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Showing posts from June, 2014

After Pronouncing

The following post is adapted from something I read at the San Francisco Veterans Affairs Geriatrics, Palliative, and Extended Care memorial service.  The case has been anonymized to protect confidentiality. 
- Alex Smith @AlexSmithMD

Many of the veterans we care for are fortunate to have family and friends with them during their last days. Some of you are here today.

Some veterans have no family or friends. Over the years, these veterans have either pulled away, or been pushed away, from their loved ones. Let us take a moment to remember the these veterans.

Last year I was asked to come and pronounce that a veteran had died in our hospice unit. I had just taken over for another attending physician and had not met this veteran while he was alive.

“Did he have any friends or family?” I asked. “No,” said our social worker, “we contacted everyone we could reach. We’ve tried for weeks. None of them would come. They are too angry.”

I went in the room. He appeared to be at peace. …

Snow and Lollipops: Reflections on caring for the dying while raising children

Over the past year of my palliative care fellowship, I have learned that the discoveries made by the dying are not always that unlike the discoveries of my newly growing children that somehow get lost to us who are hopefully somewhere in the middle. While I am far from a philosopher, it is with humility that I would like to briefly share 5 lessons I have learned from my three year-old son, Ezra, as a reflection of the many wonderful people whom I have been privileged to care for over the past year.

Lesson #1: Snow

“Snow” is a children’s book about the adventures of two little children on a snowy day. They throw snowballs, sled, ski, and build a snowman together. Then in the midst of their fun day, the sun comes out and their snowman starts to melt. Ezra, who has never seen snow, looked at me worriedly the first time he heard the story and asked, “Mommy, am I going to melt?” Even at three years of age he confronted impermanence. He slept in our bed that night, scared, and needing to …

Motivating Aging Friendly City Design with a Personal Touch

The WHO Global Network of Age-friendly Cities and Communities (GNAFCC) promotes the generation of knowledge on how to assess the age-friendliness of a city or community, and provides guidance on how to create age-friendly urban environments. All members of the Network share a commitment to creating physical and social urban environments that sustain age-friendly, healthy, livable communities for older adults.

Having the option to age independently within one’s community is a fast emerging global prerogative. Cities and communities can share experiences by joining the network directly or through sister organizing bodies such as the American Association for Retired Persons (AARP). They can access the global resources and approaches cities and communities are taking to define baseline measures for policy and practice and exchange results under commonly defined domains and categories.

Over the last two years, the City of Chicago in partnership with Northwestern University has conducted…

World Elder Abuse Awareness Day (WEAAD) is June 15 – Take Action to Protect Older Persons

It is estimated that 5 million older Americans are abused, neglected and exploited each year yet only about one in five of those crimes are ever discovered. WEAAD was launched in 2006 to promote a better understanding of abuse and neglect of older persons and to highlight its significance as a public health and human rights issue.

Each year communities and organizations around the world plan activities and programs, both small and large, in an effort to make a difference in the lives of vulnerable elders. Consider taking a moment to visit the Administration for Community Living (a part of HHS) website on WEAAD, for a variety of tools, tips and resources you can use in support of efforts to raise awareness about the importance of preventing, identifying and responding to this often hidden problem (World Elder Abuse Day Tools).

by: Joan Abrams, MPA
Associate Director UCSF Northern California Geriatric Education Center

Behavioral Symptoms of Dementia Should Be Treated WIth Behavioral Approaches

Persons with dementia often suffer from behavioral symptoms such as agitation and aggression.  For the caregiver, these symptoms can be very distressing.

Consider the case of a daughter trying to take care of her mother.   Daughter is doing her best, and after a long day of work, comes home to take care of her Mom, and help with her activities of daily living.  While trying to help her mother bathe, Mom gets angry, swings her arm toward her daughter, and yells, "why do you always try to hurt me?"  The daughter loves her Mom, but stuff like this is often the breaking point that makes transfer to a nursing home necessary.  And it is not like Mom's agitation will be much better in the nursing home.  Often, the nursing home will treat Mom with an antipsychotic drug.  The drug will be marginally effective at best at improving the agitation, and will also increase the risk for stroke, heart attack, and death.

There has got to be a better way.

