GeriPal - Geriatrics and Palliative Care Blog

by: Gretchen Schwarze, @GretchenSchwa10

My husband, also a surgeon, was recently discussing donor-nephrectomy with a healthy 65 year-old woman in his transplant clinic.He told her the 30-day survival for this operation was excellent.She was shocked he would quote such metrics, “I don’t want to live for just 30 days!”Yet for years, we in surgery have judged our successes by the number of patients who don’t die within 30 days of surgery.
I know it is easy to find examples of surgeons behaving badly over a postoperative patient whose death seems to threaten his “numbers,” but as a surgeon who has been there I can tell you that it is viscerally painful to watch a patient you operated on succumb to postoperative complications. Deep notions of error and responsibility are ingrained in our culture and are reinforced in many ways including M&M conferences and NSQIP (National Safety Quality Improvement Program) reports. While I’m all for improving safety and quality, I shudder to think about…

Have you ever had a patient at home who was in need of dental care? Perhaps they were receiving hospice services or maybe they were just discharged from the hospital not on hospice, but still too frail to get to the dentist. Of course the focus is often on the medical issues, yet the most significant issue was broken rotted teeth, which made oral intake nearly impossible without pain. Clearly, the answer here is not opioids for pain control, but rather to take care of the root problem: access to dental care.

Clearly dentists and their staff are not part of a hospice or palliative care IDT, but when you need them, boy do you need them. If the short case I outlined is not clear enough for you, I would really encourage you to read “Love” by Jean-Noel Vergnes, DDS, PhD recently published in the Annals of Internal Medicine (paywall). Written by a dentist in France caring for his wife who had a stroke and was desperately in need of dental care he himself could not provide, it illustr…

Generally at GeriPal we focus on low tech, high touch interventions.  Like talking to people.

But this week we had an inspiring visit this week from  David Atashroo, MD, from Stanford.  The title of his talk was "Innovation in Aging."  And some of the stuff he shared is really exciting, and worth sharing.  These are innovative technologies that can be used to help aging seniors.  Many of these are in the early stages of development or are at the startup level.

1.  Check out this wheelchair.  Who says wheelchairs have to be, well, ugly?  This thing looks cool!  Made by Whill.



2.  Now check out this car.  You can roll your cool wheelchair right into it.  And it's electric.  Brilliant!  Made by Kenguru.


3. Check out this spoon.  You know how noise canceling headphones block out background noise?  Well, this spoon, made for patients with essential tremor, cancels out the tremor, so the spoon stays steady.  Made by LiftLabs.


4. This is a dog avatar that for people with demen…

My husband and I took a beginner’s improv class not long ago. Two of the most fundamental rules they taught about performing improv with a partner were: (1) never say “no”—it kills the storyline that you should be working with your partner to build. And (2) never say “yes, but...”…. because you might as well have just said “no.”

It plays out something like this: You and your partner get a prompt, such as pretending to be cops. Your partner has an idea for where the scene could go next. Little does your partner know that you have a brilliant idea for where you want to take the scene next. Your partner boldly proclaims, “Alright, partner, I just heard from the sheriff and there’s a murder to investigate.” Still holding to your own idea, you reply, “Yes, but before we get there, we first need to fulfill our assignment as undercover go-go dancers.” Yes, but… you just killed your partner’s storyline instead of building on it.

It sounds so simple. An easy two words to avoid. …

by: Alex Smith @AlexSmithMD

Vivek Murthy was nominated for Surgeon General of the United States by President Obama in November of 2013.  A bipartisan group of Senators approved his nomination in February 2014 and pushed it forward for a full vote.

A (not so) funny thing happened on the way to the vote.

In his confirmation hearing, Dr. Murthy was asked by Senator Lamar Alexander about his tweet that gun control is a public health issue.

Tired of politicians playing politics w/ guns, putting lives at risk b/c they're scared of NRA. Guns are a health care issue. #debatehealth
— Vivek Murthy (@vivek_murthy) October 17, 2012 Senator Alexander noted that "Americans have a first amendment right to advocate the second amendment."

