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Showing posts from October, 2011

Some days I hate POLST

There are days I hate the POLST form (Physician Orders for Life Sustaining Treatment). In concept, it’s significantly better than the pre-hospital DNR and a generic Advanced Directive. But here in the state of California where I work, the POLST form is misguided, poorly worded, and highly charged with negative connotations. Don’t get me wrong, I still use the POLST all the time. But I have decided it’s time to update the form. Let’s start with the name of the document: Physician Orders for Life-Sustaining Treatment. The first thing we learn as geriatricians and palliative care providers who regularly have “goals of care” and “end of life” discussions with our patients is to avoid terminology which is medical jargon or laden with weighted connotations. We know that for many of the frail and ill patients with whom we have these complex discussions, cardiac resuscitation and mechanical ventilation often do not actually sustain life in the way most of them would define the quality of

The Biggest Questions in Palliative Care and Geriatrics Finally Answered

Every week we have been posting a lot of questions on GeriPal about some of the biggest issues in geriatrics and palliative care. These range from how to define our professions (both in geriatrics and palliative care), how to communicate with patients and family members, and how best manage serious progressive illness. The thing is, it turns out to be a lot of work to think through these questions.  What if there was a better way? An easier way? Well, thanks to the power of Alex’s new iPhone 4s, there may be. We found that Siri, the new iPhone’s personal digital assistant, can tackle some of the biggest issues in both geriatrics and palliative care.  Do you think we're kidding?  Maybe this conversation will sway you (and yes, the italicized print are real responses to real questions) What is palliative care? “I found seven hospices fairly close to you.”   What is the difference between palliative care and hospice? “I don’t know that. Would you like to search the

Jane Gross on the Failings of Medicare

In the most recent Sunday New York Times, Jane Gross gives a devastating critique of Medicare's Failure to support the needs of the most vulnerable elders. It is must reading for all who care for frail elders, policy makers, and Medicare officials. Ms. Gross brings interesting perspectives to the workings of Medicare. She is one of the nation's best health journalists, who has long focused on the needs of older persons and their caregivers. She is founder of the wonderful New Old Age Blog at the New York Times. But she also has a deeply personal perspective, stemming from years as a caregiver for her mother who was severely disabled from numerous health problems. Ms. Gross indicts Medicare for generously funding many services that are harmful to frail elders, but providing little support for services that would actually help improve their quality of life. She notes that Medicare will pay for virtually any traditional disease focused treatment, irrespective of whether the

Take the "H" out of AAHPM/HPNA? Let's Discuss.

Should the word "hospice" be taken out of the professional society names: "American Academy of Hospice and Palliative Medicine," and "Hospice and Palliative Nurses Association?"  AAHPM would become AAPM.  HPNA would become PNA. This idea is completely new to me so I don't feel informed enough to give an opinion yet.  Let me present some of the arguments as I understand them.   I'll start with reasons for keeping the H. Reasons to keep the H: Palliative medicine grew out of the hospice movement in the US.  There are strong historical reasons to recognize the powerful role of hospice in nurturing palliative medicine.  There is no need to shoot hospice in the foot. Many people in these professional societies work for a hospice.  Many identify as a "hospice" provider first and foremost.  They may not feel included in an organization that did not include the name hospice in the title.  Perhaps they would splinter. Hospice is distinc

Inappropriate prescribing

It's been a while since I posted but I had to share frustration! This week I saw a new patient who has been receiving prescriptions for Librium and Serax (benzodiazepine) from her dentist/oral doctor. That was only one of a long list of issues this woman had which were concerning to me. But when there's a trickle, there's a flood. I also just received notice of a new referral for a woman needing geriatrics care whose ophthalmologist has been filling her ativan. These specialists may very well be well-meaning, trying to help these women's anxiety in the face of either poor or lack of primary care. But the unintended consequences of such prescribing is frightful to think of. It raises for me the profile of: The lack of knowledge most practicing providers have on inappropriate medications for older adults The likelihood that there are probably countless more patients who are receiving prescriptions for medications which not only should not be prescribed to them

