Thursday, May 10, 2012
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| Me with Ruth Hancock out side of KBR* |
Since completing a hospice and palliative medicine fellowship, I have been privileged to work alongside fantastic nurses who have been wonderful teachers, mentors, clinicians, and leaders. I am especially reminded because in the past two weeks I have had several interactions with nurses from my past education and work experiences. These chance meetings reinforced how indebted I am to the many hospice nurses who have helped form my approach to patients and families.
I was the sole fellow at the Hospice and Palliative CareCenter in Winston-Salem NC in 2003-4. Dr. Dick Stephenson was a exemplary fellowship director, but there was not the luxury of numerous physician faculty many programs have today, so there was a lot of on-the-job training. I loved this experience and would not trade it for anything. By default, my key teachers were the people I worked with every day. The hospice nurses at the Kate B. Reynolds hospice house, in IDG and traveling around central North Carolina to patients homes were the most experienced and available clinicians. I could ask them so many questions about patient and family communication, medication side effects, wound
As I began to get back into my Pallimed blogging mode, I will work the rest of the year to find more nursing related research, news articles and leadership stories. Also in a small token of recognition I am making a $100 donation to the Hospice and Palliative Nurses Foundation in honor of National Nurse's Week and I would encourage any other doctors who read this to do the same. I know I am not the only doctor who has been influenced by great hospice and palliative nurses.**
So thank you to Ruth, Becky, Elaine, Tiffany, Sally, Maria, Pat, Michelle, Janet, Melissa, Sue, Karen, Jennifer and many other hospice and palliative nurses who have taught me so many useful things over the years, and have been willing to listen to me spout off about ABHR gel and other esoteric topics. I am a better physician and a better person because I have worked with all of you.
If you are interested in hospice and palliative nursing, please check out the HPNA page on career options.
*No, the photo has not been Instagram'd, it was scanned from a time when I did not have a digital camera!
**If you email me that you have donated any amount I will update this post to show others how many doctors have participated. You can choose to have Anon, First name only or full name recognition.
Thursday, May 10, 2012 0
Friday, May 4, 2012
This week the American Geriatric Society is holding their annual meeting and they announced they will now do a fellowship match starting with the 2014 academic year. This is huge news for geriatrics since they have been without a match since they were first officially recognized by the ACGME in 1988. It also serves as an important benchmark for palliative medicine fellowships.
Why is this important news? Both fellowships have a lot in common and hopefully directors at geriatrics programs can work with their HPM colleagues to accelerate working through the complexities of getting a HPM match. We have seen posts on GeriPal and Pallimed about the frustrations caused by not having a match.
With Geriatrics now having a match, hopefully our field will be inspired to do the same in a rapid manner. This should be easier because we have gotten past the toddler years as a subspecialty. Can you believe it was only 6 short years since ACGME officially recognized HPM? We now have over 70 HPM fellowships and a few score that have been existence under voluntary guidelines for more than a decade.
The match offers many benefits to future fellows: more opportunity to see other programs besides their home program, and more clarity on the timelines on when programs will take applications, interview, and make offers. With all these benefits it is surprising to me that out of nearly 150 recognized specialties only 50 or so participate in a match. Thankfully our field is marching towards a match, but it is not as easy as one might think.
I have been in discussions at meetings with over 40 fellowship directors in the room who are all desiring great candidates in a fairly small pool. When the match comes up, the tension in the room can rival a challenging family meeting when you start talking about what dates work, and how soon to implement a program. One thing nearly everyone agreed on is the importance of a match for fairness to programs and applicants. The challenge is more in taking a good idea and making it reality.
If you may not understand why this is important, I again encourage you to read Brian McMichael’s post on what it is like to be an applicant in the current system:
“My [application] process was cut short by a spoils-to-the-swift ethic. Because of the asynchronous timelines, I had to decline interview offers from programs I was very interested in. Given the inherent power disparity in the roles and the dynamics involved, I did not believe I had the latitude to walk away from offers from great programs in order to "explore my options" further. Perhaps my issue, but I doubt mine alone."It is sad that this is the first impression that we give applicants coming to the field. I am happy that Geriatrics has accomplished this and that we now realize we do not have to wait 24 years for palliative medicine to do the same. We will do better.
