam, and morphine. “The hospice nurses know more about this than I do, don’t they?” she said. Yesterday, a longtime palliative care nurse told me she didn’t want to put her mother with end stage heart failure in a nursing home with hospice, because “they’ll just give her morphine and ativan. I want her heart failure managed.”

I worked as a hospice case manager in the community for eight years prior to becoming a nurse practitioner (NP) and have blogged in the past here about similar concerns. In my experience, most hospice nurses know a lot more about how to manage generic end of life physical symptoms than many physicians, particularly pain management and psychosocial symptoms/issues. Highlight generic. Physicians and NPs are trained to …

The last year of life in the oldest-old

There is a very interesting study in the January issue of the Journal of the American Geriatrics Society that characterizes functional status during the last year of life in the very old. The study illustrates a point we have recently stressed on GeriPal: The vast majority of older persons will have some degree of significant disability in the last years of life. This is in contrast to the popular perception that disabiity can be prevented if one does all the right things. Encouraging good health habits is a very good thing. However, suggesting that if you become disabled, it must be because you did something wrong is a very bad thing.

This clever study, led by Jun Zhao of the University of Cambridge in the United Kingdom, leveraged the Cambridge City Over 75 Cohort Study. This longstanding study originally enrolled a representative sample of persons over age 75 and has been following them for over 2 decades. This analysis examined the 321 subjects who died after the age of 85, who h…

Medicine In Translation

“But what will you be doing to cure my disease?” the interpreter said, relaying the words of our patient.

Was there an error in translation? Perhaps there weren’t clear equivalents of “cancer” and “metastatic” in Mandarin? Perhaps the patient somehow didn’t know her diagnosis after 5 years of illness?

The possibilities of confusion were endless. But it was a frigid December night, and Mrs. Liang (not her real name) sat with us in her hospital room, gripping the telephone that connected us together via a far-off Mandarin-English interpreter.

We didn’t know why Mrs. Liang had been admitted to the hospital. She had a remarkable performance status for some who’d just been through breast cancer and was now battling widely-metastatic colon cancer. She was 51, alone in this country, somehow managing to climb two flights of stairs in her walk-up apartment every day, despite the “too numerous to count” mets in her liver and the “too numerous to count” mets in her lung. The cancer was in her spine…

Feeding Tubes in Advanced Dementia: It's all About Location

Feeding tubes are often placed in the hospital setting for patients with advanced dementia, even though there is pretty much a lack of evidence for their effectiveness in improving survival, preventing aspiration pneumonias, or helping resolve issues like pressure ulcers. One big question though is why does there seem to be so much variability in why patients with advanced dementia get feeding tubes?

A group of researchers from Brown University and Harvard Medical School looked at this question by trying to identify specific characteristics of acute care hospitals associated with greater rates of feeding tube insertion. Their study, published in this weeks JAMA, looked at over a quarter of a million hospitalizations in 163,022 previously non–tube-fed nursing home residents with advanced cognitive impairment, aged 66 years or older, who were hospitalized between 2000 and 2007. Nearly 20,000 feeding tubes were inserted. In 2007, 6.2% of hospitalized advanced cognitive impairment patie…

The Cultural Distance Between Geriatrics and Palliative Medicine

I just read Chris Feudtner's brief piece, "The Breadth of Hopes," in the New England Journal.  Among other things, the article helps me articulate a difference between care at the end of life (last years, months, days) for many older people and care at the end of life for younger people. The distinguishing characteristic here is whether or not an individual has seen death coming, even distantly, and processed that, even a bit. Not all older people have done so, but many have – I think of the patient in David Reuben's recent JAMA paper who said, “When you’re 83, it’s not going to be 20 years.” And many families have come to a similar point when an older family member develops a life-threatening illness. In contrast, few younger people come to such a point before developing a serious illness. As one of my colleagues says, in geriatrics, our patients are nearer the end than the beginning, and they generally know that. This is not the case for younger people, and in our…

Persistent Vegetative State: An apt description for the media coverage of PVS

The New England Journal of Medicine released a study today revealing some awareness in a minority of patients diagnosed with Persistent Vegetative State (PVS). Researchers used functional MRI tests on 54 patients with PVS or minimally conscious state (MCI). The MCI patient data is interesting but the meat of the study is in the 23 patients diagnosed as being in a persistent vegetative state, meaning that clinically all exams showed no signs of awareness. Four of these 23 patients showed brain activity in areas similar as healthy control subjects when given specific commands. One of these four patients was also able to respond to factual statements correctly by using a technique similar to answering yes-no questions.

My favorite part of the article is in the discussion section:
In the future, this approach could be used to address important clinical questions. For example, patients could be asked if they are feeling any pain, and this information could be useful in determining wheth…

Social Media in Palliative Care Communities: A New Workshop at the AAHPM/HPNA Annual Assembly

A new workshop on the usage of online social media has been added to the AAHPM/HPNA Annual Assembly this March. The session, titled "Social Media in Palliative Care Communities: Developing and Maintaining your Online Presence", will be led by a panel of bloggers from GeriPal and Pallimed and will take place on  Friday March 5th, 7-8:15am (I know, it's early, but it's nothing that a double expresso can't fix). 

The goal of the workshop is to bring people together interested in using social media to advance the field of Hospice and Palliative Care.  The great thing about setting up a workshop like this is that we get to take advantage of the resources that these online networks give us in developing the actual content. One of these tools is a brief survey that Christian Sinclair created to get an understanding of what potential attendees may want from such a session.   So take 3 minutes of your time and either fill out the survey or post comments here or at Pallim…