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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: Contact VJ Periyakoil Thanks in advance for your time and expertise.


I have many many suggestions for JPM on these issues, however will stick to 2 for just now as I could go on all day:

1. Regulatory and Care issues surrounding patients living in assisted living facilities and board and care facilities (RCFEs).

2. Clinical care of patients with advanced dementia and behavioral outbursts (both pharmacologic and non-pharmacologic interventions).

Would love to be involved in this!
Alex Smith said…
Terrific idea VJ. Glad JPM is interested. I like Ab's suggestions, however I think RE his suggestion #1, the major point is that there is NOT any regulation around palliative care in assisted living and board and care facilities, nor is there much research into the quality of care in these settings. This is an important point to make, but I'm not sure if it fits in with your vision of a skills based series. Perhaps that point would fit in with a larger piece about hospice and palliative care and regulatory issues in nursing homes? You could ask Susan Miller, Melissa Carleson, and Ab Brody to write a piece together on the topic. Other "low-hanging fruit" topics I'd like to hear more about - treatment of non-cancer pain (e.g. due to OA or compression fractures); diagnosing hospice eligibility in patients with dementia residing in nursing homes; and issues around feeding patients with advanced dementia. I'm sure there are bazillions more, but those are the first that come to mind.
VJ Periyakoil said…
Thanks Alex. Appreciate the input. This is topic close to my heart and with the population aging and more likely to spend the end of their lives in some institutional setting; it feels like we really should get the Pall Care in LTC fleshed out.

RE: Skill based: This is not a rigid requirement. My thinking is that it should be practice relevant first and foremost. Typically, skill based topics are and hence the wording. Makes perfect sense to add key knowledge pieces as well. At this point, we are in the “blue sky” mode and taking all topic suggestions (with the understanding that we will need to rank order and prioritize).

Finally, I have connected with Ab Brody and definitely like the idea of an article on regulatory issues in nursing homes related to pall care.

While there is little regulation regarding palliative care in these settings, there is a lot of regulation that affects our practice.

For instance, did you know that a DNH is pretty much useless in an RCFE if the patient is not on hospice? This is b/c the RCFE fears losing their license because the regs in California require them to call 911! This is only one of many issues with the regs that affect clinical care of our palliative care patients in these settings.

Looking forward to see where this goes!!!
Betty Lim said…
I think this is a fantastic topic. Long Term Care is so often neglected, even among Geriatricians. If you are interested in exploring regulatory issues, I would suggest looking at the January 2010 special themes edition for Health Affairs (it's a prominent Health Policy journal) where they highlight regulatory issues in Long Term Care and have several articles involving pall care. Diane Meier, Melissa Carlson and I do have a perspective piece in there about acces to Pall Care in NH.
Otherwise, pain in dementia is always a good topic. Or transitions of care between LTC and acute care. Pall Care for those in the inbetween settings such as Assisted Living and Board and Care Homes probably deserve their own special section. I'm very excited about this and hope to help out and contribute any way I can!
Eric Widera said…
I love the idea of a prognosis article specifically for the LTC setting. We know these patients are sicker and have worse functional status then their peers living in the community. It would be nice to summarize the literature regarding overall prognosis with specific attention put on co-morbidities like dementia.
ken covinsky said…
The series sounds like a terrific idea! In terms of practice relevant material, something on the palliative management of the post-stroke and post-hip fracture patient would be useful.

Along the lines of what Alex was suggesting, I'd consider some articles that go beyond the skill-based. The point of this thought is that the Geriatric/Nursing Home Palliative Care interface is still poorly defined. A series like this can help define it. So, consider encouraging some commentaries that offer critical thought about this interface.

As an example, Diane Meier and colleagues have recently suggested that palliative care should be part of the care of pretty much all nursing home patients. It was be ineresting to see this concept developed (or debated) further. What implications would such an approach have for the management of persons in long term care?
VJ Periyakoil said…
Thanks guys- terrific ideas and a great discussion!

Y'all know what happens to people who suggest topics right.....? They get asked to take the lead on their suggested ideas and write about these things :-)
Jay R. Horton said…
I think this is a great idea for a series. In addition to the terrific ideas above, I would be interested in seeing some commentary on the ongoing efforts to find common ground between geriatrics and palliative care. I work in a Department of Geriatrics and Palliative Medicine (at Mt. Sinai in NYC). At 2 separate geriatric research forums outside my institution in the past few months I have encountered suspicion and even hostility to the idea that geriatrics and palliative care might co-exist in some settings. The first geriatrics researcher took offense at my department incorporating "palliative medicine" into its name. The second small group of geriatrics researchers were upset that there was a proposal for a geriatric palliative care symposium at a future conference. One said "you know, not all geriatric patients are dying." Of course I replied by saying that neither were all palliative care patients, but I still wonder what we can do to help our geriatrics colleagues understand what our intentions are. Perhaps a piece could be co-written by one person from geriatrics and one from palliative care.

Thanks for the opportunity to make a suggestion.

Jay R. Horton, NP, MPH
VJ Periyakoil said…
I am so glad that Dr. Horton raised the sub-text to the text and I agree that this ( relationship between Geriatrics and Pall Care) is a delicate dance and we need to commit to work together to betterunderstand the ground rules of engagement.

I see this issue as having two parts to it:

PART ONE: There is significant overlap between Geriatrics and Palliative Care and thus there is a bit of a turf issue. Those of us who are dual citizens do not have to worry about this. But if you are not trained/practicing geriatric care and pall care, I can see why the turf issue could escalate.

PART TWO In a recent JPM round table, Dr. Porter Storey and Diane Meier et al discussed the "radioactivity" of palliative care as evidenced by the paparazzi hoopla about death panels. I can understand why a card carrying geriatrician would be wary of being painted by the same "radioactive" brush and would prefer to keep at a safe distance.

PROPOSED SOLUTION:It seems to me that when we face an "allergic response" we have to slow down and gently try to tease apart the issues and work collaboratively to build trust between the two fields. I am very encouraged to see that leadership in AGS and AAHPM are making great strides and have created a collaborative working arrangement ( as evidenced by joint focus groups they conducted, shared pre-conference sessions on Geri-Pal issues in 2010 and 2011).

Doctors as a tribe have been historically influenced by their professional societies. I am thus optimistic that with the support of the AGS and AAHPM, and with them modeling friendship and collaboration that we are on the right track.
Vinisha said…
This is a wonderful opinion. The things mentioned are unanimous and needs to be appreciated by everyone.

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