Poster Sessions at Medical Meetings: A Better Approach

The poster session is a ubiquitous part of most medical and scientific meetings. The format is pretty much always the same. The presenter prepares a large poster describing their research project and findings, tacks it to a board, stands by the board, and waits for meeting participants to come by and talk to them about their work. It's kind of an open secret that the typical poster session at most meetings is not useful for either the presenter or the attendees. For many of the attendees, the poster session ends up being more of a social gathering than a scientific session. There can be dozens (sometimes hundreds) of posters to see. The posters one visits may be guided more by which friends are presenting than trying to learn anything new. For the presenter, the randomness of the event means that only seldomly does one get good feedback on your work. Poster sessions can be painful for junior researchers early in their career who may not know many people attending the meeting

What We Can Learn While Driving to Work

Here is today’s GeriPal puzzler: what can medicine learn from Click and Clack, the Car Talk guys? Give up? I did after guessing that maybe it's how to fix a patient’s carburetor. Lucky for me though, last weeks JAMA gave me the answer in the first sentence of an editorial by Gurpreet Dhaliwal : “Students learn reasoning by listening to others reason.”  And there is no better example of problem solving and clinical reasoning than Tom and Ray Magliozzi , the hosts of Car Talk . Dr. Dhaliwal gives us some specifics in his editorial about how Click and Clack demonstrate elements of clinical reasoning, including: Building the rapport that is critical to eliciting a good history and using humor to do so Generating and selecting hypotheses by initially making many diagnoses based on the history then verifying or rejecting those hypotheses by further questioning Showing how experience and study provide the potential solutions that lead to efficient information gathering. D

Three times higher rates of surgery before death in Munster, Indiana than Honolulu, Hawaii

A McMansion in Munster, IN, from Wikimedia Commons Honolulu, HI, from Wikimedia Commons Following up on our previous post about study that hinted at substantial regional variation in the effectiveness of advance directives, a new study in the Lancet describes considerable regional variation in surgical procedures right before death.  The authors examined claims for nearly 2 million Medicare recipients over age 65.  They found: 32% had surgery in the last year of life 18% had surgery in the last month of life 8% had surgery in the last week of life The good news is that rates of surgery before death varied by age, with the lowest rates among the oldest patients, suggesting some discretion on the part of surgeons The bad news is the tremendous regional variation in rates of surgery before death.  Rates of surgery before death were 3 times higher in the highest region (Munster, IN) than the lowest region (Honolulu, HI).  As a Hawaiian who was transplanted to the midwest f

Advance directives reduce end-of-life costs in New York and Los Angeles

Image from the Dartmouth Atlas: When have advance directives ever been shown to do anything?  They were a complete failure in SUPPORT .  Study after study demonstrates that few people fill them out, rarely are they used, and that health care proxies don't have a great idea of what their loved one want anyway.  As Angela Fagerlin and Carl Schnieder famously opined: "Enough: Failure of the Living Will." And yet, over the last few years a series of studies have breathed new life into advance directives (see here and here ).  A new study published today in JAMA adds another piece to the puzzle.  The challenge is that it's a somewhat puzzling piece. A terrific group of researchers from the University of Michigan used a nationally representative survey of older adults followed through death.  They examined variation in medical expenditures for persons with advance directives that state treatment should be limited in certa

Ever visited a patient's Facebook page? Had a patient visit yours?

The other day Eric Widera and I were teaching a course to the medical students about writing for social media outlets like Twitter and GeriPal.  One of the students asked us if a patient had ever contacted us online - my answer was no, I think Eric said he discovered a caregiver's blog.  We've mostly been able to duck this issue so far, but it's only a matter of time. A new study in the Journal of General Internal Medicine adds some empirical data to this issue.  In a survey of medical students, residents, and practicing physicians: 15% of practicing physicians had visited the online profile of a patient or family member 28% of practicing physicians were aware of a patient or family member visiting their personal site 35% of practicing physicians had received a "friend" request from a patient or family member 5% of practicing physicians had requested to be a "friend" with a patient or family member 22% of all respondents felt it was ethically