Daily Show commentator Jon Stewart responded on his show "Yes, Americans have a first amendment right to advocate the second amendment.  And apparently, you don't have a first amendment right to have a different opinion from that.  Everyone …

Tonight I was having a discussion with some close friends.I’ve got to brag here, I have some very smart, passionate physician friends from residency.One of the hospitalists asked for our collective advice about a recent difficult clinical encounter:
“How would you handle a 90 year-old patient in the hospital who refuses to let the nurses change her until we let her go home?She’s been sitting there in her own urine for 24 hours, and I just don’t know how to help.”
Five months into my geriatrics fellowship, I thought maybe I could handle this one.I suggested that likely she’s likely very frustrated about her declining health and her ability to care for herself.She recognizes that her independence and freedoms are slowly being taken away from her.She’s probably trying to exert control the only way she can.
The other comments from the group were very different.“More colace,” one said jokingly (from the friend who thinks that’s all I prescribe).“Oh that’s ‘failure to thrive,’ she should b…

Over the past decade, the disciplines of Geriatrics and Palliative Medicine have become intellectual cousins.
Within Palliative Medicine, the recognition that Palliative Medicine is not just about end of life care has been a paradigm shift.There is now recognition that core skills of Palliative Medicine, including symptom management, communication, and caregiver support are needed throughout the course of serious illness.While these needs of seriously ill patients transcend age, it is a demographic fact that older persons will be the bulk of persons with these chronic palliative care needs.So, the population that has long been of interest to Geriatrics is now of great interest to Palliative Medicine.
Within Geriatrics, we have become consumed with the recognition that most frail older persons have multiple illnesses.We realize that treating each illness separately, rather than treating the whole patient leads to considerable harm.Geriatricians strongly advocate for a focus on whole p…

by: Alex Smith @AlexSmithMD

You don't get something for nothing.

We've blogged previously about the silent long term care system of informal caregivers in the US.  These are the families and friends who provide the bulk of care for older adults in the US.  The National Caregiving Alliance estimates that nearly 1/3 of US aldults are caregivers.  This caregiving is seemingly "free" - it appears to cost the US Healthcare System nothing.  Often, however, this work comes at great cost to the caregivers, including higher rates of depression and other health effects.  It also means the caregiver is providing care, and not earning an income for themselves or their family.

Today we have more information about the economic costs of informal caregiving in the US.
Amalavoyal V. Chari and colleagues published a national study of the costs of caregiving for elders in the US in the journal Health Services Research (link to an interview with Dr. Chari here).  They focused on how …

The December issue of Consumer reports is truly amazing. It’s filled with articles to help consumers find the right headphones, smart phones, and smart watches. One hot new piece of gear that is rated quite highly by consumer reports in this issue is something you may have heard about once or twice before, Hospice and Palliative Care.

You can access the for free all of the articles on their website at this link. This is a really well thought out webpage that is written by consumers, for consumers and includes the following resources:
The story of Paul Scheier's life and death: The website includes a 17 minute long video that discusses the importance of hospice and palliative medicine, addresses myths often connected to these programs, and includes a tear shedding journey of Paul’s life and death.A guide on how to pick a hospice Advice about advance directives including a link to an app by the American Bar Association called My Health Care Wishes (Android and iOS) that lets you …

by: Alex Smith @AlexSmithMD

Every once and a while, a new innovation comes along that makes you go, "Wow!" or, "I never would have thought of that" or, "Not sure if it will work, but I'm sure interested to find out."

The following three are interesting not only because of the ideas themselves, but also because of the different ways they are going about funding: for-profit (Vital Decisions), both for-profit and not-for-profit (ResolutionCare), and non-profit (Caring Advocates).

1.  Cold calling patients with serious illness and engaging them in advance care planning conversations.  Vital Decisions, a large and growing for profit company, obtains lists of patients with serious illness from insurance companies.  Counselors working at Vital Decisions call patients and engage them in advance care planning conversations.  NPR did an interesting story on this company in August.  As Bob Arnold said at the end (to paraphrase), "would it be better if t…

by: Alex Smith @AlexSmithMD and Rebecca Sudore @PrepareForCare

Do you have Spanish-speaking patients?  If you do, then point them toward PREPARE in Spanish! 

The rising tide of palliative care has not lifted all boats equally.  For example, hospice use among African Americans decedents increased from 5% in 1992 to 34% in 2010.  However, hospice use among white decedents increased even more, from 10% to 46%, over the same time period.  Hospice use increased at a faster rate among whites than African Americans.  The gap actually got bigger.

We haven't paid enough attention to disparities.  There is a real risk that many of the services, tools, and skills of palliative care may benefit majority patients more than minority.  The explosion of palliative care may have the unintended effect of increasing ethnic disparities rather than reducing them. 

That's just one of the reasons that work like Prepare in Spanish is so important.
We previously blogged about the launch of PREP…