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Showing posts from October, 2015

Moral distress among residents: the hidden price of futility

Crash cart.  Courtesy Wikimedia. 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 oozi

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

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, follo

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 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 Missis

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 wel