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Showing posts from May, 2013

When Not to Follow an Advance Directive

by: Eric Widera (@ewidera)

An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home's garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “Comfort Measures Only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.

What do you do? How do you reconcile her previously expressed hypothetical wishes in an Advance Directive with what is now a rather unanticipated scenario?

In a paper published today in JAMA Internal Medicine, Alex Smith, Bernard Lo, and Rebecca Sudore developed a 5-question framework to help physicians and surrogates through the decision making process in time like this. The framework proposes 5 key-questions to untangle these conflicts:
Is the clinical situation an emergency? In view of the patient’s values and goals, …

CPR Discussions and Harm Reduction

By: Bree Johnston

One issue that I think we have not examined sufficiently is the impact that repeated discussions about code status have on patients, family, and health care providers. I believe that repeated discussions about CPR are traumatic to the patient and family, erosive of trust, ineffective, and tend to distract the treating team from discussions and interventions that could be beneficial to patients and families.

I believe that is much more productive to think about harm reduction than to try to talk patients and their families them out of CPR. I agree with Blinderman, Krakauer, and Soloman that we need to think more actively about not offering CPR as an ethical option that is an appropriate path to harm reduction in some instances. This is the approach in the UK, and when I was there during the summer of 2010, I found that it was refreshing not to have to focus so much time on the code discussion.

Many hospitals have non-beneficial care policies in place in order…

Discussing CPR: What Makes It So Different?

by: Josh Lakin, MD Palliative Care Fellow, UCSF

This week has been full of active discussion around “the code”. As a malleable and growing fellow in palliative care, I believe that I have spent more time on the single intervention of CPR than I have eating breakfast over the past 300 and some change days. As such, the discussion around code status, what to call a code or a lack thereof, and the default with which the medical system presents our patients have been incredibly interesting for me.

But, as Diane Meyer, Rebecca Sudore, and Craig Blinderman all discussed in their replies to Alex Smith’s post from this week, possibly the more salient and controllable piece for care providers is the conversation around goals and how we recommend or don’t recommend therapies in light of those goals.

In that light, I would again like to call attention to the study that Craig brought up in his reply to Alex’s post . In that March 2012 JAMA thought piece, Craig, Eric Krakauer and Mildred Solomon …

What Is A "Natural" Death, Anyway?

by: Alex Smith, @alexsmithMD

Eric kicked off the week posting about a study comparing use of the phrase "Allow Natural Death" with "Do Not Resuscitate."  Surrogates were far less likely to opt for CPR if the physician used the phrase Allow Natural Death.

But here's the thing - what is a natural death, anyway?

I get it - death is part of the cycle of life. Seasons change.  The moon waxes and wanes.  We are born. We die.  Death is natural.

But what is a "natural" death?  Seriously, what comes to mind when you think of natural death?  Here is a video of a natural death, taken from the Planet Earth series by the BBC's NATURAL History unit (you can skip the add after a few seconds):


Death in nature is often violent, brutal, and messy.  The same adjectives could be used to describe a code.
If the video doesn't make the point, perhaps a story will.  (Thanks to Amber Barnato for this story, I'm anonymizing it).

A man pressured his pregnant wife …

The Clinician as the Choice Architect - Nudging an Informed Choice About CPR

by: Eric Widera (@ewidera)

In the first two posts of “code discussion week” we talked about how preferences for cardiopulmonary resuscitation (CPR) are not necessarily deeply held, rather they are highly susceptible to the way we present information and choice to the decision maker. As clinicians, we can potentially use this knowledge about how to influence others to “nudge” individuals to make decisions that may be in their best interest, while still preserving their autonomy as they can easily choose otherwise.

One can argue though that using these techniques to influence decisions should be avoided as we are not really helping our patients make truly informed decision making, we are just being manipulative. Furthermore, the most vulnerable of our population may also be the most susceptible to effects of these nudges through the way we frame choice.

