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Showing posts from April, 2010

Thoughts on Disability

As a Geriatrician, it is fair to say that we work with a fair number of patients who have disabilities. We are excellent at doing gait assessments, having fall clinics, and reporting changes in functional status. We know how to refer to physical therapy and occupational therapy, and we know how to try and make elders safer at home. We go through these motions, yet I wonder if we understand the emotional impact of what a disability means, and if we actually understand what it means to ask our patients who are wheelchair bound, who can’t drive, or who use a walker to come see us in our clinics. I wonder if we’ve stopped to ask them about their experience and about what the functional impairments mean to them. Have their social relationships changed? Do they hesitate to leave the house? As an anthropology student at Barnard College, in one of my classes on medical anthropology we were studying conceptions of illness, and the place of sickness in society. We read books such as Susan Son

Palliative Care: Transforming the Care of Serious Illness – A Book Review

On my way out of the hospital this evening I ran into a soon-to-be palliative care fellow. Our conversation quickly turned the topic of what one should read prior to beginning a fellowship in order to hit the ground running. This used to be a tough question for me, considering the myriad of key journals, textbooks, and novels that have helped shape my understanding of the field. The answer, though, has become a lot easier after reading Diane Meier’s new book, Palliative Care: Transforming the Care of Serious Illness . Palliative Care: Transforming the Care of Serious Illness is a whirlwind tour of the history of the hospice and palliative care movement and how it is reshaping the care given to those with serious illnesses. It is edited by Diane Meier, Stephen Isaacs, and Robert Hughes, and incorporates some of the very best works that the field has to offer. The book begins with Dr. Meier's original article on the "Development, Status, and Future of Palliative Care"

America's Best Hospitals: A Devastating Critique

America's leading teaching hospitals anxiously await the release of the annual US News hospital ratings. The "winning" hospitals will heavily market their rankings. However, there is now evidence these rankings are little more than a glorified popularity contest, and of little value as a measure of hospital quality. This critique of "America's Best Hospitals" was published in a study led by Dr. Ashwini Sehgal of Case Western Reserve University in the Annals of Internal Medicine. I suppose reasonable people could disagree about the value of hospital reputations. And I guess it would be hard to object if US News portrayed America's Best Hospitals as little more than a reputation survey. But the problem is that Americas Best Hospitals is seriously misrepresented as something much more than a reputation survey. It is suggested that the ranking are a complex amalgam of an evaluation of structure, process, and outcomes, based on "hard data." The

POLST: Standardizing End-of-Life Orders rather than Patient Communication

Over the last 30 years we have tried to standardize patient communication about end-of-life issues though the utilization of statutory advance health care directive forms. While this approach has not been a complete failure , the results have been less than stunning given the amount of resources allocated to this endeavor. Is there a better way? At the Coalition for Compassionate Care of California (CCCC) Annual Meeting, Charles Sabatino, JD, talked about one possibility – the POLST paradigm . Mr. Sabatino is the Assistant Director of the American Bar Association’s Commission on Law and Aging, as well as a professor at Georgetown University Law Center. At today’s CCCC meeting , Mr. Sabatino gave a presentation on the inadequacy of a legal transactional approach that has dominated advance care planning, best exemplified by the Advance Directive document. He describes how the transactional approach is beginning to give way to “communication approach” to advance care planning, where

Driving and Dementia: An Excellent Guideline, and A Missed Opportunity

The American Academy of Neurologyrecently released a very useful guideline on the evaluation of driving risk in patients with dementia. This very nicely written, evidence-based guideline is one of the best articles I have read on this subject. It should be required reading for all who care for patients with dementia. By sponsoring this informative guideline, the AAN will help physicians, caregivers, and patients protect the public health by providing guidance as to when a driving by a cognitively impaired patient is unsafe. However, an important role of professional societies is to serve as advocates for their patients. I wish the AAN had leveraged the release of this guideline to strongly advocate for their patients with dementia. First, some details about the guideline. The authors conducted an extensive literature review to determine what characteristics differentiate between cognitively impaired patients who can or can not drive safely. As a matter of public safety, it is i

Are social networks blurring the boundaries between professional and personal lives?

Facebook, Twitter, Yammer and the Internet overall is a game changer. The rulebook of how we practice medicine has changed. The NY times posted an article in which a young trainee describes caring for a dying patient in the ICU who reached out to her thru Facebook. She describes how she struggled with this and describes his eventual death. I find that people I meet in a clinical setting as well as in a professional setting have typically "googled" me before they step foot into my office. Maybe this is a "silicon valley neurosis"... ...maybe it is a whole new world in that we live in a fish bowl. I am curious to know whether others have had patients who "poked" you on Facebook? How are you dealing with the blurring boundaries between your prefessional and personal lives (assuming that you have time for a personal life, that is :-)

An ER Physician’s Take on DNR Orders

It is a story that happens all too frequently in a fragmented healthcare system. A woman with cancer on chemotherapy codes in the emergency room. Nobody knows her code status. The ER physician uses the skill and talent gained from years of training to successfully resuscitate her. The family arrives to let the physician know that the women had a DNR order. After discussions with the women’s oncologist and ICU team the family decided to not pursue dialysis and withdraw the ventilator. Disappointment sets in for the young physician as seemingly everyone gives up on his “save”. It is hard not to feel bad for everyone in this story as heard on today’s NPRs morning edition . The woman who coded endured an ending to her life that she specifically asked to avoid. Her family had to both see the outcome of the code and be burdened by the resulting medical decisions. The ER physician, Dr. Boris Veysman, felt heartbreak that his efforts were not only in vain, but also undesired by all. His

