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Showing posts from 2012

Medical Foster Homes: An exciting alternative to Nursing home care

A frail older patient has reached the point that living independently at home is no longer possible and family are not available to provide care. You prepare to discuss recommendations for a different site of care, and as you begin to broach the topic, you immediately hear, "But I don't ever want to live in a nursing home!" Wouldn't it be nice to have good alternatives!

Assisted living often is incapable of meeting the frailer patient's needs. The Green House model is one way of de-institutionalizing care facilities by creating small communities with high level care, and worth a look if you are not familiar with them, but there is still an institutional component to them.

A truly exciting alternative from the Department of Veterans Affairs is Medical Foster Homes. Watch the recent profile on NBC's Making a Difference and you will be won over. Like foster care for children, Medical Foster Home (MFH) places frail older patients into family homes. Medic…

The Business of Selling Hope

This is the third post to be loosely inspired by our recent trip to the Coalition for Compassionate Care of California (see here and here for the first two).

At the meeting, someone stood up and talked about how some hospitals will pander to patients who are intent on finding a cure, saying they are in the business of selling hope.  One could argue they are in the business of selling fear, but it seems they are two sides to a coin.

Let's take, just for example, the Cancer Treatment Centers of America.  I know nothing about this company, really, other than their advertising.  But here are some examples of their advertising:

Palliative care is not one of the 21 services listed on the Cancer Treatment Centers of America Treatments page.  Thanks to some further digging by Eric Widera, try sticking "advance care planning," or "advance directive," or "POLST" into their search box.  Nada, nothing, zilch.
And hospice?  Here is what they say about hospice:

Man Dies after Cowardly Battle with Cancer

Full credit to the Onion for the title idea for this post, and thanks to James Mittelberger for the tip.  This is the second post to be loosely inspired by our recent trip to the Coalition for Compassionate Care of California annual meeting.

We've ranted before about the terminology used by medical professionals and the media to describe patients' struggle with serious illness: Senator Kennedy loses the battle with cancer,  war on cancer, fighting the disease, etc.

The reason the Onion story is so funny is that it reduces the war metaphor to the absurd.  If the normative approach is to fight the disease, then what does that say about those who accept the seriousness of their condition?  It's ridiculous to call someone who has come to terms with a poor prognosis, and chooses to focus on comfort rather than cure, a coward.  But that's what our societies normative standards for approaching serious illness would imply.

I'll conclude by quoting from Patrice Villars or…

The Disconnect Between the Advance Care Planning Needs of the Healthcare System and the Needs of Patients

I recently attended the California Coalition for Compassionate Care’s (CCCC), Physicians’ Orders for Life Sustaining Treatment (POLST) meeting last week.  The room was filled with amazing, caring individuals from around California who are passionate and dedicated to improving advance care planning. The CCCC along with the California Health Care Foundation and California community leaders have made great strides in getting the word out about advance care planning and disseminating POLST forms.

A major theme about advance care planning that kept emerging during our meeting was the large disconnect between what the healthcare system needs (documented forms with check boxes to help direct medical care) and what patients and families need (information about the outcomes of treatment, prognostic information, and support making medical decisions).

Patients often do not think in terms of specific treatments, such as being on a ventilator, but rather what their life will be like after being…

Parenteral Fluids at the End of Life

It is better to die dry than wet. At least that is the gist of traditional thinking in hospice and palliative care, where parenteral (IV or subcutaneous) fluids are often avoided at the very end of life to prevent fluid buildup in the lungs and other organs.

The problem is that delirium often complicates end of life care as well. It is one of the four most common emergency calls for individuals receiving palliative care in the home and a common reason for admissions into inpatient hospice units. Reduced oral intake, a part of the natural dying process, may result in dehydration in some but not all individuals at the end of life, and may be a factor in the development delirium. Studies in the geriatric literature suggest that early recognition of dehydration and volume repletion is an important component of delirium prevention.

So, how do we reconcile our desire to avoid the unintended consequences of IV hydration in those at the end of life with that of treating dehydration to …

Bereavement Does Not Immunize the Grieving Person Against Major Depression

This is a guest post by Dr. Ronald Pies in response to this week's GeriPal post about the removal of the Bereavement Exclusion from DSM-5.  Dr. Pies is the Editor-in-Chief Emeritus of Psychiatric Times, Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, and Clinical Professor of Psychiatry at Tufts USM.

Dr. Widera is quite right: ordinary grief is not an illness, has adaptive value, and does not require professional treatment. But grieving persons are not immune to major depressive disorder (MDD), and, indeed, bereavement is a common trigger for MDD. There are, nevertheless, substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference. The elimination of the bereavement exclusion from DSM-5 will not change that. Let’s consider the following scenario: Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, “I feel…

Star Wars, Behavioral Economics, Geriatrics, and Palliative Care

Obi-Wan: "These are not the droids you're looking for."
Stormtrooper: "These are not the droids we're looking for."
Obi-Wan: "He can go about his business."
Stormtrooper: "You can go about your business."
Obi-Wan: "Move along."
Stormtrooper: "Move along....move along."

