GeriPal

This is the ninth 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 9 BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer. She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilate

I saw one of my favorite philosophers speak yesterday:  Peter Singer .  His book Animal Liberation is reason I became a vegetarian for 3 years...until I was an intern, post-call, hungry, and it was "rib day".  It was either a baked potato or the ribs.  The potato lost. His current work focuses on a philosophical shift, from being a "preference utilitarian" to being a "hedonistic utilitarian."  Loosely, his interpretation of hedonism in this context is "happiness."  His talk ranged widely, from a discussion of strength of orgasm, to the movie "The Matrix," to Daniel Kahneman .  I freely admit I understood less than 25%.  But as near as I can tell, he was speaking about something that might relate in a profound way to geriatrics and palliative care. What do we value as a society?  In the US, we tend to value the accumulation of wealth, as in the Gross Domestic Product (GDP).  Other societies have prioritized happiness.  Singer gave

Everyone involved in geriatric care has heard the news: The “Silver Tsunami” is coming and the U.S. healthcare system is not prepared. According to the Eldercare Workforce Alliance (EWA), the current health care system is already overwhelmed by demands for geriatric care and those specializing in the care of older adults cannot meet the current demand let alone the projected needs. EWA outlines the critical workforce shortage in detail. There are only 7,029 certified geriatricians practicing in the U.S., roughly half the number currently needed, and falling. I remember first reading this and feeling somewhat saddened and overwhelmed. What could I do to address this shortage other than start taking an antidepressant and continue working with a population that I love? It occurred to me that I could make a difference by helping others prepare. My question changed from “how can I make a difference?” to “how can I help my non-geriatrics trained colleagues prepare to meet this need?”

The United States spends more on health care than any other country. By far. Yet life expectancy in the United States is about the lowest among Western industrialized countries. While I can't prove it, I am coming to believe these is at least a partial cause and effect relationship between these facts. How can that be? How can spending so much on health care actually be bad for the health of our country? There are several possible links: Many tests and procedures that are performed are unnecessary. Unnecessary tests and procedures cost a lot of money and harm patients. The dysfunctional primary care system in the US leads to uncoordinated care, less opportunity for preventive care, and more care in expensive acute care settings instead of from primary providers. This leads to both higher costs and poor health outcomes. The high cost of US health care makes both individuals and society poorer. Wealth is one of the strongest predictors of life expectancy--a fact

This is the seventh 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 7 JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam. Prior to her hospitalization, she took oxycodone ER 30mg q12h. Currently she is on a hydromorphone IV PCA at 2mg/hour, with 2mg q30 minute boluses. She used 72mg of IV dilaudid in the last 24h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe

This is the fifth 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 5 In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice?” Which one of the following is not a potential scenario to use octreotide? Choose the best answer. a) A 37 year old male with end stage alcoholic hepatitis who starts vomiting blood  b) A 90 year old with a severe diarrhea w

A dominant focus of research in Geriatric Medicine has been on the prevention of the types of disability that are common in older persons. This research is important, because if it is successful it will lead to more years of independent living in which seniors do not need the help of caregivers or care in nursing homes. But in our zeal to prevent disability in older persons, we sometimes paint an overly bleak picture of disability. Preventing and delaying disability is a very good thing. But there are no interventions or lifestyle changes that fully prevent late life disability. Rather, effective interventions slow down the process. The vast majority of persons who live to old age will experience a period of disability, and this period will often be prolonged. Our research on prevention of disability needs to complemented by studies that teach us how to help frail and disabled elders have an excellent quality of life. Is it really possible for a senior to be sign

For the most part in geriatrics and palliative care we like to point the finger at other medical providers and say, "STOP."  Stop giving so much chemotherapy.  Stop giving so many medications.  Stop scanning. But now it's time to take a long hard look in the mirror. Medical specialty organizations are being asked to come up with a list of 5 tests or treatments that are over-utilized or may actually be harmful.  This effort, called the Choosing Wisely Initiative , is being spearheaded by the American Board of Internal Medicine ( ABIM ) Foundation.  ABIM President and renowned geriatrician Christine Cassel was quoted in today's New York Times saying: “In fact, rationing is not necessary if you just don’t do the things that don’t help.” This same article notes that as much as 1/3 of health care costs are wasted on unnecessary hospitalizations, tests, and treatments. So far 9 specialty boards have come up with their lists - the boards and there list are here

Have you ever read something that made you very sad? I did at the end of last week. It was an earlier post on this blog – Being Accused of Murder – that Dan Matlock had written. It’s frustrating, as I know all too well, this system of ours when it comes to letting – or not letting -- someone die. The story below is the tale of a death when there isn’t a champion like Dan who is inside an institution and who stands up to speak for a patient. It’s the tail end of a story that began when a family caregiver was rescued from an endless round of diagnostic appointments by a geriatrician who said “here’s what we’re going to do” and laid out a practical course of action that covered the medical and social needs of the patient in question. It’s a tale of a death in a nursing home where hospice beds were very new and the culture change had been slow to follow. It’s been over a decade now and the story still makes me mad. It’s the story of my aunt, the story of how she died. I wa

Bill Thomas is a very busy man. He is the founder of the Eden Alternative that has been on the forefront of transforming nursing homes into elder-centered communities.  He developed the Green House Project , which focuses on replacing institutional nursing homes with smaller, 10-12 person homes.  He has given talks on the need to change the culture of aging (see the  TEDx video  below).  And now, he has released his latest book, the Tribes of Eden , a novel inspired by his "life’s work as a self-proclaimed nursing home abolitionist seeking to change the way society views aging." I was given the opportunity to interview Bill Thomas about the experience of being a writer and how the Tribes of Eden book can impact the way we care for our aging population.  Here is the transcript: Widera: So what is the connection between the Eden alternative and your new book Tribes of Eden? Thomas: For the past twenty years the Eden Alternative has been working to make long-t