[Ed. note: I appreciate what GeriPal and Eric Widera have accomplished and their ongoing contributions to the field. I enjoy working with him and the writers at Geripal. These words represent no one but myself. This is not a war between us, so please don't make it out as such. This is more of a creative writing exercise because after reading his post I felt insulted. Not as a board member, or as a blogger, but as a member of this field. We have studious people accomplishing great things in palliative medicine and hospice organizations. We are not perfect and it is good to encourage us to do better, but language matters. Our work makes this clear. - Christian Sinclair]
Friday, May 4, 2012 0
Tuesday, May 1, 2012
This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
We welcome comments about any aspects of the questions or the answers/discussions. The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.
Mr. Smith is a 72 year old patient was admitted to hospital from his nursing home for respiratory distress due to CHF exacerbation. Despite aggressive diuresis attempts, his respiratory distress continued and his urine output remained minimal (~30ml/day).
PMH: heart failure, moderate dementia, renal insufficiency
Home medications: furosemide 40mg po bid, metoprolol 25mg bid, donepezil 10mg daily, olanzapine 5mg qhs.
After a conversation with his son (health care proxy) the patient was "made CMO" (comfort measures only) by the hospitalist service and resident team two days ago. He was then started on a morphine drip “titrate by 1mg as needed for pain or shortness of breath”, his donepezil, olanzapine and diuretics continued, other medications stopped.
His intern calls in a panic: “We promised to make him comfortable, that he would die in 2 days, but he is still alive and the family does not know why he is in such pain – even with light touch – crying out & jerking.”
What is your recommendation?
a) Stop morphine drip and start fentanyl and lorazepam prn
b) Increase morphine and olanzapine
c) Increase morphine and add lorazepam prn
d) Stop morphine drip and start fentanyl, increase olanzapine
Discussion:
Tuesday, May 1, 2012 0
You can break down the basic answers in a couple of categories that all have their pros and cons.
- No. Absolutely no! - Obviously this answer doesn't take into account any of the unique aspects noted below that may influence the decision. This response often comes from the feeling that protecting children form the sadder, darker sides of life is the best thing to do. But this may come at a price later, when the child grows up and really has a less nuanced and full understanding of how death fits with life. Finding the teachable moment as a parent is one of the trickiest skills to master.
- Yes. Absolutely yes! - Well if absolute one way isn't so smart, absolute in the other direction must be brilliant. (Only in politics, am I right?) Sadly an always yes statement falls into a similar trap of missing the unique identifiers which guide the most beneficial path. Forcing children to learn about something can backfire if they are not prepared.
- How mature is the child? - Well if you cannot answer the question with an answer, then try a question. I have heard this often and used it occasionally. Assessing for a child's maturity and more importantly understanding of the concept of death is not the simplest task. Sometimes my 6 year old is very mature, often times she is not. The inherently relative nature of the question may not always be helpful.
- Was the child close to the person? - Closeness to the deceased may or may not be a great indicator of readiness to attend a funeral. But if the child is cl
- What does the child want to do? This is the BEST RESPONSE IN MY OPINION. It empowers the child to have a say in this very important family event. From this you can get a sense if the kid feels obligated, indifferent, overwhelmed from the entire situation. In fact with death and dying discussions with children (and even adults) the best advice I was ever given was to ask what questions they have and answer them simply and leave room for more questions and discussion. Do not try and be an expert and explain everything to a child. They will let you know where they want to go with the conversation if you let them.
- Plan for a separate viewing and/or ceremony for children - If you are not sure how the child may react many funeral homes can work with you and have a smaller viewing or plan a ceremony to honor the loved one. This way the child is included but does not have to be subjected to the pressure of a larger group and the Aunt who just never has the right thing to say.
- Access your hospice experts - Even if you have not had services provided by a hospice agency, you can usually reach out to one of the bigger ones in your community and ask to talk to a bereavement counselor and possibly a child-teen specialist. They have a great knowledge base and can connect families with resources in their community which focus on grief and loss challenges of kids and their families. Comfort Zone Camp is a great example that runs multiple camps nationwide.