What if there was a tool, or set of tools that could influence our behavior in ways that we didn't recognize, or even denied?  Would you call it The Force?

Well it turns out there is such a force, and it's called behavioral economics.  I recently finished reading a  book by Daniel Kahneman called Thinking, Fast and Slow.  Kahneman won the Nobel Prize for his landmark research that led to the field of behavioral economics.  The idea is that you can alter the context in which decisions are made. You can take advantage of the irrational (fast) way in which humans are hardwired to make decisions.

My question is, how can we harness this force for t…

DSM-5: Grieving Over the Loss of the Bereavement Exclusion

Have you been tearful and sad after the death of a loved one?  Did you notice changes in appetite, difficulty sleeping, troubles concentrating, and decreased energy for at least two weeks after the loss? Did you think that was a normal, healthy, and adaptive response to a major loss? Well, if you believe the new DSM-5 criteria approved today by The American Psychiatric Association's (APA) board of trustees, you would be wrong, as your reaction would now fit the criteria for Major Depression.

Under the current DSM-IV criteria, you would have been right, as the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.   It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to m…

Bed Alarms in Hospitalized Patients: Useless

Many older patients fall in the hospital and these falls often lead to injury.  Hospitals are under a lot of pressure to reduce falls.   Generally, these falls happen when patients transfer such as when an older person tries to get out of bed or get up from a chair.   While hospitalized, many patients are weak, dizzy, or confused, and they can be at risk of falling when ambulating without assistance.

To reduce this risk, bed alarms have become ubiquitous at hospitals throughout the US.  When a patient is deemed to be at high risk of falling, weight sensitive pads are applied to the bed, chair, or commode.   When a patient tries to get up, an alarm sounds in the room and at the nursing station.  The alarm reminds the patient to wait for assistance, and alerts nursing staff to assist the patient.

Remarkably, these alarms have become widely used with virtually no evidence that they actually reduce falls, let alone any studies that examine the adverse consequences of restricting mobilit…

The new brain scan for Alzheimer's: what's early certainty worth?

Last week the NY Times story on a new scan that identifies Alzheimer's in the brain caught my eye, and probably caught yours too. What is the benefit of this test, wondered my colleague Alex Smith in a recent Geripal post, and is it worth the cost?
What is the value of "knowing for sure -- period"?
I can't say I know the answer for sure, but I do know that the period of uncertainty is hard on most families when we work up early cognitive impairment in the outpatient setting. (It usually lasts for months, if not longer.)
I also know that for geriatricians in outpatient clinical practice, the diagnostic question isn't just "Is it or isn't it Alzheimer's?" It's also:
What's causing this cognitive impairment? Is it dementia (of any stripe)?Are there any additional factors making the cognition worse? (As in: medications, medications, and oh yes, medications. Benzos and anticholinergics, I'm talking about you.)
The new brain scan, obviously, do…

Phishing for Geriatrics and Palliative Care

This is generally not a post that I would do for GeriPal but in the last week I’ve received about 20 direct messages on twitter from well known faculty in both geriatrics and palliative care.  The content of these messages are all similar:

“Exactly what have you been doing in our video clip” “Hi. somebody is saying real bad rumors about you here ” “Have you seen what this person is saying about you?” “Hey someone is making up dreadful things that are about you” 

This is a phishing scam. What ever you do, do NOT click on the link. Once you do you will be asked to fill out login information so the scammers can steal your username and password. Once they have your password, they may send out messages to all your twitter followers or try your password and email combinations on banking or ecommerce websites.

So please, don't click on the link.  You may have done something embarrassing.  However,  I can promise you, if one of your colleagues found out about your embarrassing video…

Without a Treatment, Why Test for Alzheimer's?

The New York Times has a front page (at least online) story today about testing for Alzheimer's Dementia.  The story follows a 61 year old woman who has started to forget things.  She undergoes testing for Alzheimer's and the test is floridly positive: she has the early stages of Alzheimer's dementia.

The problem, as the article notes, is that treatments for Alzheimer's dementia are not effective.  The test is about knowing for sure - period.

I'm interested to hear what other folks think about testing.  We at GeriPal are obviously big proponents of estimating prognosis (see ePrognosis), but testing for Alzheimer's strikes me as both similar and different at the same time.

Knowing your prognosis can help with a whole host of decisions, such as medical decisions like screening for cancer, or life decisions such as spending time with the grandkids while you're still able.  Testing for Alzheimer's may also help clarify such health decisions and life choi…

Vaseline Balls for Constipation?

Note: Before you read any further, please consider taking Candice Tavares’ 3 minutes survey on use of Vaseline balls ( in hospice and palliative care. Candice is currently completing a specialty practice residency in palliative care and can really use your help with her research project evaluating the opinions and experiences of hospice and palliative care nurses, pharmacists and physicians with the use of petroleum jelly oral preparations for the management of constipation.

The first time I’ve ever heard of Frozen Vaseline balls was at this years AAHPM annual meeting. At first I thought it was a joke, but after seeing several tweets go out about this, I thought that eventually I’d need to look it up. We’ll the time has come.

