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Showing posts from December, 2012

Medical Foster Homes: An exciting alternative to Nursing home care

A frail older patient has reached the point that living independently at home is no longer possible and family are not available to provide care. You prepare to discuss recommendations for a different site of care, and as you begin to broach the topic, you immediately hear, "But I don't ever want to live in a nursing home!" Wouldn't it be nice to have good alternatives!

Assisted living often is incapable of meeting the frailer patient's needs. The Green House model is one way of de-institutionalizing care facilities by creating small communities with high level care, and worth a look if you are not familiar with them, but there is still an institutional component to them.

A truly exciting alternative from the Department of Veterans Affairs is Medical Foster Homes. Watch the recent profile on NBC's Making a Difference and you will be won over. Like foster care for children, Medical Foster Home (MFH) places frail older patients into family homes. Medic…

The Business of Selling Hope

This is the third post to be loosely inspired by our recent trip to the Coalition for Compassionate Care of California (see here and here for the first two).

At the meeting, someone stood up and talked about how some hospitals will pander to patients who are intent on finding a cure, saying they are in the business of selling hope.  One could argue they are in the business of selling fear, but it seems they are two sides to a coin.

Let's take, just for example, the Cancer Treatment Centers of America.  I know nothing about this company, really, other than their advertising.  But here are some examples of their advertising:




Palliative care is not one of the 21 services listed on the Cancer Treatment Centers of America Treatments page.  Thanks to some further digging by Eric Widera, try sticking "advance care planning," or "advance directive," or "POLST" into their search box.  Nada, nothing, zilch.
And hospice?  Here is what they say about hospice:
Hos…

Man Dies after Cowardly Battle with Cancer

Full credit to the Onion for the title idea for this post, and thanks to James Mittelberger for the tip.  This is the second post to be loosely inspired by our recent trip to the Coalition for Compassionate Care of California annual meeting.

We've ranted before about the terminology used by medical professionals and the media to describe patients' struggle with serious illness: Senator Kennedy loses the battle with cancer,  war on cancer, fighting the disease, etc.

The reason the Onion story is so funny is that it reduces the war metaphor to the absurd.  If the normative approach is to fight the disease, then what does that say about those who accept the seriousness of their condition?  It's ridiculous to call someone who has come to terms with a poor prognosis, and chooses to focus on comfort rather than cure, a coward.  But that's what our societies normative standards for approaching serious illness would imply.

I'll conclude by quoting from Patrice Villars or…

The Disconnect Between the Advance Care Planning Needs of the Healthcare System and the Needs of Patients

I recently attended the California Coalition for Compassionate Care’s (CCCC), Physicians’ Orders for Life Sustaining Treatment (POLST) meeting last week.  The room was filled with amazing, caring individuals from around California who are passionate and dedicated to improving advance care planning. The CCCC along with the California Health Care Foundation and California community leaders have made great strides in getting the word out about advance care planning and disseminating POLST forms.

A major theme about advance care planning that kept emerging during our meeting was the large disconnect between what the healthcare system needs (documented forms with check boxes to help direct medical care) and what patients and families need (information about the outcomes of treatment, prognostic information, and support making medical decisions).

Patients often do not think in terms of specific treatments, such as being on a ventilator, but rather what their life will be like after being…

Parenteral Fluids at the End of Life

It is better to die dry than wet. At least that is the gist of traditional thinking in hospice and palliative care, where parenteral (IV or subcutaneous) fluids are often avoided at the very end of life to prevent fluid buildup in the lungs and other organs.

The problem is that delirium often complicates end of life care as well. It is one of the four most common emergency calls for individuals receiving palliative care in the home and a common reason for admissions into inpatient hospice units. Reduced oral intake, a part of the natural dying process, may result in dehydration in some but not all individuals at the end of life, and may be a factor in the development delirium. Studies in the geriatric literature suggest that early recognition of dehydration and volume repletion is an important component of delirium prevention.

So, how do we reconcile our desire to avoid the unintended consequences of IV hydration in those at the end of life with that of treating dehydration to …

Bereavement Does Not Immunize the Grieving Person Against Major Depression

This is a guest post by Dr. Ronald Pies in response to this week's GeriPal post about the removal of the Bereavement Exclusion from DSM-5.  Dr. Pies is the Editor-in-Chief Emeritus of Psychiatric Times, Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, and Clinical Professor of Psychiatry at Tufts USM.


Dr. Widera is quite right: ordinary grief is not an illness, has adaptive value, and does not require professional treatment. But grieving persons are not immune to major depressive disorder (MDD), and, indeed, bereavement is a common trigger for MDD. There are, nevertheless, substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference. The elimination of the bereavement exclusion from DSM-5 will not change that. Let’s consider the following scenario: Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, “I feel…

Star Wars, Behavioral Economics, Geriatrics, and Palliative Care

Obi-Wan: "These are not the droids you're looking for."
Stormtrooper: "These are not the droids we're looking for."
Obi-Wan: "He can go about his business."
Stormtrooper: "You can go about your business."
Obi-Wan: "Move along."
Stormtrooper: "Move along....move along."

What if there was a tool, or set of tools that could influence our behavior in ways that we didn't recognize, or even denied?  Would you call it The Force?

Well it turns out there is such a force, and it's called behavioral economics.  I recently finished reading a  book by Daniel Kahneman called Thinking, Fast and Slow.  Kahneman won the Nobel Prize for his landmark research that led to the field of behavioral economics.  The idea is that you can alter the context in which decisions are made. You can take advantage of the irrational (fast) way in which humans are hardwired to make decisions.

My question is, how can we harness this force for t…

DSM-5: Grieving Over the Loss of the Bereavement Exclusion

Have you been tearful and sad after the death of a loved one?  Did you notice changes in appetite, difficulty sleeping, troubles concentrating, and decreased energy for at least two weeks after the loss? Did you think that was a normal, healthy, and adaptive response to a major loss? Well, if you believe the new DSM-5 criteria approved today by The American Psychiatric Association's (APA) board of trustees, you would be wrong, as your reaction would now fit the criteria for Major Depression.

Under the current DSM-IV criteria, you would have been right, as the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.   It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to m…