GeriPal

by: Eric Widera (@ewidera)

There are two main drug classes use to treat Alzheimer's disease, cholinesterase inhibitors (ChEIs) and the NMDA-antagonist memantine. Both have shown statistically significant improvements in outcomes for patients with AD, but the clinical significance of these benefits is marginal at best.   Furthermore, these benefits vary with disease severity, with ChEIs showing benefit from mild to servere dementia, and memantine showing benefit only in moderate to severe disease.

So how closely does clinical practice mirror the evidence behind these drugs?   A new study in JAGS suggests that your chances of being started on these drugs is about 50/50, and has less to do with FDA approved indications, and more to do with who you see and where you live.

The Study

The authors used a national sample of Medicare beneficiaries enrolled in Medicare Part D from 2008 to 2010 and evaluated the frequency of ChEI’s and mematine prescription fills in people with a diagnosis of …

by: Eric Widera (@ewidera)

Some of the best evidence for palliative care comes from interventions focused primarily on individuals with advanced cancer.  The problem is that most people in the United States die from diseases other than cancer.    So, how well do we serve them?

A new study published today by Melissa Wachterman and colleagues compared patterns of end-of-life care and family-rated quality of care for patients dying with cancer and other different serious illnesses.   What they found continues to demonstrate the benefits of palliative care, but also shows that we need to expand our world view beyond cancer.

The Study

The authors looked at inpatient deaths in 146 medical centers within the Veteran Affairs health care system between 2009 and 2012.  They further restricted their analysis to patients with clinical diagnoses categorized as end-stage renal disease, cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, fra…

by: Eric Widera (@ewidera)

We’ve written about the harms and lack of efficacy of docusate a fair amount on Geripal (here, here, and videos here).   This week in JAMA IM another fantastic research letter came out that should put another nail in docusate’s coffin by focusing on the indirect costs of prescribing this medication.

What did they do in this study?

The authors used pharmacy data for fiscal year 2015 from the McGill University Health Centre in Canada. They compiled doses and drug costs for the medical and surgical units for oral laxatives.   They also estimated that it took 45 seconds of nursing time for each medication administration and used Quebec base salary for university-trained nurses to estimate nursing costs.

What did they find?

Doctors love writing for docusate.   It was the most commonly prescribed laxative, accounting for 64% of all doses of laxatives.   This meant that nurses spent 2,065 hours to administer over 165,000 doses of a docusate, despite a paucity of data…

I met him once. He was referred to me for pain management and depression. In our visit, he described a series of losses over the previous six months—he had lost his identity when the cancer, radiation and surgery had deformed his face; he lost intimacy with his wife as the odor from dead tissue kept them distanced; and he lost connections with friends as it became more difficult to speak clearly. His biggest worry now was about losing his dignity. We talked about what dignity felt like for him, and what a death with dignity would look like. He spoke of choice, control and independence. He defined loss of dignity as the moment when he needed full care—complete dependence. This was the line for him and he was coming frighteningly close to it. I was able to treat some of his symptoms, offering antidepressants, opioids (with some control over dosing), hospice referral and continued conversations with a caring provider. Almost in a disconnect with the hopelessness that he exuded, he polit…

by: Alex Smith MD, @AlexSmithMD


I've written before about my evolution in thinking about aid in dying.  How, while I was in medical school, my parents were very in favor of legalizing aid in dying in Michigan after my dad was diagnosed with brain cancer.  Also while in medical school, I read two books that further inspired me to go into palliative care: A Midwife Through the Dying Process by Tim Quill, and Dying Well by Ira Byock.  These two authors and luminaries of palliative medicine also happen to be leading voices at opposite ends of the spectrum on the issue of aid in dying.  These readings implanted an early ambivalence about legalization of aid in dying.


Later as a palliative care physician in training I became even less enamored with aid in dying, as all the patients I cared for who expressed a wish to die stopped making such requests with multidisciplinary attention to reversible sources of suffering.


Many in palliative care have worked hard to distance themselves from …

By Laura Petrillo, MD, @lpetrillz

As of today, it is legal for seriously ill patients in California to request lethal medication to end their lives from their physicians. That’s the verb that the End of Life Option Act uses, request.  One imagines a very determined patient, let’s call her Helen, asking her physician about something that’s been on her mind since she learned about her metastatic cancer: “Doctor, will you help me die?”  Maybe she saw Brittany Maynard on the cover of People magazine, or read about Jerry Brown’s opinion that it would be “a comfort” to have that option if he were dying and in pain. She is educated, like most of the people who use the Death with Dignity Act in Oregon, and eager to have control over the moment of her death. 
But what if Helen hadn’t read the news about the End of Life Option Act, and didn’t know that aid in dying was now legal in California? Imagine instead that she has just come to her follow-up appointment, nervously, to find out the resul…

by: Elizabeth Dzeng (@LizDzeng)

On September 11, 2015, the legislative bodies of California and the United Kingdom were both faced with the decision to legalize physician assisted dying. Both bills were remarkably similar and based on the Oregon Death with Dignity bill. However, UK lawmakers decisively rejected their bill while their California counterparts approved the End of Life Option Act.

Post-hoc analysis of why the bill failed in the UK and why it succeeded in California point to the usual arguments; concerns about the protection of vulnerable populations and fears of a slippery slope on one side and calls for control and dignity to the end on the other. However, I believe that the different paths taken this day might reflect the different philosophies these countries hold regarding the primacy of choice and autonomy.

That it passed in California might reflect America’s sociopolitical tendencies towards individual rights and autonomy, and the nation’s mistrust of institut…