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Showing posts from August, 2012

Retirement When Coping with Serious Illness

I have been thinking about retirement a lot lately (no, not my own!) While retirement may be mentioned in terms of the economic crisis or in blissful advertising of various products, I have been wondering about how palliative care patients face the issues of retirement and how retirement is viewed in the context of serious chronic illness.

I was slightly saddened but not surprised by the recent announcement that my friend and colleague David Oliver, PhD would be retiring. Perhaps you saw his story on CBS This Morning with Charlie Rose or at Christian Sinclair’s Plenary Session at this year’s AAHPM. I also learned that he and his wife, Debra Parker Oliver (a nationally known researcher in hospice care!), have been invited to address a plenary session at the 2013 AAHPM. If you don’t already know about David, please take some time to look at his blog (David’s Video Blog) about coping with cancer and his experience facing terminal illness, titled.  It has received over 44,000 hits-to-d…

TAVR: Life-prolonging and palliative or risky and costly?

Transcatheter aortic valve replacement (TAVR) is a therapy proposed “as the standard of care for symptomatic patients with aortic stenosis (AS) who do not have reasonable surgical alternatives” in the recent report of the 2 year outcomes from the Placement of AoRTic TraNscathetER Valve (PARTNER) trial which compared TAVR to standard medical therapy.  Proponents of TAVR suggest that this procedure provides a non-surgical alternate intervention for frail elderly patients who have life-limiting, symptomatic AS. Geriatric and palliative care practitioners need a working understanding of the potential risks, benefits and burdens of TAVR, especially for vulnerable older adults with multimorbidity.

In a recent geriatrics journal club, we summarized the 1 year and 2 year outcomes from the PARTNER trial as follows:

Of 3105 patients screened, 12% (358 patients) were randomized to transfemoral TAVR vs Standard Rx. In Standard Rx, 82.3% underwent balloon valvuloplasty. This efficacy trial was fu…

Photo of the Week - A Novel Way to Express End-of-Life Preferences

This license plate takes the concept of a DNR tattoo to the next level.  My only question is, if the car battery dies, do you attempt to jump start it?

A big thanks to Priscilla for the photo!

by: Eric Widera (@ewidera)



US Healthcare Costs Explained

Here's another facet to the phenomenon laid out in the previous post.

Coming into work today, I was struck by the latest radio advertising from CPMC (a San Francisco hospital) touting "Robotic-Assisted Cardiovascular surgery".  Being the cynic that I am, I was skeptical that this new procedure was clearly better than previous surgeries and my brief reading of the literature confirmed my suspicions.  But this highlights why our systems costs so much more than any other country, without improving outcomes.

1)  Americans love technology.  CPMC is not stupid.  They feature "Robotic-Assisted Cardiovascular Surgery" because that's what people think the latest and greatest medical breakthrough should sound like.  CPMC is merely giving what the people want:  High-tech, unclear benefit healthcare.

2)  The American System doesn't care about costs.  Medicare is expressly forbidden to consider costs in coverage decisions.  As you may guess, Robotic assisted surger…

The Over Diagnosis of Disease: How Medical Technology Can Endanger Your Health

Do you feel well?If so, DO worry.Emerging medical technology will soon fix that problem and cure you of your sense of well being.Medical technology is advancing our ability to find more and more diseases.   Even if you feel well, advancing medical technology will soon find a disease with your name on it.  
It turns out that in a lot of people who think they are well, we can find pathological evidence of some disease process if we look hard enough.And technology is improving our ability to look.If you feel good, maybe we should just look harder and try to find something wrong.
This vision of medicine is not far fetched.As a fascinating editorial in the Archives of Internal Medicine notes, this era is already upon us.Authors Jerome Hoffman and Richelle Cooper write about how overdiagnosis of disease is becoming a modern epidemic.  It is created by medical technology and forced on an unsuspecting public that may not realized that more diagnosis can sometimes endanger their health.
The e…

A Reluctance to Disagree with Recommendations

I remember when my son was about 2 years old he developed a very minor case of acute otitis media. I took him to his doctor who recommended and subsequently prescribed a course of antibiotics. I asked a couple questions but I really didn’t push her on my reluctance to go along with her recommendation for antibiotics. I left the office visit nodding that I’d give the antibiotics to him, but when I got to the car I placed the prescription in my glove box, where I’m pretty sure it sits a year and a half later.

