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Showing posts from January, 2014

“Can't go home, can't be admitted” – the emergency room purgatory

A 92-year-old woman with a history of stroke comes to an emergency department and is found to have fractures of her cervical spine. Neurosurgery sees her but doesn't think she needs surgery. The emergency department physician tries to admit her to the hospital as she has a new functional disability due to the fall but the hospitalist refuses as the patient doesn’t meet criteria for inpatient admission. And there she sits for another 23 hours while her fate is being decided… She has now entered a new state in modern medicine: purgatory. "Purgatory" can be defined as "a place or state of temporary suffering or misery."   This is a very apt description, used in a recent JAGS article by Timothy Platts-Mills, Scott Owens, and Marvin McBride , for what happens when patients are seen in the emergency room for an non-surgical injury but don't meet standard hospital admission criteria (as detailed in the InterQual guidelines) and can’t safely return home

Still Needed: Guidance for the “GeriPal” Patient with Heart Failure

As a (geriatric) primary care provider and (palliative medicine) specialist who cares for patients with heart failure (HF), the 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guideline for Management of HF should be directly relevant to my clinical practice, right? Well, as recently stated by Dr. Fred Masoudi in Journal Watch , these guidelines are an important comprehensive revision and reflect a growing evidence base. He notes that the guidelines provide a concrete definition of guideline-directed medical therapy (GDMT) and place substantially greater emphasis on care transitions, patient engagement, and quality improvement. In particular, Table 34 (Plan of Care for Patients with Chronic HF) may be a helpful resource, though pragmatic interventions for older HF patients with palliative care needs remain largely absent. While the 2009 guidelines had a brief section titled “End-of-Life Considerations,” these updated guidelines highlight r

Antibiotics in hospice

by: Alex Smith @AlexSmithMD Case 1: You have a 94 year old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum.  Her daughter asks if she can be treated with antibiotics "to make her feel better."  The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also hoping to live until her first great grandchild is born.  Should you treat with antibiotics? Case 2: You have an 84 year old man in the hospital being treated for a fungal infection of the heart.  The condition is non-operable and he decides to focus on comfort. The plan is to discharge to hospice.  The infectious disease team recommends a 12 week course of IV antifungals, or at the every least oral anti-fungals.  The patient, who has already had one stroke from a fungal clot in his heart that shot up to his brain, is willing to ta

One Last New Year's Resolution: Become an advocate for better health care for older adults and those with serious illness

So you have been working hard to keep your New Year's resolutions. Why not add one more resolution this year to engage in advocacy and advance health policy solutions that will improve care for older patients with serious illness? Don't let the political challenges of the day- such as government shutdowns- make you cynical. There has never been a better time than now for you to get involved! Readers of this blog know that geriatric care and palliative medicine are the cure for what ails this country. You know that older adults with >4 chronic medical conditions account for 80% of medicare spending , and that effective geriatric and palliative care improve quality of life and maintains independence.  It is time to share that knowledge and your personal vision for better health care for the US with policy makers.  They count on those on the front lines of health care to ensure they are informed.  And if we are not weighing in to tell them how policies under consideration

Does vitamin E and/or memantine help in mild to moderate Alzheimer's disease?

Alpha-tocopherol (vitamin E) and dementia have had a long and confusing history. For the prevention of dementia, Vitamin E has generally been shown to be ineffective over follow-up periods that ranged from 7 to 10 years. Even more concerning, higher doses (more than 400mg a day) have actually been shown to increase mortality (in one meta-analysis the all-cause mortality risk difference in high-dosage vitamin E trials was 39 per 10,000 persons). For the treatment of dementia, Vitamin E’s story is even a little murkier. There was an Alzheimer's Disease Cooperative Study (ADCS) randomized control trial of Vitamin E (alpha-tocopherol) , selegiline (a monoamine oxidase inhibitor), both, or placebo in adults with moderately severe Alzhiemers disease. There was no significant differences in the primary outcomes, however the authors argued that they needed to make statistical adjustments since the placebo group had higher MMSE score at baseline. After adjustment, the authors f