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| Kansas City Star Mom2Mom poll |
Are there any tips you might share?
- I've tried to teach my kids (even when I can tell they don't want to hear it) that everything living will die someday. Death is part of life ("Circle of life, Simba"). That discussion is wasted if they're too young to comprehend.
- I was 8 when I went to my first funeral and it was my father's and it was very uncofortable/terrible experience for me. Still to this day I remember the image of my fathers's body in the casket and the memory of seeing my father like that haunted me!
*I use the term broadly here to even reach to young adult.
References:
Black, D. (1998). Coping with loss: Bereavement in childhood BMJ, 316 (7135), 931-933 DOI: 10.1136/bmj.316.7135.931 (Open Access PDF)Holland, J. (2004). Should Children Attend Their Parent's Funerals? Pastoral Care in Education, 22 (1), 10-14 DOI: 10.1111/j.0264-3944.2004.00281.x (Open Access PDF referring to this study)
One quality measure as you can see from the picture above is the link to actual state registries.
Could something like this work for advance directives like durable power of attorney or a living will? In addition to listing family you could also list who your DPOA was. It may even lead to an interesting study to see how networked DPOA's are and even if they might be able to find each other better and talk about how to be a better DPOA. I'm unsure if I will post my organ donor status on Facebook. I post a whole lot of other things, but this feels like it crosses a different threshold.
What will you do if you are on Facebook? (I already know what everyone who is anti-Facebook is going to say, but you can share your thoughts too of course!) Is Facebook the right platform to merge online registries for health issues that are struggling to get more traction? You want to be where the eyeballs are right?
The New York Times and The Atlantic cover the issue in more detail if you are interested.
Thursday, April 12, 2012
Yes it is that time of year again. If the weather is starting to get nice and there are a few storms coming through your area it must be Spring and that means Taxes right? Well yes there is April 15th where we have to pay our taxes. But more importantly to the hospice and palliative medicine community is National Healthcare Decisions Day (US) and National Advance Care Planning Day (Canada) on Monday April 16th.
2012 marks the 5th year of NHDD, an initiative spearheaded by Nathan Kottkamp, a partner at McGuire Woods law firm in Virginia. He is living proof of the famous Margaret Mead quote, "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."
I have had the pleasure of working with Nathan in 2011 on NHDD and I strongly support this great initiative which should be thoroughly embraced by the all of us. It speaks to our professional values and gives us a day where we can freely talk about advanced care planning without any sense of taboo feeling of the lingering spectre of death. This is an empowering event that emphasizes "Your Decisions Matter"
There are many simple ways you can participate and the NHDD website is a great resource. If you haven't planned anything for the public you could just focus your efforts on your friends and family. Or maybe your whole hospice office could make sure everyone has completed their advanced care planning. Or you can participate in the blog rally on Monday and use your social media platforms to spread the message. And you can have fun with it like these medical students did in their Star Wars themed Advanced Care Planning Video.
Most of all don't be hypocritical. If you are going to encourage everyone to complete it, take the first step and do it yourself. If you can't convince yourself to complete your advance care plan then how well will you be able to advocate for others.
Thursday, April 12, 2012 0
Monday, April 9, 2012
This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
We welcome comments about any aspects of the questions or the answers/discussions. The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.You visit a patient at home receiving hospice care for cancer. Her pain has been well controlled with long acting morphine 60mg BID and occasional PRN doses of short acting liquid morphine (10mg) over the past few weeks: she had been tolerating this well. She has had recent progressive functional decline and is currently at a PPS of 20%. In the last 24 hours the patient has vomited and has been more lethargic and having difficulty swallowing pills. She appears uncomfortable. In your examination you see a very thin patient who appears to be dying with a prognosis in the few days to a week range.
The patient’s son is a respiratory therapist at a hospital and is insisting you change the patient’s opioid to a fentanyl patch because “it is less sedating than morphine.”
