GeriPal - Geriatrics and Palliative Care Blog

Dear Insurance Company Executives:
Our hearts go out to you. Many in the public simply do not understand how hard your jobs are. And no where is your job as hard as when it comes to your Medicare Advantage product.
Most Medicare patients are in fee for service Medicare. Medicare pays providers for each service the senior needs. Medicare Advantage plans offer an additional option for seniors. Instead of fee for service Medicare, they sign their care over to a Medicare Advantage plan offered by your companies.
The good part about this is that your company gets paid by Medicare. But the bad news is that your company then becomes responsible for all the senior's health care costs. If the senior costs less then your payment from Medicare you make money. But if they cost more, you lose money. And many seniors need a lot of healthcare and cost a lot of money. Money that should be going to your shareholders and funding the large bonus payments you so richly deserve gets diver…

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

A new survey commissioned by the California HealthCare Foundation gives some great insight into the attitudes and experiences that Californians have with death and dying. The survey, conducted by Lake Research Partners and the Coalition for Compassionate Care of California, polled a representative sample of 1669 adult Californians including 393 respondents who lost a loved one in the past 12 months. The results can be summarized as follows:

Californians Want to but Don’t Put their Wishes in Writing

This survey shows that people when asked, actually want to discuss and plan ahead regarding end of life issues.

Approximately 45% state that it is very important to put end of life issues in writing, followed by 37% somewhat important, 12% not to important, 4% Not at all important and 1% refused. However, only 23% have put it into writing, 76% have not and 1% refused.When asked if a loved one was seriously ill, would you want them to fill out a POLST form so that you would be clear about what…

This month the Journal of the American Geriatrics Society is e-publishing ahead of print a special article you should read, “Report of the Geriatrics – Hospice and Palliative Medicine Work Group: American Geriatrics Society and American Academy of Hospice and Palliative Medicine Leadership Collaboration.”

In 2009, the leadership of the American Academy of Hospice and Palliative Medicine (AAHPM), the American Geriatrics Society (AGS), and the John A. Hartford Foundation brought together leaders in geriatrics and hospice and palliative medicine to identify areas of synergy between the two subspecialties and to work together in areas of common interest. While regular readers of GeriPal should have no problem articulating the overlap between the two specialties, the article nicely summarizes similarities and differences and includes a nice figure adapted from Sean Morrison which will be a great visual resource for presentations (see Figure 1 in the article.)

Focus groups were held in 20…

Palliative Medicine specialists do much to improve quality of life in persons with serious illness. But ultimately, providing better care to persons with serious illness demands that we improve the Palliative Medicine skills and competencies of those of us not trained in the discipline.
A wonderful review of Palliative Medicine, published as part of the Annals of the Internal Medicine In the Clinic Series nicely meets the grade. The article is directed at practicing physicians with no special expertise in Palliative Medicine. Authors Keith Swetz and Arif Kamal take a pragmatic focus and use clear lucid language.
The section on symptom management was particularly useful. The clear practical guidelines for dosing opiods were very useful. There was also an excellent discussion of management of other distressing symptoms including shortness of breath, nausea, agitation, and delirium.
Other excellent parts of this review were discussions of differences between Palliative Care and H…

My neighbor told me recently about a musician named Glen Campbell who is still performing despite Alzheimer's dementia.  This shows my age, but I had never heard of him.

His story is inspiring for the support he is receiving for continuing to perform while living with early stage dementia.  His children are his backup band, and they occasionally have to remind him "we played that one already, Dad."

Mr. Campbell's wife says that a music and performing are therapeutic for him.  The new memories don't form well - he has to be reminded that he has Alzheimer's disease - but the songs and guitar skills, honed with decades of performing, are still there.  Theresa Allison has written previously on GeriPal about how singing to people with dementia improves quality of life - I'm sure that people with dementia who sing and play music experience similar benefits.

Here's a nice video about the story.


