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Showing posts from June, 2010

The Right to Fail?

Recently, Zaldy Tan MD wrote a thoughtful article in JAMA (The “Right” to Fall, JAMA. 2010;303(23):2333-2334) regarding the autonomy of elders and the tension we often face in the geripal world between doing right for the patient and preserving the rights of the patient. I’m sure many of us have experienced this and have repeatedly discussed in team and with families whether there is “anything we can do” to help the patient who is surely a slow-motion train wreck waiting to happen. Unlike Wall Street banks, we allow patients to decide to “fail” on a regular basis: she doesn’t want more help, doesn’t want to consider moving to a higher level of care, doesn’t want to have that test/procedure/ medication/(fill in the blank), and HAS capacity, however limited, to make her own decisions even when those decisions may result in injuries or hospitalizations.

Dr. Tan writes of the impact the patient’s decisions have on her aging daughter and on the treatment teams and concludes that “I would…

The breadth of life-sustaining treatment

In a recent story in the New York Times, Katy Butler described her parents' experiences with illness, the health care system, and the decline of her mother's well-being in-step with her father's physical and cognitive decline.

Butler's beautiful account of her parents' lives before the onset of illness and subsequent to her father's stroke, pacemaker placement, and progression to advanced dementia and frailty are moving in the human story alone.

But what struck me in reading the story, and some of the hundreds of comments which were posted from readers, was that this story is not just about pacemakers, health care costs, and the age old conflict between the risks and benefits of medical interventions and appropriateness in individuals of a given age or level of frailty. A retired cardiologist commented that the pacemaker was not, as with a defibrillator, keeping Butler's father alive (in what Butler described as his final years in "purgatory") but…

Presenteeism: A Public Health Hazard

Are you a good worker? Do you work hard? Do you care so much about your job that you show up to work even when sick?

Well if your answer is yes, and you work in health care, you may be a public health hazard.

An important article in the Journal Of General Internal Medicine illustrates the potentially serious public health hazards of presenteeism, or showing up to work even when sickness compromises your ability to do your job. The lead author was Dr. Eric Widera, from the UCSF Division of Geriatrics (and GeriPal!). Co-authors included Drs. Anna Chang and Helen Chen.

Dr. Widera presents a compelling case of a nursing home gastroenteritis outbreak that lasted 24 days and was prolonged by staff members coming in to work sick. Gastroenteritis outbreaks, in which numerous patients develop an illness characterized by nauseau, vomiting, and diarrhea, are very common in nursing homes, or any setting in which people live closely together (such as cruise ships or college dorms). In healthy peop…

End Stage Dementia: What to do with treatment?

Hospice programs provide much needed care and support for patients, families and caregivers for people with end-stage dementias. Thanks to the evolution of medical therapeutics, some of theses patients have been managed with cholinesterase inhibitors or NMDA receptor antagonists prior to their ultimate decline and the advent of hospice care. Physicians, families and hospice programs are then faced with a dilemma: should these medications continue?

A recent Brief Report in the Journal of Palliative Medicine (Shega, et al J Palliat Med 2009) provides perspective on this issue by surveying 152 hospice medical directors on practice patterns and clinical experiences. Seventy three percent and 33% of respondents reported more than 20% of their patients are on cholinesterase inhibitors or NMDA antagonists, respectively. Eighty percent of responding physicians would recommend discontinuation of the agents as part of the hospice plan of care. At the same time, 72% report that families had diff…

NY Times Article on Delirium

There is an article in today's New York Times about delirium, a VERY common but poorly understood condition among hospitalized elders. Delirium is an acute confusional state usually caused by an acute illness (or unfortunately the treatments we give acutely ill patients) or surgery. While patients with delirium clearly have serious brain dysfunction, the inciting causes are almost always outside of the brain.

Numerous studies suggest that delirium effects at least 1/4 of hospitalized persons over the age of 70. But it is properly diagnosed less than half the time. It is very serious. Hospitalized elders who become delirious are at much higher risk for bad outcomes including disabilty and death, as well as nursing home placement.

Delirium is commonly confused with dementia. Dementia is a chronic decline in cognitive function. Delirium is an acute change in cognitive function. Dementia and delirium commonly coexist---and patients with dementia are more likely to also get delirium.…

Preventing Disability vs. Improving Quality of Life for Elders Living with Disability: Both are Important

I heard a prominent speaker talk about studies at the National Institute of Aging.  The speaker described several new large and well funded trials aimed at preventing illnesses associated with aging, such as dementia and disability.  These studies are terrific, and worthy of funding.  I was disappointed, however, that little was said about funding for studies of older adults already living with dementia and disability.  Research in prevention will not help these patients.  I asked: where is the funding that focuses on improving the quality of life for these patients?  The speaker replied that the National Institute of Nursing Research is the funding center for end-of-life research. 