Frozen vaseline balls for constipation/impaction.Not published but I'm wondering why not study it. Get an Ignobel prize? #HPM
— Christian Sinclair (@ctsinclair) March 9, 2012
Tip frozen Vaseline ballswork really well for consti…

Is it time for another lawsuit? Advocating to change the Medicare Hospice Benefit eligibility requirements

By now most everyone has heard about the proposed settlementof a nationwide class-action lawsuit against Medicare that would do away with the requirement to show a likelihood of medical or functional improvement before Medicare would pay for skilled services such as physical therapy.

This has led me to wonder if it is time to rewrite the Medicare manual to do away with the requirement for Hospice patients to:
Have a life expectancy of 6 months or less if the illness runs its normal course Sign a statement choosing hospice care instead of routine Medicare covered benefits {i.e. curative care} for their terminal illness.
The case for the Medicare skilled nursing benefit lawsuit (according to the New York Times):

Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.
I found

SNF’s - the discharge pathway of choice for those at the end of life

Few details are actually known about the proposed settlement of a nationwide class-action lawsuit against Medicare that would do away with the requirement to show a likelihood of medical or functional improvement before Medicare would pay for skilled services such as physical therapy.    However, unless there is a monumental change in how we deliver skilled care to Medicare enrollees, there are two conclusions that I feel safe in making:
More individuals will be using the Medicare Skilled Nursing (SNF) benefit at the end of lifeThe ability to provide high quality palliative care to these individuals will be diminished
Why will more individuals use Medicare SNF Benefit at the end of life?

There will be little incentive to prevent more and more individuals with limited ability to improve with skilled care to move quickly from hospitals to SNFs. It is easier, quicker, and often feels "safer" to send someone to a SNF from a hospital than it is to spend hours on having difficult …

The Landscape for Rehab After the Landmark Medicare Class-Action Lawsuit

A landmark settlement of a class-action lawsuit against Medicare may change how patients with chronic disabling conditions receive care. Until now, patients with chronic progressive conditions are considered ineligible for, or discharged from, rehabilitative services such as physical therapy and occupational therapy if they are deemed "unable to improve" or to have "plateaued".

The following New York Times articles describe the class-action lawsuit and the settlement which is pending judge approval:
Settlement Eases Rules for Some Medicare PatientsWhat Medicare Will Cover Even if You’re Not Likely to Get Better
Several patient, healtlh, and legal advocacy groups joined together in the lawsuit against Medicare. The decision, if accepted by the judge, will have profound consequences for patients whose conditions are expected to follow a course of progressive decline. The advocates argue that for certain conditions--maintaining an individual's functional stabili…

Most Patients with Incurable Cancer Think Chemo Might Cure Them

I'm at the National Palliative Care Research Center's Annual Foley Retreat in Deer Valley, Utah - rough life of the researcher, I know - and all the buzz is about the study published today in the New England Journal of Medicine.

In this study, Jane Weeks and colleagues surveyed 1,193 patients with incurable stage IV lung or colon cancer receiving chemotherapy.  They asked patients if they thought the chemotherapy might cure them.  They then tried to figure out if certain groups of patients were more likely to think that chemotherapy might cure them.  The remarkable findings:

69% of patients with metastatic lung cancer and 81% of patients with metastatic colorectal cancer thought the chemotherapy might cure themNon-white patients were more likely to believe chemotherapy might cure them than white patientsPatients who rated communication with their physician highly were more likely to believe chemotherapy was curative
That last sentence is not a typo!  Phrased differently, patie…

Poetry Slam

Seems like there's been a lot of poetry in the blogosphere recently.  See for example GeriPal's Haiku contest (short-long-short allowed) and Pallimed's Haiku contest (strictly 5-7-5).

And then I read a gem of a poem in today's JAMA titled, "Do Not Resuscitate," by Brenda Butka.  I'm not going to plagarize the journal, you should go read the full poem for free.  Here are the last tantalizing lines:

I can say we should not do this. He will never be the same. I can say if it were my father. I can say do not confuse resuscitation with resurrection, although neither works particularly well. You look like you are drowning, pallid and slow in the waiting room’s underwater light. So. Tell me. Tell me again. Tell me about your father.
What struck me about this poem was the true-to-life interior rush of thoughts that goes through one's head caring for a patient and family member in a situation like this.

And most importantly, that she brings it back to the patient's fath…

COO of the American Geriatrics Society @nlundebjerg on Twitter

It's time to up the ante on the push to get more GeriPal readers on twitter. Today, we have Nancy Lundebjerg (@nlundebjerg), Deputy Executive Vice President and Chief Operating Officer of the American Geriatrics Society, answering some questions on why twitter matters. She also just gave me word that all Reynolds Grantees Attending #DWRF12 can win an iPad by tweeting and successfully answering short daily questions via @theBlueCast (for more info on the game check out AGS's website here.

Widera: In your opinion, why should we get on twitter?

Lundebjerg: It’s a very powerful tool for getting the word out about geriatrics and palliative care You can use it to communicate to the world and with each other. Most politicians are on twitter and we have not yet begun to tap the power of including a mention of them in our twitter messages.

Widera: Can you give an example of an interesting way twitter can be used in geriatrics or palliative care?

Lundebjerg : There are two deba…