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Showing posts from May, 2012

"He will definitely not survive" - I do not think it means what you think it means

Photo Copyright Annie Levy, 2008 Sorry, stuck on the Princess Bride references. At our most recent geriatrics journal club we discussed a terrific article by Lucas Zier (first author, UCSF internal medicine resident), Doug White (senior author, Pitt), and colleagues.  The article is titled Surrogate Decision Makers' Interpretation of Prognostic Information , published in Annals of Internal Medicine. Here is the setup.  You're working in the ICU.  You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions.  You sensitively state the facts: the patient has less than a 5% chance of survival.  Or perhaps you say "he will definitely not survive."  The family confers, and decides that they want to focus on keeping him alive as long as possible.  You wonder to yourself, "I know what I said. What did they hear? Do they understand that he's dying?" In this study Zier and colleagues surveyed surrogates of seri

USPSTF Recommendations for Falls Prevention

The United States Preventative Services Task Force just released a final recommendation about falls prevention strategies in the primary care setting. It’s interesting reading: Key take-home points include: The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls ( B Recommendation ). More specifically… There is high certainty that exercise or physical therapy has moderate net benefit in preventing falls in older adults There is moderate certainty that vitamin D supplementation has moderate net benefit in preventing falls in older adults (with meta-analysis showing a number needed to treat of 10 to prevent one fall)  No single recommended tool or brief approach can reliably identify older adults at increased risk for falls, but several reasona

Rant: "Hospice and Palliative Medicine" Not Listed

Quick one here (a little too long for a tweet).  I've been filling out re-credentialing at the hospital, and was asked to list my primary specialty (internal medicine) and subspecialty.  Hospice and Palliative Medicine was not listed as a subspecialty option.  I selected "other" and then typed it in. I don't think I've ever seen Hospice and Palliative Medicine listed in any of the many credentialing processes I've been through.  For that matter, when signing up to review for a journal, or for a medical conference, they often ask for subspecialty.  I can't recall (other than AAHPM) that Hospice and Palliative Medicine has ever been listed. It's been 4 years now since the American Board of Medical Specialties recognized Hospice and Palliative Medicine as a subspecialty, isn't it about time we were added to these lists?  I think we've outgrown "other". by: Alex Smith

A Chance to Revise the POLST

We have written a lot about POLST (Physician Orders for Life Sustaining Treatment) in previous GeriPal posts. Mostly, with great admiration for the entire program and for the amazing efforts of partnerships like the Coalition for Compassionate Care of California .  But, just like every in life, even the best programs can always be made better.  With that in mind, the Documentation Committee of the POLST Task Force is now considering suggestions and recommendations for changes to the form. Submissions are due June 15th, 2012, and importantly, these submissions should provide significant or substantial improvement or clarification to the form.   With that said, I'd first like to encourage all of you to submit recommendations if you have them.  Secondly, I'd also like some feedback on two of the recommendations that we are considering submitting.  Both come from previous posts (see here and here ) and mainly revolve around avoiding value-laden phrases that we think add litt

Death of the Gerontological Nurse Practitioner: Part 1 of 2

The Advanced Practice Registered Nurse Consensus Work Group and the National Council of State Boards of Nursing Advanced Practice Registered Nurses (APRN) Advisory Committee has decided to eliminate the Gerontological Nurse Practitioner track and its associated national certification exam by 2015. At the University of California, San Francisco (UCSF), this means that the last class of Gerontological Nurse Practitioners (GNP) will graduate in 2013. Starting this fall, incoming UCSF Nurse Practitioner students who wish to focus on the care of older adults will be entering the Adult-Gerontology Primary Care Nurse Practitioner track. This new program will be preparing students to care for persons aged 15 to 105. Geriatric content will be merged into the current Adult Nurse Practitioner program. All graduate schools of nursing who once offered GNP programs are affected by this change. I am struggling to make sense of this. Most of us are aware that the population of adults 65

The longer you live, the longer it will take to die

Age is one of the great modern adventures, a technological marvel—we’re given several more youthfulish decades if we take care of ourselves. Almost nobody, at least openly, sees this for its ultimate, dismaying, unintended consequence: By promoting longevity and technologically inhibiting death, we have created a new biological status held by an ever-growing part of the nation, a no-exit state that persists longer and longer, one that is nearly as remote from life as death, but which, unlike death, requires vast service, indentured servitude really, and resources...  Part of the advance in life expectancy is that we have technologically inhibited the ultimate event. We have fought natural causes to almost a draw. If you eliminate smokers, drinkers, other substance abusers, the obese, and the fatally ill, you are left with a rapidly growing demographic segment peculiarly resistant to death’s appointment—though far, far, far from healthy. These are the words of Michael Wolff writt

Coffee Is Bad For You. Coffee is Good For You. Why Am I So Confused?