For me, the way to reconcile the importance of the nudge while also promote truly informed decision-making is to view the clinician …

Changing the Default Code Status to DNR for Seriously Ill Patients

by: Alex Smith @alexsmithMD


What if the above form was the default for patients with serious illness?  Most current advance directive forms and the POLST have no default - although one could argue that our default without a form is full code. But what if we could set a default on these forms, so that when a patient received a diagnosis of a serious life limiting-illness, the default option was Do Not Resuscitation (DNR)?

Scott Halpern and colleagues tried this approach in a study published in Health Affairs of 132 seriouly ill outpatients with incurable diseases.  Patients were randomly assigned to complete one of three advance directives:
Comfort default: default of DNR.Life-Extension default: default "full code."Standard advance directive: patients chose preferences for rescusitation. Patients in the two "default" pathways could change their advance directive by crossing out the default, initialing the cross out, and selecting another option.  You can see examples…

It’s all in the Framing: How to Influence Surrogates' Code Status Decisions

by: Eric Widera (@ewidera)

We intuitively know that the words we choose when talking about whether or not to attempt cardiopulmonary resuscitation (CPR) may influence the decision of a surrogate. Now we have some evidence to back this up thanks to a fascinating study published in Critical Care Medicine by Drs Amber Barnato and Bob Arnold at the University of Pittsburgh.

The study randomized 256 adult children or spouses to take part of a Web-based interactive simulated family meeting.  These surrogates were asked to imagine their loved one in a hypothetical situation in which they were admitted to the intensive care unit (ICU) on life support due to a pneumonia, severe sepsis, and acute lung injury. During the simulated family meeting, the actor playing the ICU doctor tells the surrogates that their loved one has a 10% likelihood of survival to discharge in the event of cardiac arrest requiring CPR. The actor then asks the surrogate to decide the patient’s code status.  The trick…

Point/Counterpoint: Using Deception, Study Finds Clinics Violate Disabilities Act; Should Clinics Be Protected?

Point: Physicians do not deserve IRB protections like vulnerable patients

by: Sei Lee

The recent article by Lagu and colleagues entitled, “Access to Subspecialty Care for Patients with MobilityImpairment” in Annals of Internal Medicine found that when subspecialty practices in 4 US cities were contacted about a patient who was obese and hemiparetic, 22% stated they could not accommodate this disabled patient. As disturbing as this finding was, I was even more surprised to hear that the authors were required by their Institutional Review Board to shred identifying information as soon as research was completed. Thus, when they were contacted by the attorney general in one city and asked to identify which practices were discriminating against disabled patients, they informed the AG that at the instruction of the IRB, they had destroyed the information.

First, I am not an ethicist and therefore may be ignoring important considerations. However, it seems that research ethics appropri…

Leadership IS a geriatrics competency

by: Helen Chen, MD

Riding back to DFW on the airport shuttle after attending the Pioneer ACO presentations during the last session of the last day of #AGS13, I struck up a conversation with another attendee who is in private primary care practice. After learning that I am a PACE medical director, she responded, “What’s PACE?” I was surprised at the context, but not by the question. This is a conversation I have at least once a week in the community.

Invariably, after describing how the integrated, coordinated, PACE model of care serves frail , nursing home eligible, mostly dually eligible elders with the goal of helping them to remain in their communities as long as safely possible, most people I talk with want to know, “How can I get that for my mom, grandfather, (other older relative)?” Unfortunately, as many regular readers of GeriPal know, even though On-Lok began PACE in the early 70s, 40 years on, it is available in only 30 states, and serves a combined national panel s…

