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Showing posts from October, 2013

On Cooks and Cookbooks: Failure of a Palliative Care Pathway

by: Alex Smith @AlexSmithMD

Wouldn’t it be great if we came up with a standardized approach to caring for hospitalized patients in the last two days of life? Think of it. Experts in hospice and palliative care could come to consensus on the best palliative care pathway for hospitalized patients nearing the end of life. Standardized assessment of distressing symptoms, the use of opioids, and other common medications used near the end of life. We could incentivize use of pathway, and improve care across the board. We should do it, right?

Well in the UK, they did it. It was widely adopted in the UK and throughout Europe. And now they’re retracting it.

The Liverpool Care Pathway was just that – an intervention designed to export the best of hospice and palliative medicine to non-palliative care clinicians caring for hospitalized patients in the UK.  And now the government is scrapping it.

How did this happen? First, two critical must reads for more details. Stories in the med…

Literature Potpourri

by: Alex Smith, @AlexSmithMD

Some great paper GeriPal readers should be award of published recently:
In the Journal of Pain and Symptom Managment, Harvey Chochinov calls for action on dignity conserving care.  He argues for just 20 minutes of dedicated time four times a year to reflect on the subject of caring, using brief videos as prompts (a very GeriPal concept).  Here is an excerpt, "Formal education for healthcare providers lacks a continued focus on achieving a culture of caring. If caring really matters, healthcare systems can insist on certain behaviors and impose certain obligations to improve care tenor, empathy, and effective communication....Healthcare professionals must set aside some time, supported by their institutions, to advance a culture of caring—now is the time to take action."Opioid prescribing for chronic pain is a hot topic - see this New York Times article about the forthcoming FDA restrictions on Vicoden prescribing, restrictions opposed by the Ameri…

Doing the Right Thing and Making It Pay

Advanced care and palliative care can reduce healthcare costs for people with serious chronic illness. It’s hard to dispute that this is a good thing. But some dispute it anyway, using graphic language to frighten people into believing that something wonderful will be taken away from them in a heartless attempt to cut costs.

Yes, these are scare tactics, but they are more than that. They reflect a deep cultural anxiety that the mistakes that led to the downfall of managed care will be resurrected by health care reformers. “Death panel” rhetoric may give voice to justifiable fears that access to services wanted by patients and their physicians will be denied by agents of payers and of providers who are increasingly assuming financial risk.

These fears must be confronted head-on. Advanced care and palliative care take no test, procedure or intervention off the table. They take nothing away. In fact they provide new services and a new kind of support to seriously ill people and their lo…

Specialized Care for Older Hospitalized Adults as a Palliative Care Intervention

Hospitals are dangerous places for older adults.   Nearly a third of hospitalized older adults are discharged with a new major functional disability they didn't have before becoming to the hospital. They are also at greater risk for being unable to return home, to require nursing home placement, and to be rehospitalized within 6 months.  Moreover, having delirium in the hospital is even worse, as it is associated with an even greater risk of long term cognitive impairment, institutionalization, and death compared with those who don't develop delirium.

Thanks to our geriatrics colleagues, a number of interventions, including acute care of elders (ACE) units and the Hospital Elder Life Program (HELP), have been developed around the idea that a redesigning the hospital care system can improve these outcomes.  What though are we to make of a new negative study published in BMJ by Sarah Goldberg, Rowan Harwood and colleagues on specialized care units for older adults with deliriu…

Peace

I walked into her room. She was lying in her bed, her silver hair in one long, beautiful braid down the side of her face, her eyes closed, arms crossed over her chest, breathing quietly. She had one leg up, bent under the blanket. At the foot of the bed her cat was curled in a ball. The walls were covered in cat pictures, cat sayings, cat drawings: a feline-lover’s dream. She was even wearing cat pajamas.

I came to the side of her bed, to whisper hello and listen to her lungs. Instead I burst into tears and could not stop. In 25 years of practicing medicine I have never done this. As I wept, our recreation director came in to give me a hug. And then she told me not to cry, because Sandy was not suffering any more.

Sandy has early-onset Alzheimer’s disease. She and her husband Gary led a life together full of passion for the outdoors and for animals (sheep dogs AND cats). Gary cared for her at home as long as he could. But Sandy started having severe neuro-psychiatric symptoms and…

Do Not Hospitalize orders for nursing home residents with advanced dementia

by: Alex Smith @alexsmithMD



Advanced dementia is a terminal illness needing palliative care. Unfortunately, there is a great divide between this statement of the world as it should be, and the current reality of the world as it is.  Rates of pain and shortness of breath are high for patients with advance dementia.  Patients with advanced dementia often reside in nursing homes, and few nursing homes offer specialized palliative care services.  And, as we can see from an article in this months Journal of the American Geriatrics Society, communication about prognosis and goals of care is still lacking.

In this study, Elizabeth Mann and colleagues asked health care proxies (generally family caregivers) of nursing home residents with advanced dementia a series of open-ended questions about Do-Not-Hospitalize orders.  Hospitalizing patients with advanced dementia is often (though not always) more  harmful, leading to potentially burdensome and painful interventions (feeding tube insertion, n…

ePrognosis: What are the Next Steps

by: Alex Smith @alexsmithmd



We need your help.

We've come a long way with ePrognosis, our online and now mobile tool kit to estimate life expectancy in the elderly.  To quickly review:
Published systematic review of prognostic indices for older adults (JAMA link)Launched ePrognosis in January 2012.Over 1 million page views since launch, most from mobile devicesLaunched mobile-friendly responsive web-design version of ePrognosis this summer (2013).  Responsive web design allows you to access ePrognosis from a web browser on any size device - a PC, laptop, tablet, or phone.  The website will automatically resize the browser window and the information in the window for the size of screen you are using.ePrognosis users said the "bubbleview" home page was too complicated.  They just wanted to be quickly pointed to the best index for the patient in front of them.  We re-designed the landing page to be much simpler, asking easy questions that quickly take users to the highest qu…

Adding Prognosis to Cancer Screening Decisions: The ePrognosis Cancer Screening App

The goal of cancer screening is to identify asymptomatic cancer well before it causes symptoms or death.  This means that there is a long “lag time" before a patient sees a benefit from these screening tests.  This is in direct contrast to harms, which often occur rather immediately with these screening tests.  It would make sense then for us as health care professionals to focus cancer screening on those most likely to benefit from these medical interventions, and conversely, avoid screening in those who are unlikely to live long enough to see a benefit but will be exposed to immediate harms.  The problem is that as health care professionals, we aren't very good at this.

Multiple GeriPal posts have documented the health care systems proclivity at performing cancer screening in indivudals with a poor prognosis.  For some egregious examples, just take a look at these posts about cancer screening in those with dementia (here and here) and those with unresectable cancer (here a…