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Showing posts from August, 2015

The experience of dementia OUTSIDE the nursing home: pain, weight loss, and transitions in care

by: Alex Smith, @AlexSmithMD About 4.5 million people have dementia in the US.  Thanks to the fantastic work of palliative care researchers like Joan Teno, Susan Mitchell, Jane Givons, and Laura Hanson we know a tremendous amount about the experience of dementia for people residing in nursing homes.  Although the nursing home is sometimes the final place of residence for persons with advanced dementia, many people reside in the community with dementia for years, including the end of life.  In fact, about 25% people with dementia live in nursing homes.  The remaining 75% live in the community, either in private residences or residential care facilities.  Unfortunately, compared to the experience of dementia in nursing homes, we know very little about the experience of dementia among community dwelling older adults. It's a relief, therefore, to see this issue covered in the most recent issue of JAGS . In a study of about 800 community dwelling older adults enrolled in t

Is work life balance a first-world privledge problem, or not?

by: Alex Smith, @AlexSmithMD In geriatrics, and to a much greater extent palliative care, work/life balance is recognized as critical to finding meaning in your work, to being at your peak at work and at home, and to avoiding burnout. So last week I read with fascination a Washington Post story about pilot program at Stanford that supported physicians work/life balance.  Here's the brief story in bullets: The powers at Stanford realized that many women were dropping out of academic medicine, despite generous leave policies, benefits for part time work, etc. They wondered why.  They hired a firm to investigate.  The firm concluded that the at Stanford culture dictated "all-out devotion to work, all the time."  No one was using the generous family-friendly policies. People were doing all sorts of unfunded work that ate huge chunks of time: mentoring, committee work, extra shifts, etc. Stanford started a pilot program where physicians and basic scientists could u

Why you got to be so rude: the impact of rudeness on the performance of medical teams

A fascinating study came out in Pediatrics recently on the impact rudeness plays on the performance of teams that I just couldn't help but write about (partially because I cant get that song out of my head from the video at the bottom of this post). Enough about you Eric, tell me about the study Ok. Let’s break it down real quick. The authors took 72 Israeli NICU professionals organized into 24 teams and put them in a training simulation involving a preterm infant whose is getting sicker due to necrotizing enterocolitis. These teams were evaluated in their performance in the simulation by 3 independent judges who used structured questionnaires to assess diagnostic performance, procedural performance, information-sharing, and help-seeking. Now here is the rub. Before the start of the simulation a "visiting" head of an American ICU joined via webcame to observe and comment (While the article didn't include picutres, I’m thinking this person had a mustache,

Lawmakers rush to reintroduce End of Life Options Act, but haste makes bad policy

By: Laura Petrillo, MD (@lpetrillz) The End of Life Options Act, which would legalize physician-assisted suicide, was stalled in the California legislature earlier this summer and seemingly shelved until next year. But in a surprise move, lawmakers introduced a new bill with the same purpose on Tuesday , during a special session on healthcare financing called by Governor Brown. The new bill would bypass the Assembly committee where SB128, the former bill, was stalled for lack of support. The issue that lawmakers are trying to rush through the legislative process is not a trivial one— the bill would give physicians the power to prescribe medication with lethal intent to terminally ill patients, a fundamental shift in the role of medicine to date. This is an issue that deserves deep contemplation, expert and community input, and thorough vetting to ensure the safety of everyone who might be affected. Instead, the lawmakers found a way to charge ahead in a special session and byp

Choice and Control at the End of Life – The 3 Wishes Project

One of the advantages of getting behind in reading medical journals is seeing links between articles when I finally try to catch up in one mind-numbing session.  In reading some articles from this past week’s lineup of journals (which admittedly doesn’t count as “falling behind”), one theme was the choice and empowerment that clinicians do and don’t provide to patients in late life.  One article in particular caught my eye: a piece by Cook et al in Annals of Internal Medicine on the 3 Wishes Project .   This project encouraged patients dying in the ICU - and their family members and clinicians - to generate and implement at least 3 wishes, for example bringing personal mementos into the hospital room, renewing wedding vows at the bedside, recreating a date night in the ICU, or allowing a mother to lie in bed with her son as he died.    Not surprisingly, the project was well-received, with mixed-methods approaches finding that it helped improve patients’ dignity, give their fami

Is antiepileptic therapy indicated for primary prevention after an ischemic stroke?

Mrs. C is a 79 year old nursing home resident woman who suffered an ischemic stroke about 10 months ago. She also suffers from depression, multiple frequent falls, dementia with behavioral disturbances, and psychosis. She was started on Levetiracetam (Keppra) 750 mg by mouth twice a day for seizure prophylaxis in the hospital after her stroke. The consulting neurologist at the nursing home recommended continuation of this antiepileptic for seizure prophylaxis. Thinking about how can I optimize her care, I wondered if in older adult patients with history of an ischemic cerebrovascular event, are antiepileptic drugs indicated for seizure prophylaxis? To find the answer to this Therapy question, I began my search with Pubmed Clinical Queries using the terms “older adults with stroke and antiepileptic drugs for seizure prophylaxis” looking for randomized controlled trials or meta-analyses. The result of my search resulted in a Cochrane review originally published in 2010 with an update

ePrognosis 2.0: PPS and Cancer screening

by: Alex Smith, @AlexSmithMD The geriatrics, general medicine, and palliative care communities have spoken, and we've been listening. ePrognosis is the website we created to help clinicians in everyday practice calculate prognosis or life expectancy.  Two things we've heard over and over about how we could improve ePrognosis : "We want the PPS!"  "The Palliative Performance Scale (PPS) is likely the most widely used prognostic scale in hospice and palliative care, why isn't it on ePrognosis?"  "ePrognosis doesn't have any really short term prognostic calculators." "ePrognosis the app in the iTunes store is great, but I'm not an apple person.  Can't you make something like that for android?"  In response to this feedback, we're excited to announce the addition of the PPS and ePrognosis: Cancer Screening to our website.  Key features of the PPS: From the main page , you can get to the PPS one of 3 ways.  W

What's your favorite reference book in geriatrics and palliative care?

by: Alex Smith, @AlexSmithMD It’s summer, and the new fellows have started. I usually post around this time about a basic concept to teach new fellows. See previous posts about: How to explain palliative care to patients and families? How to explain hospice? Talking with families about imminent death  For this post, I’d like to hear people’s opinions on their favorite reference books to recommend to new fellows in geriatrics and palliative care. Here’s my favorite reference book for palliative care fellows: A Physician's Guide to Pain and Symptom Management in Cancer Patients , by Janet Abrahm . The evidence base for symptom management, particularly in cancer care, is growing by leaps and bounds. That said, in the larger picture, there is still little evidence for much of what we do. Why do we choose this opioid over that opioid? Why do we choose this stimulant laxative over that stimulant laxative? In such situations, we turn from evidence to “guru” medicine.