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Showing posts from 2015

Families caring for families

by: Amy Getter, who blogs regularly at hospicediary.com

“A nation’s greatness is measured by how it treats its weakest members.” Mahatma Ghandi.

When my children were little, I provided day care in my home, and I often heard my working mothers make comments about having “quality time” in the evening with their kids. I wondered, having my own kids and knowing the busy times around dinner, followed by bathing, bedtime stories, and night time rituals, how that chaotic amount of doing could actually be referred to as “the quality” time. I considered all the hours during the day: sitting on the couch and reading at story time, or kissing the booboos from play time outside, or exclaiming on the beauty of a messy art project, or carefully saving that first lost tooth; and I knew how much those working moms missed that I was privy to. It’s true, there are lots of other things moms are busy doing during the average day, and children don’t have just our undivided attention, but I certainl…

PTSD at the end of life

by: Alex Smith, @AlexSmithMD

I want to draw GeriPal readers attention to a remarkably powerful story in the current issue of NEJM by VJ Periyakoil, MD, a geriatrician and palliative medicine physician at Stanford and the Palo Alto VA (tweets @palliator).  The story is titled, "A Never-Ending Battle."

VJ tells the story of a man who has been haunted his whole life by memories of his time in Vietnam as a scout.  He sleeps in a different room from his wife out of fear he will harm her during the night while experiencing a nightmare.  He doesn't want to take pain medications because they make the PTSD symptoms worse.

And finally, while VJ is probing an ulcer, he tells the horrific story of what haunts him about his Vietnam experience.

When you read it, you too will feel haunted.

Ken Covinsky posted about PTSD in late life way back in 2010.  At that time, he noted:

As with my patients, many will be reluctant to report symptoms of post-traumatic stress. You must ask. Many pati…

The most useless thing we routinely teach trainees? A vote for “A&Ox3”

by: Winston Chiong (@WinstonChiong)
As a neurologist, I read this article and was reminded of one of my pet peeves in how we teach trainees. Rapoport and Rapoport note the ubiquity of starting the mental status examination with an assessment of the patient’s alertness and orientation to “person, place and time.” Orientation to person is supposedly assessed by asking the patient to state his or her own name, and its traditional placement at the start of presenting the physical examination (just after the vital signs) might suggest that this assessment is of high clinical value.
Of course, it’s actually just about useless. A couple really nice quotes from Rapoport and Rapoport:
Unlike other principal components of the neurologic examination, orientation to person does not clearly correspond to a localizable function of the brain or nervous system, and there is no consensus on how it should be tested, what it signifies, and under what circumstances—if ever—it can truly be lost.
Although we…

Physician as Healer or Harmer? The Ethical Context of Aid in Dying

by: Elizabeth Dzeng, @LizDzeng

 As ethicists like to point out, what is the law is not always ethical and what is ethical is not always the law. Passage of the End of Life Options Act in California does not imply that we’ve resolved the debate on aid in dying, nor should it define our moral stance.

 However, it does provide us with new opportunities to find common ground. The energy and passion that motivate advocates on both sides, have always been rooted in the same desire to improve the way we die. The perspectives of those who oppose aid in dying will be especially critical, to give voice to vulnerable individuals for whom we must insure ethical responses with proper safeguards and support systems in place. This is an opportunity for us to critically evaluate and rethink our approach to improving end of life care as a whole.

 Aid in dying is controversial precisely because it exemplifies the many ethical dilemmas our society has grappled with – concerns of injustices that predomi…

A Palliative Care Fellow’s Perspective on Physician-Assisted Death

by Danny Cox (@DannyMD)

I’ll be honest. When I started my fellowship in palliative care 4 short months ago, I had not seriously considered the possibility that one day I would have a patient ask me whether I would prescribe them a medication to end their life. Of course I was aware of the Oregon experience, but living in California where I completed both medical school and residency had sufficiently inured me to this idea. But with the signing into law in California last month of the End of Life Option Act, I have started to feel troubled by this question: would I or would I not prescribe?

