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Source: Wikimedia 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 wha

AAPS objections to CMS payment for Advance Care Planning are a wreck.  Source: Wikimedia Commons 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,” simila

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.   Up

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 tre

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 rea

The most recent issues of The Gerontologist (June and August 2015) feature photos I took in 2012 on a trip to Kyrgyzstan in Central Asia. These strong  and beautiful people are descendants of Ghengis Khan and traders on the Silk Road.  I was amazed to learn the extent that elders are revered in traditional Kyrgyz society, but the collapse of the Soviet Union and globalization caused rapid economic and cultural change that have not been to the benefit of the older generation. The Soviet regime brought Kyrgyzstan jobs and education but disrupted traditional life in many ways. Mandatory work for women ceased transmission of handicraft skills. Forced abandonment of nomadic lifestyles put skilled builders of yurt components out of business. The end of Soviet domination closed most factories, and privatization of land and businesses did not stem the economic downslide that resulted in massive unemployment. A large segment of the young male population left for Russia in search of job

I seem to keep hearing stories about how fancy new technologies will transform care for older persons.  Living in the Bay Area, it is kind of uncool to not claim excitement about the possibilities. So, I guess I will avoid admitting that I am just not getting jazzed up about the possibilities.  I suppose one day something transformative will come along.  But, what older people really need, especially those facing the disabilities and frailties of old age, is more high touch.  Not high tech. Here are a few ideas I have heard pitched over the past year that create a big yawn: 1) Monitoring Grandma and Grandpa: I suppose many of you have heard this idea.  You are worried about your older parent/grandparent, so you put sensors in their home.  With home monitors, you can now get a text on your iPhone so you know what time Grandma has woken up, when she has eaten, whether she has taken her medicine, when she leaves the house, and when she comes back.  If anything is amiss, you can ta

The Supreme Court case of Cruzan (Nancy Cruzan pictured) vs. Missouri established the right of individuals to make decisions in advance about treatment in future states of incapacity. by: Alex Smith, @alexsmithMD Will it finally happen?  After death panels and all that nonsense, will we finally reimburse physicians for the sensible conversations they have with patients to plan for future care - advance care planning? Maybe. I heard that it was easy to comment on the proposed CMS rule, but sadly found that this was not so.  The first link I used did not take me to the correct page.  The second link, from AAHPM, took me to the correct page.  The link to comment is right near the top .  Unfortunately, if you want to find the actual language of the proposed change, you have to scroll down through hundreds of pages of unrelated rule changes.  I gave up and used the search function to find it using the word "Advance". I'm pasting the full wording of the rule c