Well there is a better way. A MU…

An antidote for our emotional distance

By: Laurel Coleman, MD

I have been pondering Danielle Ofri’s NY Times column, “The Silence of Doctors Around Alzheimer’s” for the past few weeks.

Dr. Ofri’s article raises some very good points, and this excerpt especially caught my attention:
“Most doctors are required to get recertification every 10 years, to undergo a battery of tests and training courses to keep us up to date and to identify shortfalls in our medical skills. We don’t, however, do any periodic checks on our inner selves, to uncover any lapses in our emotional core that might affect the care of our patients.   Just because the diagnosis of dementia can be difficult and treatments frustratingly limited doesn’t mean we can shy away from this disease. We need to face down our own uneasiness, confront our own disconcerting reactions, so that we may be there in full for our patients, their families and, indeed, ourselves.” Well-intended clinical pathways and algorithms that are designed to achieve good care do not ad…

House calls go Hollywood

Mindy Fain, Chief of Geriatrics at the University of Arizona, penned a fabulous Op-Ed in today's Los Angeles Times extolling the virtues of home care medicine to what is surely a wide new audience. Readers of GeriPal are probably familiar with how house calls can provide safe, effective care that is both cherished by patients and cost-saving to boot - but I hope visibility like this will help the message sink in with policymakers as well!

Coincidentally, I had the pleasure of meeting Dr. Fain this morning as we both arrived at a scientific workshop designed to engage geriatricians and basic scientists in a conversation about how to move recent advances in aging biology into the clinic. What a day! House calls to mouse models to clinical trials and back again. It is an exciting time to be a geriatrician!

by: John Newman

Neuropalliative Care: Call to Action and Top 10 Pointers

When I chose to pursue a residency in Neurology, the first response from my medical school acquaintances was “But, you seem so normal.”

I laughed politely while simultaneously angling myself so they could no longer see my self-drawn neuron tattoo. Inevitably my medical school classmate's follow-up statement was “I could never be a neurologist. It’s too depressing.”

But when I revealed my choice of specialty to laypersons, the first response was awe. Then I broke the bad news that I was not going to be a Neurosurgeon.  Then they would ask “well what do you do if you don’t operate?” What followed was often a longwinded explanation on my part but could have been summed up with the statement “I think about and treat patients with neurologic problems.”

After completing my training in Neurology, I chose to go into the subspecialty of Hospice and Palliative Medicine at which time I again heard “that must be so depressing,” and responded to “what exactly is that?”

To me, being a palliat…

Embracing Direct-to-Consumer Advertising by Focusing on Stopping Medications

There are plenty of examples of direct-to-consumer advertising that the pharmaceutical industry use to lure new customers. Just like the Cancer Center ads we discussed in the last GeriPal post, these ads almost universally do this by making emotional appeals to the consumer, as well as focusing on the benefits rather than presenting any real discussion of risks.

What if someone used a similar concept, but instead of trying to get people to take a drug, they try to convince patients to stop one. That’s just what Cara Tannenbaum and colleagues did in a paper published in JAMA IM, albeit they called it direct-to-consumer patient education and empowerment.

The Study

In brief, the authors of this study conducted a cluster randomized trial in Quebec in which a total of 303 long-term users of benzodiazepine medication aged 65-95 years were recruited from 30 community pharmacies. These pharmacies were randomized to either a control arm or the educational intervention arm.

The educa…

The Business of Selling Hope Part II: Direct-to-Consumer Cancer Center Advertising

The majority of cancer patients with incurable stage IV lung or colon cancer think that the chemotherapy they are receiving might cure them.  This was the finding of a study that we discussed in a previous GeriPal post.  Much was discussed about the failure of prognosis communication and the potential role that denial played in the outcome of this study.  But open up a magazine or turn on the TV and you find some other force at play, one that is in the business of selling hope and fear.  One that is best summed up by the following quote from a cancer center advertisement: “My doctor back home gave me ONLY a few weeks to live. That's when I made the ONE decision that saved my life. I went to [X cancer center]. That was seven years ago. And counting” We have written about potentially deceptive cancer center advertisments like this in the past, but a recent Annals of Internal Medicine article for the first time helps quantify the practices that these centers are using to bring in pat…