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Showing posts from June, 2013

How do you teach about Prognostication?

Prognostication is one of the most challenging concepts; however, there are some good teaching tools to get you started! A search of the Portal of Geriatric Online Education (POGOe) revealed some excellent resources:  1. Educational Products related to more general geriatric palliative care topics (i.e. hospice, advance care planning): The Medicare Hospice Benefit Game  by Shaida Brandon received 5 stars as a teaching tool which makes card ‘gaming’ as a teaching technique easy for anyone to utilize.  The Elder Care: A Resource for Interprofessional Providers: Disease Screening in Older Adults: When to Stop  by Charles Moulton is a good handout on when to stop screening based on life expectancy. 2. Critically Appraised Papers which allow both learners and teachers to access these reviews and send them along via e-mail. For example, there is a review of the ADEPT versus Hospice Guidelines Article (REF: Mitchell SL, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffe

Death of the Gerontological Advanced Practice Nurse, Part 2

-By Joannie Ericson RN, MS This is the second and last of the Death of the Gerontological Nurse Practitioner series. Part 2 is more aptly titled Death of the Gerontological Advanced Practice Nurse as both the nurse practitioner track and the Clinical Nurse Specialist track have died. For those you not familiar with the topic, Part 1 is here for reference. Well, it finally happened… my colleagues and I recently became the final graduating class of University of California, San Francisco’s (UCSF) Gerontological Nurse Practitioner (GNP)/ Gerontological Certified Nurse Specialist (GCNS) program. Shortly after we began our program two years ago, we received the news that the Gerontological Nurse Practitioner track would be eliminated and that we would thus be the final class to graduate from the program at UCSF. When we first heard the news, we were not only surprised, but also quite nervous about how it would impact us personally, educationally, and professionally. However, a

Empathy Video

 by: Alex Smith I'm interested in people's reactions to the video called " Empathy: The Human Connection to Patient Care " produced by the Clevland Clinic.  The whole video is only 4:24 long. This is a really well done high quality production.   It's quite moving.  The video tracks faces of people in the hospital - patients (young and old), doctors, nurses, staff.  Sad George Winston-type music overlay.  No spoken words - instead there are floating phrases describing the innermost concerns or joys of the people in the video.  Some examples: Day 29 waiting for a new heart Doesn't completely understand Too shocked to comprehend treatment options Visiting Dad for the last time Celebrating 25th wedding anniversary Worried how he will pay for this 7,000 miles from home Just signed DNR Questions: Does anyone know more about this video?  Were palliative care folks involved in the making?  It seems likely. I also wonder how people will use

Appearances can be deceiving: aging, homelessness, and acute care

  Before reading any further, stop to think about the last older homeless adult you saw. If you are a clinician – think of the last older homeless patient you cared for – if you can remember the last time you had such an encounter in acute care settings such as the ED or hospital, even better. Does this person you remember look anything like the gentleman pictured here? Probably not... ...but here’s the catch: the odds are very good that you've met someone (maybe even provided clinical care for someone) who was without a home but you didn't know it because they didn't “look homeless.” In a study published this month in the Journal of Healthcare for the Poor and Underserved (JHCPU), my colleagues and I described the experience of acute care from the perspective of 100 homeless individuals seen in the ED or hospitalized over a 1 year period in New Haven, CT. We found that only 2 in 5 were ever asked about their housing status during the course of their care at the

Hospice and the Transgendered

by: Robert Killeen MD Hospice is beset by many societal obstacles in its care of the transgendered patient.  I saw a most recent example of this in our local community hospice.  An elderly female (MTF) transgendered patient had developed metastatic cancer.  Chemotherapy had failed and had left her profoundly weak and infirmed.  Estranged from her family, she had only a few friends to rely on but then only intermittently so.  Hospice admitted her to their IPU and, with supportive care, her overall status did improve.  However, now she was in a dilemma.  She was well enough to leave the unit but not well enough to go home.  Too poor to afford a single room, the patient was unable to be placed.  Chronic care facilities viewed her as if she were both male AND female.  This  prohibited her placement with a roommate.  As she was physically  female she wished to have a female roommate; the facilities saw her as originally 'male' and either could not or would not comply.  In the

Prognostic Disclosure and Other Palliative Care Needs in Dialysis Patients

"Doctors are terrible at prognostication." This is a line that I often hear from other doctors in clinical practice.  While relatively untrue purely based on prognostic accuracy (our prognostic estimates do correlate with survival), this phrase is absolutely true when it comes to the delivery of prognostic information to our patients. Further evidence of this was revealed in a recent study of prognostic disclosure in dialysis patients published in JAMA Internal Medicine .  The gist of the paper is that prognosis is rarely discussed with patients receiving dialysis leading to significant discordance between what nephrologists and patients think is the prognosis, as well as their beliefs on their candidacy for kidney transplant. The authors’ of the study enrolled patients from two hemodialysis units affiliated with academic medical centers.  All of these patients were seriously ill, based on a predicted risk of dying in the next year of at least 20%.  Among the 62

Clinical Trials Discriminate Against Older Persons with Diabetes

by: Ken Covinsky (@geri_doc) Over half of persons with type 2 Diabetes are over the age of 65.  You would think that there would be tons of research studies that tell us how to best care for older persons with diabetes.  But the truth is that our understanding of geriatric diabetes is a vast wasteland.   Most major studies of diabetes have excluded older persons or have excluded older persons with co-existing disease or functional impairment.  Studies rarely tell us how treatment for diabetes impacts problems older persons care about such as functional impairment, cognitive function, falls, and incontinence. But surely help must be on the way.  There has been a lot of attention recently to the issue of diabetes in older persons.  So, it must be the case that current studies of diabetes are starting to show they care about the real world patients with diabetes who are older and often have lots of other medical problems in addition to diabetes. Well, think again.  A study in th