I’m still struck to this day on my apparent unwillingness to voice my disagreement with this physician’s recommendation.  She is someone who I very much respect and trust, and maybe that is why I failed to openly disagree with her.  However, there must be more than this, as I’m more than willing to give my opinion to my colleagues at work whom I also respect and trust. What the heck happened here?

One interesting line of evidence of what may be occurring here comes from a rese…

Low Does IV Haldol to Prevent Delirium in Post-Op ICU Patients

The reason that I love preparing talks to give to residents and fellows is that I always find new and interesting articles that I otherwise would have missed if not for my last minute PubMed searches. Yesterday’s talk on delirium was no exception, as I came across this article in Critical Care Medicine - Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: A randomized controlled trial. This study appears to be the largest trial to date on delirium prevention in the ICU setting, yet I never knew it was published, and I’m still trying to digest the facts. Here is my quick attempt:

What Did the Study Do?

This was a prospective, randomized, double-blind, and placebo-controlled two-center clinical trial done in Beijing, China. The researchers enrolled patients who were admitted to the ICU after noncardiac surgery. They had a good list of exclusions which included a history of schizophrenia, epilepsy, parkinsonism, use of cholinesterase…

OncoTalk Legacy: IntensiveTalk and GeriTalk

What a blessing for the field of palliative care when brilliant pioneers in communication, bioethics, and research put their heads together and created OncoTalk.  This work, led by Tony Back, James Tulsky, and Bob Arnold, may be the single greatest achievement in the area of communication in palliative care.  We should be proud!  (Tony Back was recently awarded the Alpha Omega Alpha Professionalism award in recognition of his work).

The focus of this brief post is on the legacy of OncoTalk.  Oncotalk has also now inspired spin-offs: GeriTalk, IntensiveTalk, and DomesticTalk.

A brief blurb about each follows.

GeriTalk (source: Amy Kelley)

Physicians who care for older adults with serious or life-limiting illness often face complex communication challenges. The Mount Sinai Geritalk program is an innovative educational intervention focused on teaching, practicing and reflecting on effective communication skills. The program, modeled on the successful Oncotalk program, is the first comm…

When Religious Beliefs are at Odds with a Natural Death

Note: The details of the story have been changed to protect patient anonymity.

We recently cared for a patient with metastatic cancer to both bone and brain, who was admitted to the hospital due to severe wasting, frailty, functional decline, and intractable pain and nausea.

The patient was told that all cancer treatments have been exhausted. She had been cared for at home by her extremely devoted father, to whom she deferred for all medical decisions. The father has consistently requested that CPR and intubation be attempted if his daughter were to die. These preferences have been consistent and clear after several conversations about the minimal to no chance of benefit from CPR and intubation and the likely significant harms. The father did agree with aggressive symptom management, even if adequate pain control required some level of sedation. The patient confirmed that she agreed with her father’s wishes.

During all discussions where the topic of prognosis has been broached, the fa…

Are you smarter than a medical intern? The why, what and how of the Medicare Hospice Benefit

The AAMC lists “presenting palliative care (including hospice) as a positive, active treatment option for a patient with advanced disease” as one of its minimum competencies for medical students. Yet few physician trainees are provided with formal end-of-life care training (Sullivan AM, Lakoma MD and Block SD. J Gen Intern Med. 2003 Sep;18(9);685-95).

I decided to do something about this knowledge gap during my first year as a faculty member at the University of Utah in the Division of Geriatrics. Each month four internal medicine interns rotate through geriatrics. The interns spend the month in a variety of clinical settings and also have multiple brief (30-60 minutes) interactive teaching activities or lectures dispersed throughout their days.

I decided to use my 30-minute block of time to teach the interns about the Medicare Hospice Benefit. I created a snazzy handout, met the interns at 8:00 am, and shared the hospice information with them. The interns did their best to …