I recently spoke with my old babysitter who cared for me early on in childhood, a wonderful elderly Honduran woman now living in Maryland who I had not spoken with in over a decade. When I updated her on my career plans in palliative care, assuming she would have no context, I was surprised to hear her quickly respond about a recently watched TV program about doctors helping terminally ill patient…

The Invisible Hand Reaches into the Exam Room: Ordinary Medicine by Sharon Kaufman (Review)

by: Alex Smith, @alexsmithMD

Alone in the room with your patient, you think you have control over what happens?  You think that it's you and the patient setting the terms and content of what tests and treatments are offered, negotiated, and agreed to?

Think again.

In a brilliant new book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line, the medical anthropologist Sharon Kaufman illuminates the role of larger forces in shaping what is discussed in clinic examination rooms, at bedsides, and in consultation.  We had the pleasure of hosting Sharon Kauffman for our fist ever UCSF Division of Geriatrics Book Club yesterday.

Her book took me back to my freshman Introductory Sociology Class at Michigan.  I remember hearing about the "invisible hand" of larger social forces that, without our intention, guide our actions.

Here are two compelling examples from her book of how larger social forces are shaping conversations between patients a…

Use and Misuse of Chemotherapy at the End of Life

by: Danny Cox (@dannyMD)

The goal of palliative chemotherapy for patients with terminal cancer is to prolong survival and improve quality of life. A major ongoing concern among many physicians is that chemotherapy given to those near the end of life might actually be doing more harm than good. The 2012 American Society of Clinical Oncology guidelines recommend against the use of chemotherapy for those with an ECOG score of ≥3 (ECOG is a graded scale of functional status; see table). The implicit assumption is that those with better functional status will be better able to tolerate chemotherapy and derive benefit.
An eye-opening new study entitled “Chemotherapy Use, Performance Status, and Quality of Life,” recently published by Prigerson et al. in the September 2015 edition of JAMA Oncology casts doubt on the perceived benefits of chemotherapy in terminally ill cancer patients even with good functional status and highlights the need for a more nuanced approach.

In this multi-center, …

An Update from the Hill: Advancing the Palliative Care and Hospice Education and Training Act (PCHETA)

Washington D.C. was an exciting place at the end of October. Sure there was a whirlwind deal to shore up the budget and avoid a crisis over the next two years.  And there was the resignation of Speaker Boehner and election of Speaker Ryan. But more importantly, AAHPM was in town to discuss the Palliative Care and Hospice Education and Training Act or PCHETA.

The take home from AAHPM fly-in is this:  Just as the construction on the Capital Dome is slow going but advancing, PCHETA is moving forward.  Progress is being made and we have MOMENTUM. Participants described constituent meetings with legislators and their staff as productive.  The legislature knows more and more about PCHETA and understands the issues better.


The PCHETA bill was first described on GeriPal in 2012. For those who think, "why is this important bill not already law"  it is important to recognize that a lot of good work has happened.

1. The PCHETA bill of 2015, which was introduced by Representatives Engel…

Recognizing the Incurable in Ancient Egypt

by Jeffrey M Levine MD

The art of medicine is as old as human civilization, and what we think is new has often been done before. When researching the history of wound care I came across an interesting historical antecedent to today’s palliative care practices. I found it in the library of the New York Academy of Medicine in Manhattan, in a translation of an ancient Egyptian medical scroll, the Smith Papyrus, pictured above.

During the American Civil War, an Egyptologist named Edwin Smith acquired the scroll and brought it to the United States where it subsequently found a home at the Academy on Fifth Avenue. The document is roughly fifteen feet long and three feet wide, and has writing on both the front and back. The scroll is made of papyrus, an ancient form of paper made from fibers of a plant native to the Nile region. Written with a reed pen, the text is a simplified form of Egyptian writing known as hieratics. The script differs from formal hieroglyphics which were more co…

Moral distress among residents: the hidden price of futility

by: Alex Smith, @AlexSmithMD


Have you ever had that experience when you think what you're doing is futile, and that thought goes through your mind:

"Why am I doing this?"

"I'm torturing him."

"This feels wrong."

