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Showing posts from August, 2013

Cancer Screening in Persons With Dementia. Just Stop It. Please.

Cancer Screening is of little benefit in persons with dementia but can cause very serious harms.   Older persons with dementia have limited life expectancies which makes any benefit from cancer screening very unlikely.  This is because cancer screening works by identifying a cancer many years (generally at least 5-10 years) before it would threaten health.

But cancer screening tests cause lots of burdens when given to persons with dementia.  The test itself often leads to discomfort, distress, and agitation.  Even worse, the results often demand a further cascade of tests that lead to more serious side effects.  Sometimes it leads to highly morbid treatment for an asymptomatic cancer that would have never caused any problems in the patient's remaining life span.

The vast majority of experts in cancer screening and geriatrics agree that cancer screening in persons with dementia is a really really bad idea.  So, you would think we would just step doing it.  But think again.  An im…

A Hospice Nurse's Experience of Assisted Suicide

by: Amy Getter, RN, MS.  is a  Hospice nurse who delivers care to the dying.  Stories about hospice care at hospicediary.org.  The name and identifying information of the patient below has been changed to protect confidentiality.

Things just seem “different” when someone “prematurely” dies. Regardless of my own feelings about what is right or wrong, moral or ethical, with what many people refer to as “physician assisted death”; Death with Dignity (DWD) is a legal course of action in the state of Washington and Oregon. This means a person who is known to be terminally ill, attested to by two physicians and meeting all the criteria, can receive a prescription which they must be able to take on their own to end their life, at their chosen time and in their chosen way. Most hospices in both Washington and Oregon when the legislation was passed evoked a neutral stance. In hospice, when I talk with people about what it means to have hospice services, I explain that a part of hospice phi…

Transfers from the Hospital to Nursing Home: An F- Grade For Quality

Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of…

The Fellowship Match Game: Gearing Residents and Programs up for the NRMP Match

Now is the time of year that residents are starting to interview at programs across the U.S. in preparation for the NRMP Specialty Match and the hopeful placement in their top fellowship program (here at GeriPal, we are still hopeful that Palliative Medicine will soon enter the match, but the good news is that geriatrics is now fully in). One of the most important aspects of the match is that everyone understands the ground rules, the most important of which is to always submit your true preferences for programs/applicants when you fill out your Rank Order List.  Residents applying to fellowships should be told this golden rule, as breaking it will NEVER be in their best interest.  To learn why this is true, try playing the following game to learn how NRPM matches residents to programs.

RULES OF THE GAME
A.  Each resident can only be accepted into one program.
B.  For the purposes of simplicity, every program in this game has only 1 fellowship position available (in real life you may …

Remembering David Solomon

I am in Lake Tahoe for a leadership retreat for the scholars in the Dennis W. Jahnigen and T. Franklin Williams Career Development Awards programs.   These awards were established about 10 years ago to support surgical and medical specialists who wish to conduct research on the geriatrics aspects of their specialties.   The agenda is chock full of inspiring talks and there is lots of time built in for networking.  There are three people missing from this meeting. 
The first two -- Dennis W. Jahnigen and T. Franklin Williams (for whom the awards were named) -- have been long gone from our ranks.  Both would be proud of these scholars who embody a vision for health care where all clinicians are providing high-quality, patient-centered health care to older adults no matter their specialty.   Both would be delighted that the National Institute on Aging has created an awards program that is supporting current and future scholars as existing funding winds down – the Grants for Early Medica…

Inappropriate Management of Hypertension and Diabetes in the Hospital

A great Viewpoint in JAMA Internal Medicine describes an important and common cause of over treatment and medication errors in hospitalized patients:   Intensifying treatment for chronic problems that are best managed in the outpatient setting.  The two most common culprits are hypertension and diabetes.

As our UCSF colleagues, Michael Steinman and Andrew Auerbach aptly note in this viewpoint, many patients, especially older patients, are admitted for acute problems like pneumonia.  They also have hypertension, diabetes, or other conditions that are unrelated to the reason for admission.

A well intentioned hospital physician may see the hospitalization as an opportunity to "tune up" the patient by intensifying treatment for these conditions.  But, this usually does more harm than good.  Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving manageme…

Research Amplifies Need for Patient-Centered Goals of Care Discussion

How important is reducing the risk of one ailment if it increases the risk of another?

A class of drugs to treat hypertension (antihypertensives) is among the most commonly prescribed medications in the United States. That probably comes as little surprise to anyone reading this. Recently, however, the online version of JAMA Internal Medicine, reported findings from a study that showed the risk of breast cancer more than doubledin postmenopausal women who took one of the drugs in this class, a calcium channel blocker, for 10 years or longer. That led me to think about the impact that these kinds of studies have on patients and families who make decisions about burdens and benefits in caring for a loved one in an aging society, where living with multiple chronic conditions is becoming the norm.

While the study underscores the importance of goals of care discussions between provider and patient, it highlights even more the critical nature of those conversations for patients living with…

2 MUST Views: Portraits of the Elderly as They Once Were and Jane Lotter Obituary

I wanted to draw GeriPal readers attention to two websites that you must view.  Really, right now. If you have 5 minutes, you won't regret it.  The first is a series of images, the second a self-authored obituary.  Both evoke a profound sense of the passage of time, of what was and what is, and manage to be wistful about the past while at the same time at peace with the present.

The first is a series of images called Reflections: Portraits of the Elderly as They Once Were by the professional photographer Tom Hussey.  In these images, the photographer portrays the elderly both as they are and as they were at a younger age in the mirror.  These images must have taken a tremendous amount of photoshop wizardry, and represent the best marriage of traditional and digital photography.  Notice how the background in the reflection has been altered to completely match the room in the portrait. 

You can use these images in your teaching with a palliative care or geriatrics team on teaching r…