When Staying Silent is No Longer Acceptable

Recent issues in the news these past weeks have given me pause to reflect on my social responsibility as a physician in my global, national and local community. I do not think I was alone in being shocked and angered when I read Kellermann’s and Rivara’s perspectives piece in February’s JAMA highlighting the systematic and complete stifling of scientific inquiry into the impact or effects of gun related violence. Starting with cutting CDC funding by $2.6 million dollars-the exact amount budgeted for the Center for Injury Prevention. When this money was eventually restored it was earmarked for traumatic brain injury research. The final appropriation contained language that no funds for injury prevention or control could be used to promote or advocate gun control. This vague yet restrictive language effectively halted research into gun violence. This edict was later extended to all Health and Human services agencies including the National Institutes of Health. What continues to disturb…

That Place Between Youth and Scattered Ashes

Being a New Yorker, I am a bit obsessed with the windows of the dowager department stores that march down Fifth Avenue.  When I first moved here, I most identified with the Lord & Taylor windows -- maybe because I grew up going to Lord & Taylor on those occasions when we needed to buy a special outfit.  More recently, I've been entranced by the Bergdorf Goodman windows (#BGwindows) and have photographed and blogged frequently on same on my personal blog (#BGWindows FolliesWow!, and Head Shots).

This month, Bergdorf's landlord (a descendant of one of the original founders) released a documentary – Scatter My Ashes at Bergdorf's.   In the great tradition of most big-budget fantasy movies these days, the social media folks created a game to go along with the move release.  It was highly addicting (four of my windows grace this post) while it was up and a great way for me to unwind as we prepped for #AGS13 and recovered from all the hustle and bustle of our time in…

Using YouTube Movie Clips to Teach Breaking Bad News

Some of my favorite teaching incorporates video.  Recently, I saw an End-of-Life Nursing Education Consortium (ELNEC) DVD with movie excerpts.  A GIANT THANK YOU to whoever put the ELNEC DVD together!  It's a fantastic teaching tool!!!

I can't reproduce the DVD, but I thought it would be fun to try and find some of these and other movie excerpts on YouTube and create a teaching guide.  

I have tried pieces of what I'm publishing below, but never all of it together.  Please let us know in the comments if you try it, what works or doesn't work, or if you have other suggestions for online movie experts.


Time 30 min -1 hr, depending on how many excerpts you show, and how long you let discussion after each clip continue.  Excerpt times are included at the start of each video.

Format: Show video clip, then discuss.  Questions for discussion are included after each clip - feel free to come up with your own. Some of these are in-your-face, and some more nuanced.

Target Audienc…

Honoring Nurses

National Nurses week begins on May 6, the birthday of Florence Nightingale, the “founder of modern nursing”, and continues through May 12. The American Nursing Association can give you more information on the history of Nurses Week. And here’s a fact sheet on stats of licensed nurses in the United States and one on nurseaides/orderlies/attendants (in my opinion the unsung heroes of nursing).
Here’s the real message for the week: No one, yup, no one in the US has not been impacted by the work of a nurse.
Our job is to protect, promote, and optimize health, prevent illness and injury, alleviate suffering, care for the sick, disabled and dying. We are bedside nurses, researchers, primary and specialty care providers, educators, clinic workers, care coordinators, discharge planners, managers, administrators, anesthetists, midwives, and more. We make sure you have the right medicines, keep you clean and safe, change your diapers, dress your wounds, clean up your vomit, put in IV lines, na…

Are Older Persons Being Over Treated for Nonmelanoma Skin Cancer?

One could argue that nonmelanoma skin cancer should not even be called Cancer.  While under the microscope it looks like cancer, it doesn't really act like what most people think of when they hear the word, "Cancer."  Unlike the much less common melanoma or cancers of other organs, plain old run of the mill skin "cancer" almost never metastasizes (ie, spread to different organs).  It usually grow very slowly, and is almost never fatal.  Often it is asymptomatic and has no impact on quality of life.  This condition just does not deserve the dread and fear associated with word, "Cancer."

Since nonmelanoma skin "cancer" usually poses no threat at all to survival, the reason to treat the "cancer" is to improve well being.    We can enhance well being by treating a "cancer" that is currently bothersome to the patient, or will become bothersome if it grows and expands.  But this is where it gets interesting.  Since many of the…