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Showing posts from September, 2014

New POLST reflects evolution of how we talk about life sustaining treatment

by: Laura Petrillo (@lpetrillz)

There is increasing interest around the country in documenting patient preferences for life sustaining treatment, with the hope that patients may receive care in line with their goals and values during an emergency.  Many states in the US do this through Physician Order for Life Sustaining Treatment (POLST) programs, which are active or developing in all but five states [1].  California has had a law in place since 2008 that mandates honoring a POLST, and on October 1st, 2014, the state will roll out a new version, the first revision since 2011.  The changes are subtle, but there are definite shifts in language and emphasis that reflect larger themes.

Here we'll take a look at how the new California version compares to POLST equivalents already in use in other states, and what the changes suggest about how attitudes about this important topic are shifting in our community. 

What is a POLST? 

The POLST is an out of hospital physician’s order that ind…

Can Someone with Debility or Adult Failure to Thrive still be Admitted to Hospice?

I’m hearing a lot of questions about whether someone with frailty, debility, or adult failure to thrive can still be admitted to hospice, especially since CMS will no longer beaccepting either debility or adult failure to thrive (AFTT) as a principal diagnosis on hospice claim forms starting on Oct. 1, 2014. The answer is YES and what follows is my attempt to help clarify the issue and secure my spot as a 2015 Hospice Hero (OK -- I made that award up).

The Difference Between the Principle Hospice Diagnosis and Hospice Eligibility

The key to untangling this question is to understand the difference between the principal hospice diagnosis and hospice eligibility. These are not the same, although they are often discussed as if they were. So what is the difference?

Briefly, the principal hospice diagnosis is the diagnosis (ICD 9 Code) that the certifying hospice physician determines to be the most contributory to the patient’s terminal condition or prognosis. This is listed on the hos…

Training doctors to be a little more like cab drivers

by: Alex Smith, @AlexSmithMD

As it's early in the year, we usually like to post about some advice for trainees, particularly fellows that are new to our geriatrics and palliative care services.

This year, let's focus on the goal of the first visit.  Regardless of the reason for consult, a primary goal of the first visit should always be "Get to Know the Patient."

This should not be hard.  Taxi drivers and barbers do this effortlessly (OK not all, but many.  And OK, my experience lately has been more with Uber drivers than taxi.  But I digress). 

The problem is that it runs counter to our medical training.  We are conditioned to get to the reason for the consult: having a goals of care discussion, introducing hospice, or treating the nausea.  To be sure, sometimes the symptoms are so severe you have to focus on them first, then get to know the patient later.  Often there is time, however, once the symptoms are under control, to get to know the patient.  And if you j…

Hey Dr. Emanuel: you might not want to die when you're 75!

by: Alex Smith, @alexsmithMD

You may have heard of a new article in the Atlantic by Dr. Ezekiel Emanuel provocatively titled, "Why I Hope to Die at 75". 

Please take a moment to read it

If you haven't read it, and are still reading this post, I get it, you're too busy. I love the Atlantic but find their articles too long too.  So I will summarize:
When we get old, we get weak in the mind and body.  Life is no longer vibrant.  Our contributions dwindle  Dr. Emanuel would not want to prolong his life past 75This does not mean he wants to commit suicide, it means he does not favor spending resources to extend his life after age 75 My initial impression, upon hearing the title, was...yuck!  This plays into every ageist stereotype - and from a renowned bioethicist no less!

On further reading, however, I realized that his argument is much more nuanced and complex than his hammer of a title would suggest. 
He describes something we have studied and blogged about: the fa…

New IOM Report on Dying in America

by: Alex Smith @alexsmithMD

I'd like to draw GeriPal readers' attention to the new report issued by the Institute of Medicine titled, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life."

This report represents the culmination of a huge amount of work by incredibly smart people.  Many of these people we know well, including Diane Meier, James Tulsky, Bernie Lo, Jean Kutner, Christian Sinclair.  Other folks contributed in different ways, like Amy Kelley and Melissa Aldridge who wrote a commissioned paper, and Susan Block, Betty Farrell, VJ Periyakoil, and Joanne Wolf who contributed to reviewing the draft.

The last report, "Approaching Death: Improving Care at the End of Life" was published in 1997, and served as a major road map for improving palliative and hospice care in this country.

I will use this brief post to review some preliminary thoughts, having read through the summary materials available on the IOM web…

Competitive Bidding? Is it really competitive or making it harder for patients to get what they need

Over the last few months, ever since Medicare started its competitive bidding process  my colleagues and I, in the UCSF Housecalls program have had a harder time getting our homebound patients the durable medical equipment (DME) they need.   The purpose behind the competitive bidding process seemed like a good idea--lower the costs and reduce fraud that has been occurring with DME.

