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Showing posts from November, 2010

The Legacy of SUPPORT: 15 years later

November 2010 marks the 15th anniversary of the publication of the SUPPORT Project, the largest study of end of life care ever conducted. This study that shook the medical world. SUPPORT was an ambitious effort sponsored by the Robert Wood Johnson Foundation to improve the quality of care towards the end of life in patients with serious illness. The finding that this $29 million effort had absolutely no impact on improving the quality of end of life care was stunning.

The failure of the intervention to improve end of life care and the strikingly poor quality of end of life care documented by SUPPORT led to calls for action in the lay media and by advocates of better end of life care. SUPPORT remains the most influential study of end of life care ever published, and with over 1300 citations in the peer-reviewed literature, by far the most cited.

The SUPPORT intervention study randomized over 4000 patients hospital at 5 US hospitals to usual care or the SUPPORT intervention. Patients had …

Palliative Care and Accountable Care Organizations – A Call for Comments

Accountable care organizations (ACO’s) are coming with a goal of creating a health care system that delivers higher quality care more efficiently. Important to both the palliative care community and the geriatrics community is whether our voice will be heard in developing the standards required of these organizations.  Don Berwick and his crew at CMS is now giving us the chance.

There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.

The dealine for comments is December 3rd, so there is little time to act. Lucky for us, Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: H…

Desktop Medicine: Here to Stay

I want to draw readers attention to a brilliant essay in JAMA by Jason Karlawish. He describes a new concept of medical practice that he calls “desktop medicine.”

Historically, we have used “bedside medicine” to diagnose pathological diseases. Bedside medicine incorporates the standard elements of the history and physical: the chief complaint, the history, review of systems, physical exam, and diagnostic studies. Bedside medicine is focused on diagnosing the presence or absence of disease: does this patient with dyspnea have heart failure or COPD? Is this pain due to cancer or osteoarthritis? Answers to these questions inform treatment decisions (e.g. lasix or albuterol, opioids or nsaids).

Desktop medicine, in contrast, uses different tools for different ends. The focus of desktop medicine is management of risk. Clinicians gather evidence from the patient and laboratory values, and use these to generate risk estimates, often with the help of a desktop computer. These risk estimates …

KUDOS to the Palliators who took the ABMS Boards on 11-16-2010

Geripal Readers, please join us in congratulating all the Palliators who took the ABMS Hospice and Palliative Medicine Boards yesterday.

The US currently has only one Palliative Care doctor for every 30,000 seriously ill Americans who are struggling with distressing symptoms and desperately need access to quality palliative care.

Palliators who took the boards yesterday: Your actions yesterday in taking the Board Exam helped greatly in the larger national effort to increase access to palliative care for all patients with serious life limiting illness and their families.

Thank you and strong work!
VJ Periyakoil
Stanford University School of Medicine

A novel therapeutic intervention: More time with patients

What would happen to the quality of patient care in the United States if we had more time to spend with our patients? Would we train better doctors if our residents spent more time with fewer patients? An essay in the Annals of Internal Medicine by Dr. Stanley Shi-Dan Liu, a resident at Johns Hopkins Bayview Medical Center suggests the answer to these questions is an emphatic YES!

Dr. Liu reports on his experience on the Bayview Aliki Service. Residents on the Aliki Service admit half the number of patients as other medical service teams. By having more time with each patient, they are charged with getting to know their patients as people, both in and out of the hospital. Residents spend much more time preparing their patients for discharge, call all their patients after discharge, and conduct post-discharge home visits on many of their patients.

Dr. Liu eloquently reports how having more time with patients transformed his ability to provide good care, noting:

"My patients, their…

Sex and Aging

It’s time to get comfortable with the notion that older Americans have satisfying sexual relationships. Studies on sex and aging confirm that most older adults retain sexual interest and ability. The problem is, as nicely summarized by Mark Lachs in this weekend's Wall Street Journal, that sex in the elderly remains a taboo subject, even among health care professionals.

A landmark study in 2007 by Lindau and colleagues helped disprove the myth that sex is no longer important as we age. They performed survey of 3005 older adults to evaluate the prevalence of sexual activity, behaviors, and problems in this population. The prevalence of sexual activity did decline with age – from 73% among respondents who were 57 to 64 years of age, to 53% among those 65 to 74 years of age, to 26% among those 75 to 85 years of age.

The authors of this study also found that among respondents who were sexually active, about half of both men and women reported at least one bothersome sexual proble…

Autonomy for Frail Elders

What does autonomy mean to a 95 year old woman with disability, dementia, and heart failure residing in a nursing home?  Beauchamp and Childress's classic text "Principles of Biomedical Ethics" devotes 41 pages to the principle of respect for autonomy; 34  pages are devoted to informed consent.  When we consider informed consent, we classically think of a major medical decision, such as writing an advance directive, deciding about major surgery, or withdrawing life-sustaining treatment.  How much relevance do these major life-altering decisions have for the frail elderly woman in the nursing home? 

As Holstein and co-authors note in their new book "Ethics, Aging, and Society: The Critical Turn," while bioethics is focused on these major medical decisions, most elders in long-term care facilities care less about these major decisions, and are far more concerned about everyday choices: the ability to make private phone calls, having a private space for visitors,…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …

This Week in the GeriPal Blogosphere

Every time I get off the phone with Christian Sinclair (AAHPM board member, Pallimed rock-star, and social media guru) I become very excited about the wonderful community of bloggers we have online. So in today's post I just want to highlight four outstanding posts that have popped up online in the last week.

1.This week's best post on grammar: Care Coordination Is Not a Noun

Chris Langston from the health AGEnda (the John A. Hartford Foundation blog) argues that far to often "we act as if care coordination was a thing that might come in a box, brought to us by a care coordinator." This post is well worth reading for the examples used to describe his conclusion, which is elequently stated as "care coordination is a system property that requires careful redesign of plans and procedures, new hardware and new software, and yes, new people in new positions, but none of these features taken alone defines care coordination."

2.This week's best post on the int…

Presidential Proclamations on National Hospice Month

Thirty-three years of presidential proclamations have solidified November as National Hospice Month. It is interesting to go back in the years looking at these proclamations. Some, like Reagan's 1987 proclamation, put emphasis on "the sanctity of human life and the dignity and worth of every individual". Others, like Clinton's 1993 proclamation, have emphasis on health care reform, as seen in the following line: "These and other changes to be brought about by health care reform hold the promise for even greater accomplishments as we try to improve the quality of life of those most in need."This year's proclamation by President Obama released on October 29th does a nice job of summarizing the excellent work that hospice provides, with the additional emphasis on reform. The following is the proclamation in full:

"During National Hospice Month, we recognize the dignity hospice care can provide to patients who need it most, and the professionals, volunte…