GeriPal - Geriatrics and Palliative Care Blog

Reviewed: The Conversation, by Angelo Volandes

Reviewed by: Alex Smith

Using video to help patients with serious illness make decisions about future care seems like a “no brainer.” Think back to your early training. Remember being at the code for that patient with advanced cancer, wondering why he wasn’t DNR? If he could only have “seen” what it was like to be coded, to be in the ICU, to live on machines. The allure of video is obvious. But as with any thing that seems too good to be true, the reality of using videos to jumpstart goals of care conversations is more laden with potential pitfalls than is apparent on the surface.

Thankfully, we have Angelo Volandes. In his book The Conversation, Angelo uses stories of patients he has cared for to build the case for video. He does this slowly, deliberately. He exposes the limitations of language through his own stories of caring for patients, where he wishes the conversation had gone differently. He does this with humility. H…

by: Stan Terman

Michael Ellenbogen has dementia.  He took the #thickenedliquidchallenge.  He never wants to have thickenedliquids again, even if his life depends on it.  Is this ethical?

Click this link if the video doesn't appear below.



Michael Ellenbogen's video addresses the #Thickenedliquidchallenge from a patient’s point of view. 

Mr. Ellenbogen tries orange soda, one of his favorite drinks, with thickener.  He reports, "The taste was terrible.  The drink lost all of it's flavor, all of the enjoyment of my favorite drink was gone."  He goes on to say, "Many people do not understand that there's a lot more to eating than just getting the nutrition into our bodies.  The texture contributes a lot to how much you enjoy it." 

Mr. Ellenbogen states that if he had advanced dementia he would never want to be fed thickened liquids, "even if my physicians thinks that my life my continued living depends on it."

More generally, his experience …

In September 2014, the Centers for Disease Control and Prevention (CDC) issued a new guideline1 recommending the administration of Prevnar13, a type of pneumonia vaccines, to adults 65 years and older.This is to be given in addition to Pneumovax23, the pneumonia vaccine that adults 65 years and older already receive based on prior guidelines.

Mr. R, my 67-year-old patient who already received Pneumovax23, was not enthusiastic about the idea. “But I already got one! Why do I need another? What is the difference from the one I already got?”
All good questions. Let’s look closely at the guidelines to see if we can answer these questions.
What is the difference between Pneumovax23 and Prevnar13? Pneumovax23 stands for pneumococcal polysaccharide vaccine (23-valent). First used in 1945, it was an important landmark in medical history. Pneumovax23 was the first pneumonia vaccine, and the first to be made from capsular polysaccharide, which can help induce immunity in host body.It is call…

by Jerry Soucy, RN, CHPN
The title of Amy Getter’s Geripal piece poses a critical question: As we face forces seemingly beyond our control, how can we stay true to the purpose of hospice, and to our patients and families? 
I share Amy’s concern. This is difficult work under ideal circumstances. We frequently face demands that compete for our time and attention. When the demands are in conflict, sources we expect to support us sometimes don’t seem very supportive.
Amy calls the Medicare Conditions of Participation (CoPs) overwhelming. I’ve worked with colleagues who see them in an even more negative light: as irrelevant, not very helpful, or even an obstacle to effective and compassionate care.
The law can seem byzantine for those of us without legal training, but I think it’s worth the effort to understand, internalize, and act on the values expressed in the CoPs. The logic and structure will become more evident as you read, and every hospice clinician will recognize the language, because…

by: Kim Evanoski, CMC MPA LMSW

Sometimes on the walking trail I get to thinking about my week. The quiet solitude gives me important time for taking those long deep breathes to reflect and come to terms with life's events.

There are particular weeks in working in palliative care that I need time to think through how to facilitate a tough conversation that a care partner, being patient or family member, is ready to talk further on. As a practitioner I think part of my job is to prepare myself for assisting families in what I term as "heartfelt care". Heartfelt care is an activity like sitting around the table while sharing information that garners thoughtful thinking, goal setting and sometimes finite decisions towards understanding how we envision one's living, dying or death. Heartfelt care uses energy, needs focus and thoughtful breathing.

Over the years I have studied my own breathing and have asked my students to pay particular attention to how it affect…

Mr J is a 67 year-old man with a history of multiple sclerosis complicated by paraplegia, bilateral upper and lower extremity contractures, and multiple pressure ulcers.  He had required multiple hospitalizations for his wounds, and I met him after an extended hospitalization necessitating debridement when he was transferred to a skilled nursing facility for ongoing wound care.  Given the extent of his wounds, he was started on electrical stimulation therapy.  I had never heard of this type of treatment, so I wondered, in patients with pressure ulcers, is electrical stimulation therapy more effective than standard wound care?

Electrical stimulation therapy is the application of a current across a wound.  The theoretical mechanism of this therapy is to replicate the “current of injury” that occurs normally when there is a break in the skin.  This current of injury has been shown in various models to promote angiogenesis, fibroblast migration promoting granulation, and keratinocyte migra…

by: Jason Johanning, vascular surgeon, University of Nebraska

We as surgeons know that the timing of an intervention is an incredibly important decision. Intervene too early and you expose the patient to potential unneeded risk. Intervene too late and the disease process has already taken its toll.

From a surgical perspective, palliative care consultation on the surgical patient can be looked at in a very similar perspective. Not all patients need a palliative care consult prior to surgery. But for a select few, the consultation provides many salient and real benefits. And this I believe can be a good thing for all parties involved.

Contrast this thought with the postoperative palliative care consult process. In my travels I have heard stories of nurses ordering palliative care consultations without surgeon knowledge or consent. I have heard of patients being taken off ventilators on postoperative day 2 without surgeon knowledge by palliative care and ICU teams. To say that…

by: Stephanie E. Rogers, MD @SERogersMD

“The two big unfixables are aging and dying...you can't fix those,” notes physician-writer Dr. Atul Gawande, in a new documentary based on his recent book Being Mortal. The Frontline documentary airs Tuesday, February 10 on PBS, and explores Gawande's frustration of not being able to “fix” all of his patients.

The Being Mortal documentary examines how Gawande and other physicians struggle to talk with patients and families about death and dying. He explores his own humble journey with the realization that "medicine fails the people it's supposed to help" at the end of life. It also provides a powerful, intimate look at families struggling with conversations about the realities of aging and death, and the uncomfortable and difficult time even well-trained physicians have at leading these discussions.

One of the most startling aspects of the documentary is watching physicians participate in these conversations with…

A recent article in the Journal of the American Geriatrics Society published a list of 27 “landmark” peer-reviewed foundational articles that have helped to shape the contemporary practice of geriatric medicine. The authors of this article did a quite extensive process to identify these articles that included:
First finding candidate articles through a literature review and expert opinion survey of geriatric medicine faculty.Winnowing this list down to 30 and then performing a bibliometric analysis that combined journal impact factor and average monthly citation index. Lastly, bring a panel together to review articles to assess each manuscript’s clinical relevance.
For each of the final 27 articles, a score was determined by averaging, with equal weight, the opinion survey, bibliometric analysis, and consensus panel review.  We’ve included in the note section below a list and ranking of the Geriatrics Landmark articles, and have included links to their PubMed pages.  While we can prob…