Coffee is one of the most widely consumed substances in the world.  I suppose many drink coffee because they believe it tastes good.  But for many, the appeal of coffee is for its medicinal properties-specifically the stimulant effects of caffeine. The popularity of coffee and its dual use as a beverage and drug make its health effects an important public health issue.  So, it is not surprising that a recent study in the New England Journal of Medicine received a lot of attention.  The study had two important findings: (1) People who drink coffee are more likely to die (2) People who drink coffee are more likely to live Huh? Well, it is actually true.  The study really did say both of these things.  And in the end, the study does not really answer whether coffee is good or bad for you.  But it is worth taking a few moments to try to understand these contradictions.  Because if you do understand, you will be a better consumer of the research you read about in the medical l

Purity of Intention is A Shaky Foundation

I wrote previously of the anti-choice attack on palliative care and the vulnerability of providers whose protection rests on proof of their “intent” when providing palliation. The powerful forces for which purity of intent is more important than relief of suffering are fixed on legislating their view of medicine’s proper role at life’s end. They are advancing their agenda with little opposition from practitioners. At its own peril the medical lobby ignores bills that 1) raise the bar on what will pass for lawful practice and thought, 2) magnify penalties for those found guilty of forbidden thoughts and intentions and 3) encourage scrutiny and whistleblowing by onlookers and medical colleagues. A recent Georgia bill illustrates the danger. Georgia's Governor Nathan Deal Georgia’s governor recently signed HB 1114 , prohibiting assisted suicide.  Shaped by Georgia Right to Life and the Georgia Catholic Conference (thanked from the floor of the Legislative Assembly) and wi

A Thin Reed to Hang On

It’s no news to most GeriPal readers that a cadre of anti-choice forces targets end-of-life care . In their sights are common end-of-life decisions and palliative support for those decisions. They are hostile to people who, at the end of a long decline or stuck in a prolonged dying process, intentionally advance the time of death and exercise their right to stop life-prolonging technology or treatment. The operative tactic is to tie the hands of doctors attending those patients, when palliative treatment might ease the patient’s chosen death. As Dr. Timothy Quill recently pointed out in the Journal of Law, Medicine and Ethics , “Widespread agreement exists in the United States about a patient’s right to forego any life-sustaining therapy, even if his wish is to achieve an earlier death.” Treatments can be stopped, and should be stopped as humanely as possible, even if the patient expresses a wish to die in so doing. Yet current understanding of the law and practice in most states

Mostly Dead vs Completely Dead: A Distinction Best Left to Hollywood

I was at a dinner a meeting of the Greenwall Faculty Scholars , a bioethics career development program for junior faculty, when an interesting issue came up.  Several folks at our table argued that patients who donate organs after cardiac death are not "Dead" (capitol D) at the time the incision begins to harvest their organs.  The question that arose was - should patients, families, and transplant doctors be informed that the patient is not completely "Dead" before organ procurement begins? I am no transplant surgeon, but here is my basic understanding of the issue (with backup from these two articles in NEJM here and here ).  Patients who donate after cardiac (not brain) death are often kept alive using life-sustaining measures, such as mechanical ventilation supplied via a breathing tube, and medications that increase a persons blood pressure.  In some situations, with the consent of the surrogate decision maker, the patient is taken to the operating room a

The Fellowship Match: Geriatrics Is In, Palliative Care is Still Out

The biggest announcement so far at the American Geriatrics Society Annual Meeting is that Geriatrics will be entering into the fellowship match for the 2014 academic year! This is huge news for geriatrics and should serve as a push for Hospice and Palliative Medicine to get out of the position of being the last fellowship program outside of the match. Why is this important news? Both geriatrics and palliative care have been stuck with a dysfunctional matchless system. We have written on the chaos of not being in the match previously on GeriPal , heard what being 'matchless' means to applicants via a Pallimed post by Brian McMichael  , and have had important foundations encourage us to join (see this Hartford Health AGEnda post ). With Geriatrics now agreeing to join the match, there is really one holdout among all other subspecialties that have agreed that residents deserve the opportunity to have more time to decide on a fellowship path (match lists are now due 5

An Appeal to Bring Medical Eduction into Nursing Homes

What happens when the head of one of the most prominent medical education journals publishes a call for every medical school and teaching hospital to develop educational experiences in nursing homes? Will a system that bows down at the alter of the hospital experience change to raise the importance of caring for the 1.4 million nursing home residents in the US, or will the status quo rule the day? Steven Kanter, MD Steven L. Kanter, MD, Editor-in-Chief of Academic Medicine, was the one to make the appeal in an editorial published this week ( Acad Med. 2012 May;87(5):547-8 ). Dr. Kanter starts off his editorial posing the following question: "Should nursing homes be part of mainstream medical education? In other words, in addition to being important sites to learn the basics of geriatrics and the principles of long-term care, should nursing homes be sites for residents and medical students to learn core clinical, communication, and team skills? Should nursing homes b

Blogs to Boards: Question 11

This is the eleventh 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 11 Mr. Z is a 87 year old with advanced dementia living in a nursing home. At baseline he cannot recognize family members, is dependent on all ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence. He speaks about 1-2 intelligible words per day and he has had progressive loss of ability to ambulate. He is now admitted to the hospital after sustaining a hip fracture from a fall. When discussing treatment options for his hip fracture, his wife asks you how long he likely has to live. Given his current state of health, what would be the most appropriate answer: a) Given that he does not meet FAST 7C