For those of us that are physicians, think back to your internship and residency training.  I think we can all remember at least one of these situations, if not more.

I remember being in the ICU as a 3rd year internal medicine resident, being sent a man with advanced cancer on blood thinners from the emergency department who was losing liters of blood through his nose.  He was DNR, but his code status had been reversed in the ED by his family to treat this unexpected event.  This decision was not unreasonable, and yet the family looked terribly distressed by the blood spurting everywhere and frenzy of activity around him .  The patient was thin, bordering on emaciated.

Blood started oozing out of his nose again, and his blood pressure plu…

The Evidence for Palliative Care Is Better Than Many Drugs Approved by FDA

by: Eric Widera (@ewidera) “But one of the most sobering facts is that no current policy or practice designed to improve care for millions of dying Americans is backed by a fraction of the evidence that the Food and Drug Administration would require to approve even a relatively innocuous drug.”Scott D. Halpern, M.D., Ph.D., NEJM
What? What??? Really? No current practice designed to improve care for dying Americans is backed by a fraction of the evidence to approve a drug? Are you kidding me? What about palliative care?

This is the second sentence of a NEJM article that was published today. While the intention of the article is actually good (more research is important in end of life care) the article completely misses the significant advances in palliative care over the last decade.

We do now have a growing evidence base for palliative care and now several randomized control trials on the impact that palliative care has on improving the care and outcomes of patients who are…

California assisted suicide bill signed into law, what next?

By: Laura Petrillo, MD @lpetrillz

Governor Jerry Brown signed California bill ABx2-15 into law today. The law will give California doctors the ability to prescribe lethal medication to competent, terminally ill patients so that they may end their lives. California is not the first state to enact such a law (Oregon, Washington and Vermont have laws in place), but it is the first since Brittany Maynard, the 29 year-old California woman with a fatal brain tumor, moved to Oregon last year to use the Death with Dignity Act and re-invigorated the decades-old legalization movement. Other states are likely to follow.

What next? If there is one message that all healthcare providers should hear, it is this: a request for assisted suicide is an opportunity to learn more about the individual’s experience, and to partner with the patient to create a plan that addresses her needs. This should include an evaluation of decision-making capacity, mood, symptoms and psychosocial support, followed b…

Report on palliative care in US hospitals: glass 2/3 full or 1/3 empty?

by: Alex Smith, @alexsmithMD

The Center to Advance Palliative Care and the National Palliative Care Research Center just released their 2015 report card. Boy is there some great stuff in there!

The major point: two thirds (67%) of US hospitals with >50 beds report a palliative care program.  So is the glass two-thirds full, or one third empty?

There's more to this question than the big picture two-thirds one-third, however. I suggest you go check out your state's "Grade" for inpatient palliative care.  California, my home state, got a "B" as 74% of hospitals with >50 beds report a palliative care program.  Not bad.  The Northeast and Mountain regions have  palliative care in almost all hospitals.  The south, not so much...so access to inpatient palliative care may be 2/3 across the country, but in some places you'll be hard pressed to find any palliative care at all.  Good luck finding palliative care if you get seriously ill in Mississippi, whe…

Drugs and Bugs at the End of Life

by: Eric Widera @ewidera

The majority of hospitalized patients with advanced cancer are given antibiotics in the last week of life. Nearly half of those individuals living in nursing homes with advanced dementia are given antibiotics in the last two weeks of life.  And yes, even in hospice, one out of four individuals  are given antibiotics within the last weeks of life.  If one would just go by numbers, it would seem that antibiotics are a mainstay of palliative care.

So that begs the question, are these medications really benefiting the patient? In this weeks JAMA, Manisha Juthani-Mehta, Preeti Malani, and Susan Mitchell wrote about these issues in a piece titled Antimicrobials at the End of Life: An Opportunity to Improve Palliative Care and Infection Management."

