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Showing posts from March, 2012

Blogs to Boards: Question 3

This is the third in a series of 41 posts from both  GeriPal  and  Pallimed  to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question ( click here for the full list of questions).   Question 3 During a hospice interdisciplinary team meeting, you hear about a 53 year old resident of the local nursing home. He has ALS with bulbar attributes, and is starting to have difficulty swallowing and speaking. He is bedbound most of the day. He has had two episodes of aspiration pneumonia in the last month. His nurse describes the scene with the patient’s wife, Sally, at his side, squeezing his hand with one hand and her rosary with the other. He explained to the nurse, “I told Sally that I don’t want a feeding tube. I’ve had a good life and have few regrets. I saw my father-in-law die on a feeding tube and I would not want to go

Aricept 23 - Another Victory for Marketing Over Patients

"What is the difference between 20 and 23? If you said three, you are off by millions—of dollars in sales, that is—at least from the perspective of Eisai , the manufacturer of donepezil (marketed as Aricept by Pfizer)."   Lisa Schwartz and Steven Woloshin , BMJ 2012 An article in today's New York Times online covers a superb piece in BMJ describing the saga of Aricept 23 - a new low in the triumph of marketing over science and patient well-being. Drug manufacturers, when faced with loss of patent protection and exclusivity for their drugs, have relied on a package of tricks to maintain a healthy revenue stream. Some have rolled out slightly modified versions (e.g., omeprazole to esomeprazole , albuterol to levalbuterol ). Some have rebranded their product for special and sometimes dubious indications (e.g., rebranding fluoxetine as Sarafem ). Some have delayed entry of generic competitors onto the market through dubious litigation and " pay-to-de

Being Accused of Murder

“You would have been hung in World War II for doing what you are doing now,” I was told by a prominent member of a surgical service at my hospital when I suggested we stop the intravenous hydration. The patient had suffered a devastating stroke. Her advance directive (notarized no less) stated that she did not want any artificial means of life support specifically mentioning artificial nutrition or hydration. Further, she also clearly stated that she would never want to be in a nursing home. The palliative care service on which I was attending was consulted to assist in removing the ventilator. We did. The next day, she was breathing on her own, showing no signs of decline, and even opening her eyes so the prominent doctor on this surgical service started intravenous hydration. I was immediately uncomfortable with this value discordant move so I called her sister who was listed as the medical power of attorney to clarify what the patient meant in her advance directive (because appa

“Elders?” “Older Adults?” “Seniors?” Language Matters

In a recent paper , some colleagues and I held the position that clinicians should routinely offer to discuss prognosis with very elderly patients. I was later interviewed about this paper by a reporter who revealed that she is in her 70’s. She asked, “what does ‘elderly’ mean? When does a person become ‘elderly’?” I bravely (read ‘foolishly’) replied, “We use the word elder as a term of respect for the older adult patients we care for. In the paper we refer to individuals over the age of 85 as the ‘very elderly.’ This is an accepted term in the geriatrics literature.” “When does someone become an ‘older adult’?” she responded. I finally sensed danger. Using my palliative care communication skills, I quickly flipped the question. “You write about issues for older adults and have been for some time. What term do you use?” “I never use term ‘elderly,’” she responded. “My readers don’t respond to ‘older adult’ either. They don’t want to be ‘older.’ We prefer the term

Rights and Dignity of Seniors in Assisted Living: A Victory

An unfortunate practice has been tolerated for too long at some continuing care retirement communities (CCRs). CCRs provide housing and services for seniors, often with a wide range of needs. Residents who are fully independent may be in one part of the CCR, while residents who are disabled and need assistance may live in the assisted living wing. Often over time, a resident will transfer from the independent to the assisted living wing. But many CCRs needlessly go way beyond separating the housing units for independent and disabled seniors. They completely separate independent seniors from those who need assistance, sometimes actively preventing contact between these groups. In these facilities, the independent and assisted living seniors eat in different facilities and participate in completely different social activities. They may never see each other. Many of the facilities claim that health needs dictate this segregation. But the need for this level of segregati

Blogs to Boards: Question 1

This is the first in a series of 41 posts from both  GeriPal  and  Pallimed  to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question ( click here for the full list of questions).   We welcome comments about any aspects of the questions or the answers/discussions.  The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome. Question 1 Ms. V is a 68 year old with metastatic non-small cell lung cancer, congestive heart failure, and mild renal insufficiency residing in an inpatient palliative care unit for management of bone pain. Her medications include morphine IR, fentanyl transdermal

Beers Criteria Contest: Submit the Craziest Medication Combinations

A colleague of mine recently told me of an encounter with a new elderly patient referred to her practice. What was most striking was the medication list that included four three different benzodiazepines and one TCA : valium, halcion, lorazepam, and doxepin . For those non-clinician’s reading this blog, this drug regimen is something that I would expect to see in Charlie Sheen’s medicine cabinet, not a frail elderly patient. Few if any physicians would ever contest that this particular cocktail of drugs is widely inappropriate to prescribe to pretty much any adult. The risks though of even one of these drugs are only magnified in elderly adults who are far more susceptible to adverse effects including delirium and falls. Yet this type of inappropriate prescribing continues. The American Geriatrics Society (AGS) is hoping to help influence this type of behavior with a newly released 2012 Updated Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Ad

The 3rd Annual GeriPal/Pallimed Party is Coming to an AAHPM/HPNA Annual Assembly Near You

It is back on - the 3rd annual GeriPal/Pallimed Party during the AAHPM and HPNA Annual Assembly!  This year's party will be held at the  Tarantula Billiards Bar and Grill on Thursday, March 8th.  We will plan to start around 9:30 PM.  We are working on reserving the four Billiards tables in the back, so look for us there. Tarantula Billiards Bar and Grill is one block away from the convention center.  The address is 1520 Stout St. The party is open to all, so drop on by. by: Eric Widera (@ewidera)

When Surrogates Override the DNR: A Terrific Geriatrics and Palliative Care Teaching Video

I'd like to draw GeriPal readers' attention to a terrific article  from the Journal of the American Geriatrics Society called, "When Doctors and Daughters Disagree: Twenty-two Days and Two Blinks of an Eye."  The paper is by Peter Abadir, Tom Finucane, and Matthew McNabney (Hopkins). While I'm sure this paper is of great interest to ethicisits, clinicians, and researchers, my primary motivation for blogging about it is the potential for use as a teaching tool.  The free availability of the video of the daughters recounting their experiences, emotions, and thoughts is such a compelling portrayal of the emotional and ethical complexities of the case.  And you won't lose the forest for the trees.  The primary teaching point - that family should be involved in advance care conversations - is made clearly by the daughter in the video. The story is familiar.  A patient is clearly DNR/DNI, and the surrogate decision makers decide otherwise.  The ICU team is i

Who Wants to Talk about Sex?

Early in my career, I cared for a gentleman with advanced pancreatic cancer. The recurrence of his cancer was devastating, and I knew his decline would be rapid. Each week he came to my office to review his symptoms, and each week was the same- a little nausea, some increased pain and no appetite whatsoever. A few weeks before his death, he came to the clinic with his wife and asked for a prescription of Viagra. With all of his symptoms, I assumed sex would be the last thing on his mind. What he said next has never left me: “There are few things in life I still enjoy. Making love to my wife is one of them, and I want to keep doing this as long as I possibly can.” After this soul etching quote, one might think I would ask each dying patient about their sexual concerns- but I have not. Year after year I struggle with asking dying patients, “Are you sexually active?” Furthermore, if I ever get the courage to ask the darn question, what on earth am I to do with the answer? As it tu