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Showing posts from February, 2016

I'll Have What She's Having: Goldilocks and the Hospice Benefit

by: Eric Widera (@ewidera)

Two reports came out last week that can easily lead one to opposite conclusions about the current state of hospice care in the U.S.

The first was a Wall Street Journal (WSJ) report on how hospice care is being used too early in the course of a Medicare beneficiary’s illness. The article can pretty much be summarized by its subheading: “More dementia patients and others who die slowly are receiving care, causing costs to rise."  NHPCO has a good response to the article, which I will not summarize here except by saying that my favorite line from it was : “People do not come with an expiration date, nor does their end-of life-care.”   While I agree with NHPCO's response, I still found the WSJ article fascinating, in particular the finding that beneficiaries who were enrolled in hospice for more than 365 days accounted for about 32% of Medicare hospice payments. More striking is that those with very long lengths of hospice lengths of stay (on averag…

Launching the Master of Science in Palliative Care Program

In June, 2015 I wrote about the need to for new training programs in palliative care because of the projected shortage in providers. At that time I wrote that: “Amos Bailey, MD, a well-known leader in the field of Palliative Medicine and a new colleague of mine at the University of Colorado has a pretty innovative idea. He has set up a task force to prepare an application to the Board of Regents to offer a new degree program: Master of Science in Palliative Care. This would be an inter-professional executive Masters that would be provided predominantly online (with three separate one-week on-campus intensives). This program will be designed for the clinicians (physicians and advance practice providers) who are already working and need or desire more training in Palliative Care” and asked people to complete a short survey to gauge interest.

Over the next 3 week 575 individuals completed the survey and 75% reported that they would be “interested” or “very interested” in such a prog…

Visits by Hospice Professional Staff Matter: Why I believe that More is Better

by: Joan M Teno (@JoanMTeno)

A high quality hospice provides the best end of life care – something that I have documented in JAMA 2004 and Journal of Palliative Medicine 2015 articles. However, an important caveat is “high quality". Both my mother and great aunt died on hospice service, for which I am very grateful for the excellent hospice care each received.

Some recent papers that I have written about the variation in key processes of hospice care, including one published in JAMA Internal Medicine this week, may lead some of you to question whether I truly support hospice. Maybe you can rightly accuse me of not being a hospice advocate. I have always been inspired by Dom Berwick's central question as interim Director of the Centers for Medicare and Medicaid Services (CMS), “How will this policy impact and improve the care of Medicare Beneficiaries?”

So why have I concluded that visits by professional hospice staff matter in the last two days of life?

First, I don’t …

Aging Veterans on the Cover of The Gerontologist

I always had a soft spot for veterans, as my father saw action in the Pacific Theater and I grew up with his war mementos stashed in a corner of my basement.  A theme in the photos I've taken for covers on The Gerontologist has therefore been veterans, with images that reflect their pride in serving our country.  I was recently asked to provide a pic for the Special Issue on Aging Veterans, seen below.  This photo was taken at the Tennessee State Veterans Home in Murphreesboro, and features a Viet Nam vet named Frank Coven being hugged by his nurse Sammie Fox.  This image exemplifies how the vets were treated in this facility.  The photo below was published on TG in December 2013 before the design change.  It features Stanley Brown who was one of the first US soldiers to enter Japan after the surrender in WWII.  He told me, "I have so many stories you couldn't have time to hear all of them!" The photo below was published on the cover of TG in August 2010 and feature…

Potpourri from clinical work IX: BiPaP, Movantik, and Lord Grantham

by: Alex Smith, @alexsmithMD


This is the ninth iteration in the potpourri from clinical work series, where I basically raise issues that were interesting from recent time on the palliative care service.  For prior iterations just enter the word "potpourri" into the search box on the right side of the screen.


1. BiPaP for patients who are DNI.  This came up for a hospitalized patient with a severe pulmonary infection and effusion (fluid around the lung).  The idea was BiPaP, a tight fitting mask hooked up to a mini-ventilator, might be used as a bridge until a needle could remove some of the fluid around his lung.  It worked.  Though his oxygenation improved, he died without ever regaining consciousness.  BiPaP is in a grey zone.  One useful question I sometime use in code status discussions  (learned from Gail Gazelle) is to ask people, "How do you feel about living on machines?"  People who don't want to live on machines are generally DNI.  The problem is tha…

The Opioids Issue: Morphine versus All Comers

by: Eric Widera (@ewidera)

Next year marks morphine's 200th anniversary as an analgesic (while it was discovered in 1804, it was first marketed to the public in 1817).  In honor of this historic event, I'm going to dedicate this GeriPal post to morphine by describing three recent trials that continue to show that morphine can hold its own when it comes to pain relief.

1. A randomized control trial of morphine vs either codeine and tramadol

We’ve never held back our disdain for the likes of codeine and tramadol on GeriPal, so why stop now? A great study recently came out that evaluated the use of “weak opioids” (you know, those step II drugs on the WHO  analgesic ladder) versus morphine for the relief of cancer related pain. This was a 28-day, open-label randomized controlled study done in 240 opioid na├»ve adults with moderate cancer pain (4-6 out of 10 pain). The participants were given either oral morphine or a weak opioid (tramadol with or without paracetamol or codeine…