GeriPal

by: Alex Smith @AlexSmithMD The patient was elderly and was hospitalized for a COPD exacerbation.  Fortunately, her breathing problems were easily treated, and came under rapid control after one night of hospitalization.  She was ready to return to the nursing home the next day. I informed our discharge planner that she was ready to be discharged, and was shocked to hear her respond that, "Her primary care physician said she needs to stay for 3 nights in order to quality for the Medicare skilled nursing facility benefit before the nursing home will take her back."  This seemed nuts - dumb even - she "needs" to stay in the hospital, exposing her to all the risks of hospitalization, to qualify for the Medicare Skilled Nursing Faciliity (SNF) benefit?  Her skilled needs would be the increased frequency of nebulizer treatments - fair enough.  At that point, she had not experienced any loss of function that would warrant skilled rehabilitation care above the usual

On June 12, Betty Jean Collins of Warsaw, Missouri, executed a Durable Power of Attorney for Health Care Choices (DPOA-HC) and Health Care Directive appointing Tina Shoemaker (Collins’ grand-niece) as her health care agent. On June 16, 2012, Betty was involved in an automobile accident near Lincoln, Missouri, and was pronounced dead at the scene. What happened after that is absolutely fascinating, and should make all of us look at our state laws on who has the right of disposition of a loved ones body. Collins’ advance directive stated that her DPOA became effective only after one physician certified that she was incapacitated and unable to make and communicate health care choices . It further indicated that her health care agent would carry out Collins’s wishes “regarding autopsy and organ donation, and what should be done with [her] body.” Shoemaker, the health care agent named in the DPOA form, wanted Collins’s body cremated. Collins’s daughters, who would have had the

Back in March, the New England Journal of Medicine (NEJM) published a study of long-term outcomes among survivors of in-hospital cardiac arrest by Chan and colleagues. The authors of this study looked at 6972 adults, aged 65 years or older, who were discharged after surviving an in-hospital cardiac arrest between 2000 and 2008. What they found in their study made headlines in the press: “ Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year ” The authors of this study suggested in their discussion that there is currently a “ nihilistic ” attitude toward resuscitation efforts, “ especially for older patients ”. They go on to say the following of the adults older than 85 years of age: “Although in-hospital resuscitation efforts in patients of advanced age may be perceived as futile, the relatively high survival rate among these patients suggests that discussions about advance directives should be individualized and informed by patients’ prefe

Despite recent attention, dying in the United States is a complex and often suboptimal experience for patients and providers alike. The reasons are myriad. Discussions between patients and providers regarding wishes for end-of-life care occur too infrequently or not at all. Health care proxies often are not documented and advance directives remain unclear for a large percentage of patients with serious illness resulting in aggressive, expensive and often undesired care near the end of life. Hospice is under-utilized and those who are referred are often enrolled very late in the dying process. Important gains are being made, however. Organizations like The Conversation Project are providing toolkits that help families talk with their loved ones about their wishes for end-of-life care. Startups like True North Healthcare are collaborating with provider organizations and EMR platforms to design user-friendly ways to record and share health care proxy paperwork across institution