The best response is:
a) Because the patient is cachectic, you tell the family that fentanyl transdermal patches are not indicated because the medication will not be absorbed.
b) Agree with the son and convert the patient to a 37.5mcg/hr fentanyl patch with oral morphine liquid 10mg q1 hour PRN
c) Because the fentanyl will not be effective for over 24 hours, continue the long acting morphine sulfate 60mg BID but give it rectally instead of by mouth
d) Suggest starting a morphine infusion via her port at 1.7mg/hr basal with a 3mg q30min bolus PRN after talking with the son about his concerns about sedation.
Discussion:
Monday, April 9, 2012 0
Monday, April 2, 2012
This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
We welcome comments about any aspects of the questions or the answers/discussions. The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.Mrs Dole, a 68 year old with 20 year history of Diabetes Mellitus Type II is referred to Palliative Care from Oncology with Stage III Nasopharyngeal carcinoma. Nausea is the key concern. For last 3 years she has had early satiety but maintained weight. Since initiating chemotherapy, she has had nausea for the first 2 days of her chemotherapy cycle, which then resolves.
1 week after the last round of chemotherapy she required intravenous fluids for dehydration. Now 2 weeks later is having intermittent severe nausea. It can be provoked by sudden changes in body position. She fell once because she lost her balance. Usually she does not vomit, but occasionally does. She describes a feeling of the room spinning associated with the nausea.
Of the following options, which drug is most targeted to this patient’s specific nausea type:
a) Ondansetron
b) Prochlorperazine
c) Metoclopramide
d) Diazepam
e) Meclizine
Discussion:
Monday, April 2, 2012 0
Sunday, April 1, 2012
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| Leaders of the APRIL-FUL showing good bedside manner |
Chicago, April 1, 2012.
by Abe R Feaulx, Pallimed Special Reporter
In a joint news conference, representatives of the Accreditation Council for Graduate Medical Comedy (ACGMC) and the Alaskan Veterinary Medical Association Accreditation Council on Comedy (AVMA COC) outlined new requirements for accreditation of fellowships in Hospice, Palliative Care and Pupplies (HPCP). As many of you will recall last April 2011, the Association of Palliative Realists Interested in Looking For Unified Language (APRIL-FUL) declared the new name for the field "Hospice, Palliative Care and Puppies."
Explaining the historic cooperation between ACGMC and AVMA COC, ACGMC board chairman Dr. Moe Howard said "the recent change in the specialty's name presented an opportunity for strategic cooperation between our two organizations that we couldn't pass by. Working together, we can fulfill our mission to assure the public that graduates of HPMP training programs are fully competent to carry out all the duties of an HPCP specialist, including finding the right type of puppy to meet a patient and families needs."
Explaining the historic cooperation between ACGMC and AVMA COC, ACGMC board chairman Dr. Moe Howard said "the recent change in the specialty's name presented an opportunity for strategic cooperation between our two organizations that we couldn't pass by. Working together, we can fulfill our mission to assure the public that graduates of HPMP training programs are fully competent to carry out all the duties of an HPCP specialist, including finding the right type of puppy to meet a patient and families needs."
The new requirements include:
- one month rotation at a veterinary hospital accredited by AVMA COC
- six month continuity clinic at a PetSmart or other similar community-based pet training center
- inclusion of a pet therapist (the pet, not the person) at all IDT team meetings that the trainee attends
- a scholarly project documenting impact of puppies on palliative care patients or staff or volunteers
In a coordinated announcement, the National Alliance of Hospice, Palliative Care and Puppies,(NAHPCP) pledged to quickly adapt the competency statements, measurable outcomes, and competency toolkit to these new requirements. "We'll be integrating evidence-based competencies that are applicable to the new training requirements into the competency toolkit. For instance, it will be very important for graduating fellows to be able to train the pet therapists on hospice IDT's in prognostication skills, such as those exemplified by Oscar the Cat," said Dr. Sitt Phydo, chair of the AAHPCP task force to promote evidence based palliative pets. (PEPP)
When asked for comment, the National Association for Cats in Hospice issued a statement declaring, "We would rather work on our own and not be dependent on any other organizations like some sniveling canine."
When asked for comment, the National Association for Cats in Hospice issued a statement declaring, "We would rather work on our own and not be dependent on any other organizations like some sniveling canine."
Sunday, April 1, 2012 0
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