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Showing posts from December, 2015

Families caring for families

by: Amy Getter, who blogs regularly at hospicediary.com

“A nation’s greatness is measured by how it treats its weakest members.” Mahatma Ghandi.

When my children were little, I provided day care in my home, and I often heard my working mothers make comments about having “quality time” in the evening with their kids. I wondered, having my own kids and knowing the busy times around dinner, followed by bathing, bedtime stories, and night time rituals, how that chaotic amount of doing could actually be referred to as “the quality” time. I considered all the hours during the day: sitting on the couch and reading at story time, or kissing the booboos from play time outside, or exclaiming on the beauty of a messy art project, or carefully saving that first lost tooth; and I knew how much those working moms missed that I was privy to. It’s true, there are lots of other things moms are busy doing during the average day, and children don’t have just our undivided attention, but I certainl…

PTSD at the end of life

by: Alex Smith, @AlexSmithMD

I want to draw GeriPal readers attention to a remarkably powerful story in the current issue of NEJM by VJ Periyakoil, MD, a geriatrician and palliative medicine physician at Stanford and the Palo Alto VA (tweets @palliator).  The story is titled, "A Never-Ending Battle."

VJ tells the story of a man who has been haunted his whole life by memories of his time in Vietnam as a scout.  He sleeps in a different room from his wife out of fear he will harm her during the night while experiencing a nightmare.  He doesn't want to take pain medications because they make the PTSD symptoms worse.

And finally, while VJ is probing an ulcer, he tells the horrific story of what haunts him about his Vietnam experience.

When you read it, you too will feel haunted.

Ken Covinsky posted about PTSD in late life way back in 2010.  At that time, he noted:

As with my patients, many will be reluctant to report symptoms of post-traumatic stress. You must ask. Many pati…

The most useless thing we routinely teach trainees? A vote for “A&Ox3”

by: Winston Chiong (@WinstonChiong)
As a neurologist, I read this article and was reminded of one of my pet peeves in how we teach trainees. Rapoport and Rapoport note the ubiquity of starting the mental status examination with an assessment of the patient’s alertness and orientation to “person, place and time.” Orientation to person is supposedly assessed by asking the patient to state his or her own name, and its traditional placement at the start of presenting the physical examination (just after the vital signs) might suggest that this assessment is of high clinical value.
Of course, it’s actually just about useless. A couple really nice quotes from Rapoport and Rapoport:
Unlike other principal components of the neurologic examination, orientation to person does not clearly correspond to a localizable function of the brain or nervous system, and there is no consensus on how it should be tested, what it signifies, and under what circumstances—if ever—it can truly be lost.
Although we…

Physician as Healer or Harmer? The Ethical Context of Aid in Dying

by: Elizabeth Dzeng, @LizDzeng

 As ethicists like to point out, what is the law is not always ethical and what is ethical is not always the law. Passage of the End of Life Options Act in California does not imply that we’ve resolved the debate on aid in dying, nor should it define our moral stance.

 However, it does provide us with new opportunities to find common ground. The energy and passion that motivate advocates on both sides, have always been rooted in the same desire to improve the way we die. The perspectives of those who oppose aid in dying will be especially critical, to give voice to vulnerable individuals for whom we must insure ethical responses with proper safeguards and support systems in place. This is an opportunity for us to critically evaluate and rethink our approach to improving end of life care as a whole.

 Aid in dying is controversial precisely because it exemplifies the many ethical dilemmas our society has grappled with – concerns of injustices that predomi…

A Palliative Care Fellow’s Perspective on Physician-Assisted Death

by Danny Cox (@DannyMD)

I’ll be honest. When I started my fellowship in palliative care 4 short months ago, I had not seriously considered the possibility that one day I would have a patient ask me whether I would prescribe them a medication to end their life. Of course I was aware of the Oregon experience, but living in California where I completed both medical school and residency had sufficiently inured me to this idea. But with the signing into law in California last month of the End of Life Option Act, I have started to feel troubled by this question: would I or would I not prescribe?

I recently spoke with my old babysitter who cared for me early on in childhood, a wonderful elderly Honduran woman now living in Maryland who I had not spoken with in over a decade. When I updated her on my career plans in palliative care, assuming she would have no context, I was surprised to hear her quickly respond about a recently watched TV program about doctors helping terminally ill patient…

The Invisible Hand Reaches into the Exam Room: Ordinary Medicine by Sharon Kaufman (Review)

by: Alex Smith, @alexsmithMD

Alone in the room with your patient, you think you have control over what happens?  You think that it's you and the patient setting the terms and content of what tests and treatments are offered, negotiated, and agreed to?

Think again.

In a brilliant new book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line, the medical anthropologist Sharon Kaufman illuminates the role of larger forces in shaping what is discussed in clinic examination rooms, at bedsides, and in consultation.  We had the pleasure of hosting Sharon Kauffman for our fist ever UCSF Division of Geriatrics Book Club yesterday.

Her book took me back to my freshman Introductory Sociology Class at Michigan.  I remember hearing about the "invisible hand" of larger social forces that, without our intention, guide our actions.

Here are two compelling examples from her book of how larger social forces are shaping conversations between patients a…

Use and Misuse of Chemotherapy at the End of Life

by: Danny Cox (@dannyMD)

The goal of palliative chemotherapy for patients with terminal cancer is to prolong survival and improve quality of life. A major ongoing concern among many physicians is that chemotherapy given to those near the end of life might actually be doing more harm than good. The 2012 American Society of Clinical Oncology guidelines recommend against the use of chemotherapy for those with an ECOG score of ≥3 (ECOG is a graded scale of functional status; see table). The implicit assumption is that those with better functional status will be better able to tolerate chemotherapy and derive benefit.
An eye-opening new study entitled “Chemotherapy Use, Performance Status, and Quality of Life,” recently published by Prigerson et al. in the September 2015 edition of JAMA Oncology casts doubt on the perceived benefits of chemotherapy in terminally ill cancer patients even with good functional status and highlights the need for a more nuanced approach.

In this multi-center, …