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Showing posts from July, 2010

Medicare's 45th

Today is Medicare’s 45th birthday. Despite its faults and limitations, without Medicare coverage, much of what we do in the GeriPal world would not be possible. I think it’s worth reflecting on what Lyndon Johnson had to say about Medicare during the struggle to pass the legislation: “I'll go a hundred million or a billion on health or education. I don't argue about that any more than I argue about Lady Bird [Mrs. Johnson] buying flour. You got to have flour and coffee in your house and education and health. I'll spend the goddamn money. I may cut back some tanks. But not on health” (from NEJM 11/27/2008) ...and what he said on July 30, 1965 during the signing ceremony: “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and thei

An inspiring addendum to Gawande's piece for physician researchers

Check out this new Huffington Post piece by Aaron Carroll, inspired by Gawande's Neworker article " Letting Go ."  Carroll and Gawande's articles reminded me of a one of the most frustrating moments in residency. I remember near the end of residency talking with other third year residents about things they were most proud of. Everyone else talked about the heroic "saves": diagnosing tamponade, recognizing aortic dissection. I remember feeling strangely guilty, but I was most proud of leading a family discussion for a patient w/end--stage CHF who had been re-hospitalized numerous times that led him to enroll in hospice. Conversely, the most frustrating moment of residency was when I could not make the system honor a patient and family's wishes. As a second year resident, I got called down to admit a nursing home patient to the ICU for pnuemonia and respiratory failure. The nursing home noticed she was having difficulty breathing, called 911, EMT'

The Americans With Disabilities Act: Happy Birthday!

This week, we are celebrating the 20th anniversary of the Americans With Disabilities Act (ADA). The ADA was historic civil and human rights legislation. It has opened doors for education, jobs, and opportunities for full participation in society for persons with disabilities. We are a better country because of the ADA. It is sometimes a good thing when what was once viewed as noble or enlightened behavior loses that status and becomes expected behavior. Once upon a time, if the best applicant for a job had a disability, it was considered noble or enlightened if the employer hired the applicant and made accomodations to make it possible for them to work. The ADA makes such behavior expected---it is the law of the land. It is an obligation of an employer to make reasonable accomodations so that a disabled employee can do the job they are qualified to do. It is an obligation of citizenship to make accomodations so that those with disabilities can rise to the heights of their talents.

REALLY Letting Go: Beyonde Gawande

by: Brad Stuart MD Atul Gawande’s brilliant essay in the New Yorker sums up the dilemma we face, whether we’re patients, families, and/or clinicians, as we near the end of life. His point is that we have to face it together: “People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come – and to escape a warehoused oblivion that few really want.” What does that statement mean? Let’s break it down. We doctors and nurses have to be willing to sit down and talk about the unspeakable – fine. Then we have to talk from our experience: that medical technology provides diminishing returns as we near death together. Again, no problem, assuming the patient is willing to go there. Many aren’t, including Sara Thomas Monopoli, Gawande’s main character. Remember Dr. Desiree Pardi, the dying palliative care physician who wouldn’t let her colleag

Atul Gawande New Yorker Article "Letting Go"

I want to draw people's attention to a fantastic new piece in the New Yorker by Atul Gawande titled, "Letting Go: What should medicine do when it can't save your life?"   The stories told are raw and emotional, and offer glimpses into the struggles of patients with life-threatening illnesses, family caregivers, nurses, and physicians.  The hospice nurse in the article is both empathetic and very direct at the same time, in a very Boston sort of way.   I was trained by the physicians mentioned in the story (Block, Marcoux, Morris, Nowak, and even Gawande for a day).  These are some of the best physicians in the world.  And yet these stellar physicians - including Susan Block, perhaps the world's foremost communication specialist - struggle to talk with patients and family members about the one clinical event everyone is 100% going to experience: death.  Gawande does an outstanding job weaving patient stories, research findings, and health policy with the inner pers

Notes from the Field: Getting Older in the Developing World

I arrived in Chiapas, Mexico, one of the most southern states in Mexico three days ago. Known as one of the most indigenously and linguistically diverse states in Mexico, it is also one of the poorest. Chiapas is also well-known for being at the center of the Zapatista uprising during the 1990s with the hope of urging the Mexican government to grant land rights and improve living conditions for the poor in Mexico. Today, many of the communities in Chiapas maintain their independence and continue to declare sovereignty and freedom from governance by whom they consider to be their oppressors. I came to Chiapas to work in a small rural hospital run by nuns from the St. Vincent de Paul Society. Before coming here, I did not know whether my skills as an Internist and Geriatrician would be of use. Certainly, the median age tends to be low in many parts of the developing world, including in Latin America. Yet, the demographic transition is continuing to occur all over the world. According to

Don't try this at home (New GeriPal video "Take out the trash")

"Don't try this at home," said Steve Pantilat, the director of our palliative care fellowship to the new palliative care fellows.  It's July, and the new fellows are learning communication skills.  "Communication skills that work well for breaking bad news and family meetings rarely work well at home." He's absolutely right.  I have occasionally attempted to use some communication techniques I learned in palliative care training at home with my wife, with disastrous results.  In my case, I usually try these techniques when I'm trying to get out of trouble for something (like not paying attention). I created this video, called " take out the trash " for all of the spouses and partners who have endured when we talk like we are running a family meeting at home.  We love you! For the "communication experts" out there - see if you can spot "Ask-Tell-Ask," NURSE (Naming-Understanding-Respecting-Supporting-Exploring), and

Why not palliative oncology?

