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Showing posts from June, 2015

A Master of Science Program in Palliative Care?

We’re in trouble.  There just aren’t enough specialists in palliative care to palliate all the suffering out there.  One estimate of provider need is over 5,000 full time employees, which could require up to 18,000 trained providers depending on the proportion of time providers devote to the practice of palliative medicine. One important strategy to address this problem, as highlighted by the recent IOM report Dying in America ,    is to improve the skills of all providers in the practice of “primary” palliative care.  Historically, some physicians have turned towards palliative medicine and hospice later in their careers – perhaps out of a desire to broaden the meaning they find in their work. However, board eligibility in Hospice and Palliative Medicine now requires fellowship training.  While this is a wonderful thing for establishing the legitimacy of the field, a potential externality is further threatening the workforce supply.  Not only are there a limited number of Pa

A better way to care for frail patients: Independence at Home

Last week the Centers for Medicare and Medicaid Services (CMS) released a report that I think will change how geriatric palliative care will be delivered in the United States. What is the report?   CMS released the results from the first performance year of the Independence at Home Demonstration .  The Independence at Home Demonstration  is modeled on the Home Based Primary Care program from the Department of Veterans Affairs (VA) which brings comprehensive, longitudinal, interdisciplinary primary care into the home setting for patients with complex, chronic, disabling disease.  HPBC has been shown to improve access to care and reduce hospitalizations while also reducing total cost to both the VA and to Medicare .  Patients of HBPC report high satisfaction with access and continuity of care.  Would such care have similar results if offered to a general Medicare patient population who are not veterans?? What were the results of the first performance year of Independence at Home (I

Flags of Grief

by: Genevieve Flagello, LMSW, ASW I am a social worker two years into my career, currently working with veterans on an inpatient hospice unit. My clients range in their generational experience of war, from the Gulf to WWII. My work with these veterans is intense, yet rewarding, and every day they teach me a little more about life. Recently, I returned to my office from an extended trip and was informed that a veteran I had worked with closely had died. This is not uncommon. I mean, I work in HOSPICE. All of my clients, veterans, will at some point die while in my care. It’s the nature of the work. I assumed that many of my clients would be gone upon my return. I had not been back to work for more than a few hours before this particular client had died. In the flurry of the day, I didn’t get a chance to see him or say goodbye. After a veteran dies on the hospice unit, the nurses clean him/her up, put him/her on a gurney, cover the body with a symbolic flag and silently proc

Top 10 Reasons Eric Widera is the Best Fellowship Director Ever

10.       Like President Obama, he keeps his wardrobe streamlined so he can focus on what’s important. 9.       He shares the dark chocolate in the fellows’ candy bowl. 8.       His door is always open for career advice, teaching, venting, and laughing. 7.       He rules the Geriatrics and Palliative Care Twittersphere. At AGS, we realized he is the closest we’ll ever get to meeting a celebrity. 6.       He only made us do the #Thickenedliquidchallenge once. 5.       He creates an upbeat environment through witty banter with his office doppelganger, @AlexSmithMD. 4.       He actively seeks out our feedback to continuously improve the fellowship. 3.       There’s an app for that: he shares his “GeriPal Depot,” the most extensive, organized collection of Geriatrics and Palliative Care PowerPoints and articles in the world. 2.       He allows us the autonomy to shape our own learning. 1.       He is a master communicator, clinician,

When to Stop Medications in Advanced Dementia

by: Claire Larson Throughout medical training, we devote extensive time learning when to start medications. We memorize the pharmacology, indications for use, side effects, and sentinel trials showing their efficacy. Yet, not until my fellowship training in Geriatrics, did I learn another key part of medication prescribing: when to stop. We’ve all seen it: patients with lists of 10, 20 or more medications, to which we are always adding and never subtracting. Most were added with good intentions and defined indications, but over time, like the medications themselves, the indications expire. The case of one of my home visit patients stands out: a 65 year-old man with very advanced early onset Alzheimer’s disease. Bedbound, nonverbal, and aspirating, when I became his primary care provider, he was still taking donepezil and memantine, which he had taken for the last 10 years. When I discussed his care with his neurologists, they were reluctant for these medications to be stopped

Copyright claims a well-validated cognitive test

A new meta-analysis of brief cognitive tests appeared in JAMA Internal Medicine this week, and I was asked to opine on its significance . Cognitive testing is an important and complex topic already, but this had an unusual but sadly unsurprising twist. Brief cognitive tests, like the Mini-Cog or MoCA, are relatively simple but powerful tools that can be used in almost any clinical setting as a screening tests for cognitive impairment or dementia. A surgeon might use one at a pre-op visit because cognitive impairment increases the risk of post-op delirium. Or a primary care provider might use one to see if cognitive impairment contributed to a patient's recent falls. For a provider who sees geriatric patients, they are as important as a pocket talker! The meta-analysis asks if there is any well-validated alternative to the Mini Mental State Exam (MMSE). Readers of this blog probably recall why many providers are looking for alternatives to the MMSE - since 2001 it

What should we call the physician-assisted act of intentionally killing oneself near the end of life

By: Eric Widera ( @ewidera ) It was a big day in California today. The California Senate passed SB 128 which would permit a doctor to provide a terminally ill patient a lethal dose of a drug with the explicit intention that the terminally ill patient make take this drug to shorten his or her life. So here is the problem that I have when trying to put my head around this issue and write about this for GeriPal . It all starts with what to call it when a physician prescribes a lethal dose of a drug for a terminally ill patient with the intent that the patient may choose to self-administer this drug to bring about his or her death. For obvious reasons, it would be hard to say this over and over again in a paragraph (as I just did), so what should we call it when we right or talk about it? Here are the leading options: Death with Dignity : I know what I’m about to say will be taken as a great offense to some who read this blog, but come on. This is just pandering. The t

International Celebration of Aging at University of Michigan Health System

A Kyrgyzstani elder watching the kids while parents are away.  My exhibit entitled An International Celebration of Aging will be featured by Gifts of Art at the University of Michigan Health System (UMHS) in the Taubman Health Center South Lobby Gallery from June 15th to August 23rd, 2015. The UMHS Gifts of Art program is a multifaceted arts in healthcare program that presents changing art exhibits in nine galleries that are viewed by approximately 10,000 people a day. These galleries are some of the most widely visited indoor, non-museum exhibit spaces in Michigan. For more information, please visit: . The exhibit features photos I’ve shot over the last 2 decades in my travels searching for positive views of people who thrived into old age. They feature images from Asia, Russia, Central Asia, South America, North America, and India, samples of which appear on this GeriPal post. They celebrate the universality of aging and the contribution of elders to