Glen Campbell performed and was honored with a tribute during…

I am fortunate to be back at the Hospital San Carlos, in Chiapas, Mexico for two weeks. I am again welcomed by the dedicated staff doctors, the St. Vincent de Paul nuns who run the hospital, and other volunteers from around the globe. During my two weeks here, I help staff the outpatient clinic “consulta externa” while helping with complicated inpatient cases, or giving impromptu brief lectures or case reports.

After my first week, I am again reminded of the complexity of providing care in a low-resource and culturally diverse setting. Not surprisingly, there are some parallels to American healthcare, and to my work at Over60, a federally qualified health center, where I must balance current treatment recommendations and diagnostic algorithms with a scarcity of resources, an unequal distribution of wealth, and a cultural milieu which may have different understanding of health and life.

The breadth of illnesses seen is extensive ranging from tropical diseases like Chagas, to foodborne il…

Applications for the second annual Geriatrics Scholarship Award Summit are now open to ACGME interns and residents in Internal Medicine or Family Medicine from across the US. This is an exceptional oppurtunity for interns and residents, so please forward this on!

The goal of the Award is to stimulate interest in a career in academic geriatrics by recognizing residents’ scholarly or research achievements in aging or geriatrics. Each award carries with it a cash prize of $500 plus a stipend to cover travel and lodging in San Francisco to present their work at a special award summit.

Each completed application will be judged based upon:

The quality of applicant/likelihood for success in academic medicine Demonstration of an interest in geriatric medicine Quality of research project or scholarly activity Please note - scholarly projects may include but are not limited to curricular design project; community, clinical or educational program development; quality improvement projects; leader…

I didn't know my Grandmother very well as I was growing up. In fact, I'm not sure I even liked her very much when I was younger. I first met my father's mother when my family moved to Taiwan in 1979. I was five and in the middle of kindergarten. My grandparents lived with my uncle, aunt, and 3 cousins in the small apartment above my family's unit in Taipei. My grandparents spoke primarily Taiwanese, a dialect I could barely understand (I was self-congratulatory when I was clever enough to announce to my Dad "It's supper time" in Taiwanese). My parents, siblings and I lived in Taipei for almost 3 years, after which point my mother brought us back to California. My Dad stayed back in Taiwan to work for several more years.

In the end, most of my Dad's family moved to the States, my grandparents with them.
My Grandfather took some English classes which helped us communicate with each other. But my Grandmother remained someone to whom I would sheepishly nod …

My mother is in her 50’s and currently resides alone. For the past year, she’s depended largely on the Internet to stave off loneliness by visiting entertainment websites and communicating with her busy children via e-mail. 
But, while visiting an online foreign newspaper, her computer contracted a virus that blacked out her desktop and rendered her computer inoperable. Suddenly, her life line had been cut off and for weeks she wallowed in isolation and despair. Sounds melodramatic, but for many socially isolated older adults, having that virtual life line that connects them to the World Wide Web has become vital to their psychological and emotional well-being.
Lately, there have been a plethora of international news regarding elders and the use of technology in mitigating the effects of loneliness and isolation. In Israel, a Virtual Day Care Center program was developed to enable homebound elders to have social interactions via Skype, a popular voice-over-Internet Protocol service …

Just finished another couple of weeks attending on the palliative care service, and wanted to share a couple of thoughts with GeriPal readers.
Heeding the advice of Ken Covinsky to SIT DOWN! We purchased a couple of portable chairs for our palliative care team.  As a rule, we generally try and sit with patients.  However, we've noticed that we've been standing a great deal recently.  We realized this is because our hospital is "chair-penic" (the state of having lower than normal amount of chairs).  It's become too much of a hassle to track down chairs for the entire team.  Consequently, we all ended up standing.  Not anymore!  Yesterday, we proudly slung our  portable chairs over our shoulders and stormed the hospital.  We were immediately noticed by the ward attendings, who said: "what is that?" "how does it work?" and "is that a palliative care device?" I'm happy to report that the stools have led to more seated conversations …