From the Medicare site:
"The program:
Helps you and Medicare save moneyEnsures that you have access to quality medical equipment, supplies, and services from suppliers you can trustHelps limit fraud and abuse in the Medicare Program" But in reality, the effects have created less competition, worse access, worse service, and patients dying or declining functionally because of difficulty getting much needed equipment. 

Case in point: a 90 yo woman died from advanced dementia and multiple worsening pressure ulcers, and was not able to get the Alternating pressure pump she needed for her hospital bed…

A False Hope: Artificial Nutrition in the Dying Patient

My patient was dying and his family was terrified. Riddled with abdominal tumors and engorged gastric blood vessels, Mr. G, a 54 year old Korean man with advanced hepatitis B-related liver cancer would not survive this hospitalization. For weeks, he had suffered from progressive abdominal pain and distention, and had recently lost his desire for food and the ability to take anything by mouth. He had difficulty swallowing anything, and he felt like his abdomen was going to explode when he tried.

His large extended family, his wife in particular, was preoccupied with feeding him. On admission to the hospital she requested placement of a tube or an IV to deliver nutrition since he was no longer eating. She was adamant that we intervene soon, since it was clear to them that he was deteriorating and didn’t have much time. It was hard enough to watch him grow sicker with cancer, but they were not willing to watch him starve to death.

 But, of course, he wasn’t actually starving to deat…

Using the Skills Learned at VITALtalk to Take Out the Trash

We just spent the last several days learning facilitation skills at the VITALtalk faculty development course.  This truly amazing course is meant to give health care professionals like us the skills needed to run communication training programs at our own home institutions.

After just finishing the course, we thought it would be interesting to do something similar to what Alex Smith did in his "Take Out the Trash Video." There, he used some of the communication techniques he learned in palliative care training at home with his wife.  His results were less than perfect.

We figured our advanced skills might be more successful.   See for yourself (if you don't see the video below click here for the YouTube version)




by: Eric WideraRachelle BernackiRoshni GuerryLinsey O'DonnellBrook CaltonLaura (aka Jillian Gustin)Mark (aka Steve Berns)Susan (aka Sara Johnson)Steve (aka Dave Kregenow)
Note: THIS VIDEO IS NOT PUBLISHED BY VITALtalk (c). It is published by adoring fans who…

Urine Catheters in the Hospital: Bad Stuff

When I was a resident, it was routine to place urine catheters (a catheter threaded up the urethra, into the bladder) in older patients when they landed in the hospital.  For some diagnoses, we were even taught that the urine catheter was standard of care.  For example, virtually any patient admitted with a diagnosis of congestive heart failure (CHF) had a urine catheter placed.

While we knew these urine catheters were uncomfortable for patients, we truly thought we were doing the right thing.  Generally, a patient hospitalized with CHF has retained too much fluid.  So, we treated the patient with drugs (diuretics) to get rid of the fluid (by making the kidneys produce more urine).  It is important to get rid of enough fluid, but it can also be hazardous to get rid of too much fluid.  We were taught that it was very important to closely measure how much fluid we were removing, and the only way to do this accurately was with a urine catheter.  This is because the urine catheter makes…

Handshakes, handholding, and other dangerous methods of transmitting bacteria

by: Alex Smith @AlexSmithMD

In a recent study in the American Journal of Infection Control, researchers coated a gloved hand in e. coli.  One person with the e coli glove then they shook hands, high-fived, and fist bumped another person with a sterile glove.  Transfer of e coli to the sterile glove was measured.

Results:

Highest transfer of bacteria: HandshakeLowest transfer of bacteria: Fist bump (high five was in the middle)Difference: Fist bump less than 10% of bacteria transmitted compared to the handshakeExplanation: handshakes have the greatest surface area in contact, for a longer time
This has been a practice changing finding for me.  Rarely are articles practice changing.  After reading these findings, I admit, I have shaken hands less.

I have not yet tried to fist bump my patients.  "Hey, I'm your palliative care doctor, punch it in there!  Knuckles!"

I use hand sanitizer before and after each visit, and also wash with soap and water after every third or so en…

The Advanced Direct Care Worker - A New Profession for a Growing Older Population

With 10,000 Baby Boomers turning 65 every day, the fastest growing jobs in the country are also some of the most critical to ensuring quality of care for older adults: the direct care workforce.

The Department of Labor says personal care aide and home health aide positions are the second and third fastest-growing occupations in the country. These occupations also provide between 70 and 80 percent of paid hands on care for older adults and individuals with disabilities. Of the 30 fastest growing occupations, they are also the two least paying (with an average annual median wage in 2012 of $19,900 and $20,800, respectively). Because of low wages, lack of benefits, and often-strenuous work, the vacancy and turnover rates for direct care work is high. It’s estimated that turnover rates amongst home care workers are between 44 and 65 percent. This occurs right at the time when we must be strengthening the workforce to care for older adults, nearly 90 percent of whom want to age at home…