WHY NOT PALLIATIVE ONCOLOGY? The goal of palliative care is to relieve symptoms, reduce suffering and improve a patient’s quality of life. In palliative oncology chemotherapy and radiation are used, not for a logarithmic cell kill, but to resolve specific problems caused by the cancer. Thus the focus of palliative oncology differs from its more aggressive traditional role. Here intent is the key difference; “curing” versus “healing”. Until recently the primary objectives of oncology had been summated in the following adage. “Foremost to cure, If no cure then to control, If no control then to palliate” With the advent of hospice and palliative care, palliative oncology should no longer be an issue of giving more and more pain medication. Chemotherapy and radiation can be administered, albeit at lower dosages and shorter schedules, for the purpose of reducing or eliminating symptomatic tumors. In short, palliative oncology can reduce the symptoms, suffering and pain medication re

3 Issues of Hospice

by: Robert Killeen MD Three Issues of Hospice I’d like to address three recurrent problems I’ve found in the field of hospice and palliative care. These three issues span our patient population regardless of their gender, race or economic stance. I would like to share the ways I view and approach these difficulties both as an oncologist as well as a hospice doctor. I hope that these perspectives are as helpful for the readers as they have been for me. 1) What is the “right” answer? With hospice and palliative care I’ve come to accept and advocate that there is no absolute ‘right’ answer. This question plagues the patient and especially their loved ones as they try to address what course of action to take in hospice and palliative care. What I try to instill in these folks is the question of what is the ‘best’ answer. I work closely with them to discover, to reach, the main problems the patient is having and what is the ‘best’ way to resolve them. I focus their attention to the f

Call for Submissions: 2011 Educational Exchange at AAHPM

Back by popular demand! The Educational Exchange at the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) will be back in 2011!! Don't miss this great opportunity to share your scholarly work in education while enjoying the beauty of Vancouver in February, 2011. 2011 Educational Exchange - Call for Submissions Abstract submissions are now being accepted until this Friday, July 16, for the 2011 Educational Exchange at the 2011 AAPHM and HPNA Annual Assembly in Vancouver. This session, "An Interactive Educational Exchange: Sharing Innovative Teaching Materials and Methods," first presented at the Annual Assembly in Boston in 2010, provides a structured, interactive, and hands-on forum for palliative care educators from all disciplines to present, share and exchange materials and methods from model educational initiatives, including curricula, program development, educational process, assessment tools, online materials, and research i

Management of Mucositis: Requesting Your Wisdom

I am hoping to get some advice from our Palliative Medicine expert readers on a problem that seems really vexing. Over the past year or so, we have admitted a number of patients on our inpatient service with chemotherapy (or XRT) related mucositis-- A very painful inflammation of the mucous membranes in the mouth and throat. I can only imagine how awful this must be. When I have had small localized apthous ulcers (canker sores), I have found them to be difficult and painful---more distressing than one would expect from somthing all the textbooks call a very common benign problem. I can't imagine what it must feel like to have the equivalent of one of these ulcers over the whole mouth and throat. The patients I have seen with mucositis are miserable. They are in pain, and it hurts just to talk or eat. In fact, it seems many develop additional complications because the pain prevents them from eating and drinking. I have not found our treatments for mucositis to work very well.

Long Term Care Options: A Novel Outcomes Study

What are the options when older persons can no longer live independently at home and need long term care? Many would say nursing home care. However, over the past decades, several alternative options to nursing home care have emerged. One alternative to nursing home care is PACE -The Program for All-Inclusive Care of the Elderly . Based on the On Lok Model developed in San Francisco, PACE provides a comprehensive set of medical and social services that are managed by interdisciplinary teams based in adult day health centers. These services make it possible for most PACE patients to stay at home. PACE is only available in regions that have PACE centers. Another option, available in almost states are Medicaid waiver programs in which elders are provided a case manager who organize the provision of inhome personal and supportive services. These services are aimed at keeping the elder at home. Resources that would otherwise go towards nursing home care support these services. Give

Palliative Care Grand Rounds – 3 Degrees of Separation

It’s that time again. Geripal is hosting Palliative Care Grand Rounds. This time we are going to try a little game to show how fun it is to blog about the work we do (come on - where else would one read about a Great Dane and a hat-shaped toilet paper cover all in the same article – not in the NEJM!) . So here is the game - we list three things described in the post and you try to guess what the post is about! Roving bands of doctors, a Great Dane named Murphy, and hat-shaped toilet paper covers Dr. Bruce Leff and the Johns Hopkins Elder House Call Program are spotlighted in this post from the New York Times blog , the New Old Age. The value of house calls program and their impact on the lives of patients are nicely presented, but it’s the comment section that makes this post stand out for us. Football, hospitalists, and missed expectations Chris Langston, from the John A. Hartford Foundation, posts about a recent NY Times article on hospitalists and transitions in care (“