It’s a short piece that makes a good quick read, and best of all, it is free! The risks of antibiotics are discussed including drug reactions, drug-drug interactions, and C. difficile infection, as well as the bu…

Hope and Uncertainty

by: Sei Lee

I wanted to alert folks to a wonderful "Piece of My Mind" article in JAMA (Mar 17, 2015) by a pediatrician about difficult conversations. As I was reading it, there were numerous phrases and sentences that poignantly rang true.

The manuscript revolves around the author and his wife’s experiences following a spontaneous abortion. Providers didn’t want to tell him the bad news, despite the fact that the ultrasound was strongly suggestive of bad news. Providers used strategies that sounded all too familiar to me.

"Uncertainty can be a 'get out of jail free' card for providers, momentarily allaying fears while punting the difficult conversation down the road."

"Hope is a powerful tool that physicians have wielded incautiously throughout the history of medicine."
As a palliative care provider, I’ve witnessed many clinicians use hope and uncertainty to avoid hard discussions. Instead of talking about what’s most likely (which is of…

A physicians group's baseless objections to advance care planning

by: Stan Terman, PhD, MD


Beneficiaries of Medicare, and their families and surrogates, may soon have more opportunity to obtain an “explanation and discussion of advance directives such as standard forms” with physicians and other health care providers for one or more half-hour, face-to-face sessions. But first, CMS must review the approximately 240 comments that were submitted before September 8, 2015.

Several comments strongly objected to the proposal. Many objections seemed derived from the same boiler plate, but one by the Association of American Physicians and Surgeons (AAPS) is both strong and unique. This non-profit, 5000-member organization, which describes itself as “defending the patient-physician relationship and the practice of ethical medicine,” characterized payments to physicians as: “financial incentives,” “inducement,” “unethical conflict of interest,” similar to other “unethical bonuses,” and a “commission-like reward system.” It criticized the option for additio…

Ambulating Manhattan

Across the globe, more than half the world’s population lives in cities, and there is a growing recognition that urban environments need to be more age-friendly.   With its rich cultural offerings and easy access to stores, New York City looks like a great place to grow old.  In this post I present photos of elders getting around the city.   


Go downtown in the early morning hours and you can see Chinese elders strolling and exercising in the parks and public spaces.  This is the Manhattan Bridge that spans the East River. 

Most of these shots were taken with my iPhone going back and forth to the hospital.  The Bloomberg administration installed bike lanes all over the City, and these are favorite places for people speeding around on motorized wheelchairs, often in the wrong direction.  

This is a well dressed trio.  The lady in the middle was photographed going to church on 125th Street in Harlem, while the lady on the right was waiting for her ride.  

Uptown, midtown, and downtown …

The Death Menu

by: Amy Getter, RN, MS


Death scenarios, debates about assisted suicide, hospice and end of life commentaries, “Death cafes” and “death dinners” have been in magazines, the subject of special reports on television, newspaper articles and in various other media sources. It seems that a new popularity has risen among the press to highlight the “taboo” subject of death. Naturally, as a hospice nurse, I am pleased to see an increasing interest from the public in things surrounding dying (since, after all, it is what I talk about every day!). More recently, palliative care has joined hospice and dying in the media’s scrutiny and discussion.

Palliative care is now a recognized medical specialty. Over half of the nation’s hospitals offer a palliative care team: a group of experts that usually consists of physicians, social workers, chaplains and nurses. One of their goals is to help a patient and their family members navigate through the maze of hospitalizations and different treatment…

Redesigning Dying

Dying is in serious need of a redesign. This is the point of BJ Miller's TED talk that was given several months ago and is now available to watch at the TED talk website. If you haven’t seen it yet, I highlight encourage you to watch it.

BJ, the Executive Director of the Zen Hospice Project and a true leader in palliative care, gives an inspirational talk about the certainty of death, the current approach our health care system takes to care for the dying, and various “design cues” we can take including our need to lift our sights to making life more wonderful rather than less horrible as death approaches.

This talk is a great reminder that as a community we can use our natural creativity to rethink dying.  Not to go against it, but as BJ says in his talk:
"We can design towards it. Parts of me died early on, and that's something we can all say one way or another. I got to redesign my life around this fact, and I tell you it has been a liberation to realize you c…