Palliative Care and the Awareness of Death

Rob Pardi’s comments in  the Pallimed discussion affected me deeply. His honesty, integrity, and willingness to share were so impressive that I feel reluctant to take issue with anything he had to say. Yet today I find myself somewhat in conflict with his message. Rob’s wife, a palliative care doctor, died of cancer recently and  her story, published in the New York Times made it sound as if she’d fought to the bitter end, in denial all the way. Rob let us know that the real story was more complex than that. Desiree Pardi, M.D. handled her illness in her own way, at her own speed, and taking her own strengths and weaknesses into account. As a cancer survivor, I understand her approach. At age 55 I did everything I could to battle prostate cancer, consenting to surgery that I knew might leave me disabled. As a clinician, I would follow her lead. When I walk into a patient’s home, at least for the first few minutes I leave my own agenda at the door. I try to practice “Ask bef

Dr. Desiree Pardi: Reconciling Her Life and Her Death

The New York Times recently ran an article titled " Helping Patients Face Death, She Fought to Live ". The article told the story of Dr. Desiree Pardi's experience dealing with breast cancer, and how she "angrily refused" palliative care consultation when confronted with the advanced nature of her underlying cancer. What makes this story so provocative is that Dr. Pardi was the palliative care medical director at Weill Cornell Medical Center.  Many questions are raised but there is little to help with the reconciling "Desiree Pardi palliative care doctor who believed in a peaceful death, with Desiree Pardi the patient who wanted to keep fighting." Well today, thanks to our colleagues at Pallimed , we hear from Dr. Pardi's husband, Robert. He very eloquently clears up some of the misconceptions about Dr. Pardi's decisions. He also does something that we as a community have difficulty with - describing to the general public the role of pall

Meaningful Activities For Persons With Dementia

There is a lot of focus on what elders with dementia can't do. But what about more discussion of what they can do? When you see a patient with dementia, how do you help family members maintain meaningful interactions with their loved ones? I am sad to admit that I don't do this nearly as well as I should. After all, this is not the type of thing we are taught in our training. The most recent posting from the wonderful New Old Age Blog in the New York Times, from guest blogger Dr. Cynthia Green, has some useful, practical advice. As she states, "the trick it do find activities that are engaging, yet doable." The general gist is to find activities and hobbies that the person has enjoyed most of their lives and make modifications so they can still do parts of them. For example, perhaps Grandma loved to cook. Maybe she can't cook a meal anymore, but mashing the potatoes, icing the cake, or using the cookie cutter may be very meaningful to her and give you somet

Palliative Care Nursing: Quality Care to the End of Life, 3rd ed. – a Book Review

Palliative Care Nursing Quality Care to the End of Life, Third Edition Marianne Matzo, PhD, GNP-BC, FPCN, FAAN (Editor) Deborah Witt Sherman PhD, APRN, ANP-BC, ACHPN, FAAN (Editor) In this comprehensive textbook on palliative care nursing, editors Marianne Matzo and Deborah Witt Sherman succeed in bringing together the heart of nursing and the true meaning of palliative care with the most current evidence based practice. I admit to being a skeptic about hard copy textbooks in the setting of new studies coming out seemingly on a weekly or monthly basis. This book may have changed my perspective. Here are several things I appreciate about this book: • The book is true to its title “Palliative care TO the end of life", not AT the end of life. This is important. There is no presumption that it is about dying, per se, no favoritism toward hospice, no agenda or assumptions about the ‘right’ or ‘good’ way to live or support someone during illness. • It starts with “Caring f

Need your input on a potential JPM Series on Geriatric Palliative Care

We need your help in identifying key topics for new inter-disciplinary JPM series: Idea: To create a regular series in the Journal of Palliative Medicine that specifically addresses skill based, practice relevant topics in palliative care of older adults in a variety of venues. The first venue we want to focus on is key palliative care issues ( clinical, process, regulatory issues) for older adults in nursing homes/long term care/community living centers. Series name: TBD in consultation with editor-in-chief (ideas welcome) Format: Recommended length: 1000-1500 word limit ( not including abstract, tables, figures, references). No more than 20 references. No more than three tables and or figures. Peer reviewed : Yes. How you can help : 1. By responding to this post with your topic ideas. 2. By volunteering to be a member of the series review committee ( term of one year, and review four contributions in that time period) 3.By authoring and submitting to the series. Questions:

What Would Don Berwick Do? Obama’s Real Plan for Health Care Reform

OK, Congress has passed insurance reform . But President Obama’s proposed nomination of Don Berwick (pictured) to head CMS says a lot about the administration’s overarching plan for delivery system reform . Wake up, tea-baggers. This is not a “government takeover” of health care. Just the opposite. It’s about paying health care innovators to re-engineer this inefficient, dysfunctional mess from the inside out. The old non-system needs to die, and a new one – a real, integrated, functional health care system – must take its place. Government isn’t about to force this on anyone. The executioners, the midwives, the innovators will be – us. Berwick, Professor of Health Policy and Management at the Harvard School of Public Health and founder of the Institute for Healthcare Improvement (IHI), is perhaps the world’s leading proponent of, and authority on the mechanics of, improving health care at the operational level. The breadth of his philosophy can be summed up by two of his famously te