GeriPal - Geriatrics and Palliative Care Blog

While sipping my coffee Sunday morning I happened across one of the doyens of NY Times political opinion, Thomas Friedman, turning his attention to the coming crisis in elder care. It is thrilling to see such attention lavished on an issue near to our hearts, but also fascinating to momentarily see our field through someone else's eyes. So how do our nation's pundits and policymakers perceive the challenges of long term care?

Mr. Friedman provocatively frames his discussion as a question of national priorities: caring for our own elders versus maintaining our military presence around the world. He argues that several "trend lines" including the aging population, rise in prevalence of dementia, and reduced savings of retiring seniors will soon combine to present the US with a stark choice: "between nursing homes in America and nursery schools in Afghanistan". The article is a sobering, realistic call for attention to a topic largely left out of the health in…

This is a special guest post by Bebe Guill - Consulting Program Director for CHAPI, the Collaborative on Healthcare for Aging / Advanced Illness Populations at the Health Sector Management program in the Fuqua School of Business at Duke University. She oversees The Hastings Center Cunniff-Dixon Physician Awards nomination process for The Hastings Center and the Duke Institute on Care at the End of Life. 
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I have mixed feelings about awards. I often think they don’t really matter – especially in cases where (as in many elementary school events these days) “everybody” gets one. Awards programs often seem ubiquitous, self-serving, and ultimately meaningless. Sometimes, however, I think awards matter too much. I’ve been second, third runner up in piano competitions, in foot races, in writing contests, and even bottom of the heap in grants competitions, (with accompanying scathing critique), often enough to know the unique sting …

Collaborating with caregivers is often an essential part of a geriatrician's work, so I was thrilled to see that this month the Pew Internet & American Life Project has released a report on "Family Caregivers Online".

The report is based on a Pew telephone survey of 3001 adults, conducted in August-September of 2010. Among the respondents, 24% were providing care for another adult. The introduction to the report states that:

"Eight in ten caregivers (79%) have access to the internet. Of those, 88% look online for health information, outpacing other internet users on every health topic included in our survey, from looking up certain treatments to hospital ratings to end-of-life decisions."

The survey also found that caregivers were particularly likely to engage in social activities online, such as using social networking sites, or even writing reviews of clinicians and medical facilities.

My guess is that this information will not come as a surprise to most…

Perhaps you have said, or heard someone declare, "I want DNR tattooed across my chest!"

Well, someone actually had it done.  See this image in JGIM of the tattoo and the unusual story behind it.  In this case, the DNR tattoo was the result of a lost bet in a drinking game - bad idea jeans - the patient actually wanted to be full code!  


In an accompanying editorial, Bernie Lo and I describe the problem with actually tattooing DNR across your chest.  As we say, the idea is intuitively appealing, but flawed as policy.


This could be used a teaching image about respecting individuals' rights to avoid resuscitation.  The idea is to provoke a thoughtful discussion.  Questions for trainees could include:

What is behind the idea of the DNR tattoo?  Why would someone say that, or do it?Imagine you are seeing a new patient who arrests in front of you.  Preparing to do CPR you see a DNR tattoo on the chest.  How do you respond?  Why? Should DNR tattoos be respected?What can we do t…

Five years ago I was given a golden ticket as a junior faculty member at UCSF. That ticket was a Geriatrics Academic Career Award (GACA). This competitive award, administered by the Health Resources and Services Administration, supported about a third of my salary and allowed me to pursue a career as a clinician-educator in an academic setting where external funding is king.  Among other things, the GACA gave me protected time to teach and develop curriculum, a nationwide network of colleagues, and resources to attend amazing programs like the Harvard PCEP program.  Without a doubt, I would not be where I am today if there was no GACA.

The time has come for a similar award in Hospice and Palliative Care. This Thursday, July 19, AAHPM's five year effort in crafting a bill aimed at expanding opportunities for interdisciplinary education and training in palliative care will go live. Senators Ron Wyden (D-OR) and Representative Eliot Engel (D-NY13) will be introducing the Palliat…

It's early July, and so many of us are working with new trainees: fellows, residents, interns, medical students, nursing students...any kind of trainee. Last year at this time I wrote a post about explaining palliative care to patients and their families, this year I thought I'd write about how we explain hospice.

 I'll put myself out there first and look forward to reading how others approach explaining hospice in the comments.

My general explanation about hospice starts out with the experiences and perceptions of patients and family.  I usually ask something like: "Have you heard of hospice?  Tell me more about what you've heard."  I try and respond to that, addressing experiences and misperceptions, and somehow work toward a statement like the following:
Hospice is both a concept of care and a benefit.  Let's talk about the concept first.   Hospice is for people with serious illness like yourself who want to focus on quality of life.  The primary foc…

"I realized how hard it is to hear a quiet patient's voice when we are surrounded by such a cacophony of sounds:  ...the need to keep up with the most advanced surgical technology, the surgical suite manager's praise and admiration when I book a heavy load of cases, the practice management consultants' chirpy remarks about the need to view patients as revenue sources...A frail, dying, elderly widow's voice becomes so hard to hear against all the noises of contemporary private practice."  (James Rickert, MD in Quiet Caring) This quote is from one of a series of wonderful and moving case stories recently published by the Archives of Internal Medicine.   These stories show how we have lost our way in medicine.  We have more technology available than ever before, but we often fail to use technology wisely, using it in ways that do more harm than good to our patients.    Through the cacophony of all this technology, the voice of the patient and their real needs m…

In this and upcoming posts, we will review some educational products in both geriatrics and palliative care.

For many of us, it is the beginning of the academic year, and it is our best chance to have an impact on the care of our GeriPal patients. Some of us are already cringing at the notion of walking in to discover that one of our GeriPal patients has received benzodiazepines overnight for behavioral problems likely related to delirium. Now is the best time to think about education interventions for our various trainees regarding the 3Ds!

To start, the Portal of Geriatric Online Education (POGOe) http://www.pogoe.org has excellent resources.

“The 3D’s of Cognitive Impairment: An interactive card-sorting exercise”. This is a fun and easy to play game. Once you print out the cards and cut up, you can easily carry around with you and no technology is needed to play! We have played this with all levels of learners-- medical students, residents, and even fellows. We have had great suc…