Aging research has always had a strong focus on quality of life concerns, but I worry that the emphasis has shifted too far toward the "successful aging" model.  This model sets up an unreasonable expectation that if you do all of the right things (eat right, avoid smoking, exercise your body and…

Best of the Web - Palliative Care Grand Rounds Coming Soon

We need your help. GeriPal will be hosting the July 2010 installment of Palliative Care Grand Rounds. For those of you who don’t know, Palliative Care Grand Rounds is a monthly blog series highlighting some of the best and most interesting blog posts related to palliative care, hospice (and in our case - geriatrics too!). If you find anything out there in the blogosphere that you think is worth passing on, please add it to the comment section below this post with the name of the website and the link (add a description if you’d like, but that’s optional). Last day to submit will be the 4th of July.

If you want to see a great example of palliative care grand rounds, check out this month’s edition at Bedside Manner.

by: Eric Widera

John Wooden's Feelings on Death

Much has been said about John Wooden's inspiring approach to life, but what can we learn about his attitude towards death? His family and former player Keith Erickson reflect that he hated being in the hospital, and wasn't happy for the last two years of his life. At the same time, the inner peace that Wooden expresses in this video evokes a powerful image of a "good death." How can his story be used to bring attention to the role and importance of palliative care?

Watch this incredible one minute video on John Wooden's feelings about death (interview with Rick Reilly). It moved me so much that I watched it several times and transcribed it below.



REILLY: Are you afraid to die?
WOODEN: No. I’m not afraid to die.
REILLY: How come?
WOODEN: Why should I be afraid? That is the most wonderful thing that’ll ever happen. It really is. Absolutely I’m not afraid to die.

"Once I was afraid of dying, Not Anymore" by Swen Nater (former Bruin player), written for Jo…

What is Our Responsibility?

Is advocating for equal access to opioid medication around the world part of our professional responsibility?  What about reducing racial disparities in access to high quality long term care?  Are these obligations or worthy aspirations? 

Several of us in the UCSF Division of Geriatrics have been talking recently about where clinician obligations ends and aspiration begins.  This discussion raises important questions about the limits of professionalism.

The image is a conceptual model of this issue from a terrific paper by Gruen, Pearson, and Brennan.

Caring directly for the patient in front of you is clearly a professional obligation.  In hospice care, this obligation theoretically extends to caring for the patient's family or loved ones.  I have some concerns about balancing obligations to patients and their families, but let's leave that for another post. I think clinicians can agree that direct patient care is the core of our professional responsibility.  Now let's m…

Health Status Does Not Equal Quality of LIfe

If you asked clinical researchers to describe the most important advances in research methodology over the past generation, many would cite advances in the ability to measure health-related quality of life (HRQOL). Health-related quality of life refers to domains of health that are important to patient's quality of life. By way of example, in a patient with COPD, this could include an instrument to measure dyspnea, or the extent to which COPD symptoms interfere with day to day function. There are many health related quality of life tools that are used in clinical research, and these tools have revolutionized our abilty to understand outcomes important to patients.

Despite the immense value of these tools, recently, some have recognized some problems in how these instruments are used and interpreted. Some of hese issues were articulated in an influential article by Gill and Feinstein. This first issue is that the very term "health related quality of life" is frought with …

Have We Improved Outcomes for Elderly Patients Admitted with Heart Failure?

Hospitalization for heart failure is exceedingly common, accounting for more than 1.1 million hospitalizations in 2006. It is also the leading cause of hospitalization in patients older than 65 years of age, accounting for at least 20% of all hospital admissions in this age group. The good news, according to a new paper by Bueno and colleagues published in JAMA today, is that we are doing a great job in the hospital of making them better and shipping them out. The bad news is that patients are more likely to end up in a skilled nursing facility or be readmitted within 30 days.

The JAMA study analyzed 6,955,461 Medicare fee-for-service hospitalizations for heart failure from 1993 and 2006, and importantly also looked at a 30-day post-discharge follow-up period. What they found was that length of stay decreased from 8.8 days to 6.3 days between 1993 and 2006. In hospital mortality was cut in half from 8.5% to 4.3% and overall 30 days mortality dropped as well from 12.8% to 10,7%. We r…