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Showing posts from March, 2017

Muriel Gillick: On Being Old and Sick in America's Health Care System

On this weeks GeriPal podcast, we have invited Muriel Gillick to discuss the state of our current health care system for older adults as they journey through our health care system. Dr. Gillick is a professor of medicine at Harvard Medical School, geriatrician, and palliative care clinician. She is also an author of multiple books, including one that will be coming out in October called "Old and Sick in America: The Journey Through the Health Care System."  Here is a link to an article about blacklisting performers by the House Un-Amarican Activities Committee  in the 1950's (including Pete Seeger).

*Update 12/5/17 - the book is now out, follow this link*

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by: Eric Widera (@ewidera)

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Transcript of the podcast:

Eric: Welcome to the GeriPal Podcast. This is Eric.

Alex: This is Alex.

Eric: And Alex, who's our guest today?

Alex: Today, we have Muriel, who comes to us from Boston…

Quality & Safety Consideration for Patients with a POLST or Living Will

Do We Ask for Permission to Treat First? Or Treat first & Ask Questions Later?


As we are educated on the ethical & financial concerns surrounding end-of-life care, we are informed by Institute of Medicine that end-of-life care is broken and accounts for $170 billion in annual spending (1). This projection will exceed $350 billion in less than 5 years. To better align patient wishes, living wills & POLST (Physicians Orders for Life-Sustaining Treatment) are necessary documents and processes. Whether you like them or not they are here to stay are we need to assure provider competency.  Additionally, Medicare now reimburses for advance care planning conversations in the office or via telemedicine. In the past, Physicians have tried to embrace living wills and more recently, the POLST paradigm has emerged to the national forefront. POLST & POLST-like processes have grown rapidly, which has outpaced the ability of states to educate to ensure the sa…

Navigating end of life issues for those with no known family and friends

Consider the following scenario:

A previously independent 80 yo gentleman develops a catastrophic illness.  His mental status is poor due to strokes during his illness and it is unlikely he’ll recover the ability to meaningfully interact with the world.  However, he also has severe lung disease and he needs a tracheostomy with the ultimate plan of going to to a long-term ventilator facility.  It is unlikely he would ever leave the vent facility.  He has no family members, no friends.

Should he get a trach?

In most facilities, my sense is that the answer is yes.  The logic is that unless we have clear and overwhelming evidence that a patient does not want a specific intervention, death is always the worst outcome and thus must be avoided at all costs.

However, I wonder if this logic is flawed.  If we have 100 patients in this scenario, it is very possible that some of them would want the trach.  But it also seems quite likely that most would not want the trach, feeling that it would p…

The Overlooked Never Event

by: Ryan Van Wert, MD

John’s Story

Since his college days, John was always a runner.  Now at age 65, limping with arthritis, his orthopedic surgeon has recommended a left knee replacement. John completed a consent form authorizing the procedure.  In the operating room, John falls asleep as the anesthetic agent runs through his veins, hearing reassuring words from his nurse that everything will be okay.  When John awakes, it is very clear that something is very wrong.  His surgeon and nurses have gathered around his bedside and have devastating news: an error had occurred.  John had been mistaken for another patient scheduled for an above knee amputation, and the surgical team had removed his left leg.

This is one of the most terrifying scenarios that patients and surgeons fear, a family of adverse events called “Wrong-site, wrong-procedure, wrong-patient errors (WSPEs)”.  At the turn of this century, increasing awareness of these events led to the contemplation of “Never Events”. Wha…

Code Blue

by: Marcia Glass, MD

I sometimes notice “DNR” on my intern’s to-do list during rounds. It usually means his resident asked why this patient, in spite of being so debilitated from his end-stage cancer, or his dementia, or his heart failure, was still full code.  The patient should be made DNR instead, but doing so involves a difficult conversation with sick patients or desperate relatives, sometimes over hours, sometimes over days. Hence, the DNR on the to-do list and the knowing looks from my team. “How’s the family?” “Do they get it?” “Are they reasonable?” Any possibility of a peaceful death depends on my medical team’s ability to make people we hardly know trust us and then change their minds.

Mrs. J. was different. In her eighties, she came to our hospital in San Francisco with her favorite blanket and a book of crossword puzzles. Her husband, close to ninety, rode two buses in his neat overcoat every day to arrive promptly at 8 a.m. before our rounds started. Mrs. J. had advance…