Wednesday, November 27, 2013
Wednesday, November 27, 2013 by Christian Sinclair ·
Wednesday, October 30, 2013
- Increased # of patients served* (1.5M)
- Increasing average length of service (71.8d)
- Decreased median length of service (18.7d)
- Slightly higher percentage of elderly patients served
- Higher diversity of patients served
- Increasing percentage of non-cancer diagnosis led by debility and dementia
- Increasing number of hospice programs (5,500)
- Increasing percentage of for-profit hospice programs
- Increase in Inpatient Hospice (GIP) days
- Declining satisfaction rates (although still high)
- 2013 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2013_Facts_Figures.pdf
- 2012 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2012_Facts_Figures.pdf
- 2011 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2011_Facts_Figures.pdf
- 2010 http://www.stjosephhospice.com/wp-content/uploads/2011/01/Hospice_Facts_Figures_Oct-2010.pdf
- 2009 http://ebookbrowsee.net/nhpco-facts-and-figures-pdf-d146287250
- 2008 http://www.lovinghandshospice.com/pdf/nhpco_facts-and-figures.pdf
- 2007 http://web.archive.org/web/20081001182409/http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdf
- 2006 Summary http://www.allhealth.org/briefingmaterials/NHPCO-NHPCOsFactsandFigures-2005Findings-760.pdf
- 2006 State Supplement http://www.hpcai.org/documents/filelibrary/documents/pdf/NHPCO_NDS_2006_State_Report_FINAL.pdf
Wednesday, October 30, 2013 by Christian Sinclair ·
Thursday, October 24, 2013
I had just begun reading Dr. Danielle Ofri's latest book, "What Doctors Feel: How Emotions Affect the Practice of Medicine", when I opened The New England Journal of Medicine to find David Korones' essay "What would you do if it were your kid?" As he points out, nearly all of us have been asked, have heard this "plea to share with them, as a partner, the heavy burden of decision making." And nearly all of us have squirmed in our seats a little each time.
I still remember the child in the ICU, sedated and on a ventilator as her parents waited for the fungus in her lungs to clear. The note on her door said, “Docs, if ‘Plan A’ didn’t work, the alphabet has 25 more letters! So stay cool.” Yet, the infection was persistent, and her parents were asked to decide – continue as is, perform surgery to remove the fungal ball, or to withdraw the ventilator support and keep her comfortable as she died. The whole team gathered with the parents – the ICU doc, the BMT primary, the infectious disease specialist, the cardiothoracic surgeon, and me, the palliative care doc. The options were presented. The table fell silent as the parents processed the decision before them. Then the father asked, “What would you do?” And after a few furtive glances, one-by-one every provider around that table shared their opinion.
There was not a unanimous response from the providers at the table. But everyone sat with the parents as they faced a heart-wrenching decision. Two years after her death, her parents sat before a group of second year residents and reflected on that family meeting, and on the empathy they felt. It buoys them on their waves of grief to this day.
While the word "empathy" does not appear in Korones’ essay, I think it is at the heart of everything he says. Perhaps it is because I was reading Ofri’s book, and on page 48 she explains,
“Empathy is a cognition, a thought process that allows you to understand the patient’s feelings while not necessarily feeling them yourself… and the empathic doctor needs to be able to clearly communicate that understanding” (p48).When a patient or a family member asks, “What would you do?”, they are inviting empathy.
1. Korones DN (2013). What would you do if it were your kid? The New England Journal of Medicine, 369 (14), 1291-3 PMID: 24088090
2. Meyer EC, Lamiani G, Foer MR, Truog RD (2012). "What would you do if this were your child?": practitioners' responses during enacted conversations in the United States. Pediatric Critical Care Medicine 13 (6) PMID: 23034458
Thursday, October 24, 2013 by Jenni Linebarger ·
Friday, October 11, 2013
- European Association for Palliative Care (EAPC)
- International Association for Palliative Care (IAHPC)
- Worldwide Palliative Care Alliance (WPCA) and
- Human Rights Watch (HRW)
As a palliative care doctor, I have seen suffering damage people and families, but I have also seen the ability for skilled clinicians taught the basics of palliative care, who are able to relieve that suffering. In that act of relief, those clinicians also create a healing process for patients and families even in the face of serious illness. With access to critical pain and symptom medications and the proper education more clinicians can make a true difference in people's lives around the world.
Friday, October 11, 2013 by Christian Sinclair ·
Friday, October 4, 2013
In the face of a crisis, many people are challenged to find constructive and meaningful ways to engage in conversation and so often they fall back on platitudes. Simple, hopeful, semi-philosophical phrases we have heard in many other situations may sound important to the speaker, but the receiver finds them meaningless and tone deaf. I'm sure you have heard many of these uttered to patients by well-meaning family friends, and even health care professionals:
"This too shall pass."
"I'm sure it will be OK."
"It is what it is."
"God won't give you more than you can handle."
"Limp, anemic sentiments will not stand in the face of a world that is not as it should be."Pyle explains that this phrase is often sourced to the Bible but the original statement is about temptation not suffering. I think this is a great post to bring to team and discuss how we as professionals who see the intersection of suffering and spirituality everyday deal with statements like this. I posted the article earlier this week to the Pallimed Facebook page, and it garnered a lot of responses. Here is one that I think many in palliative care will agree with:
Call it what you will, but someone people hang on to this for their hope and sanity. Even though I agree with this blog, even his blatant use of calling it what it is, sometimes to "correct" those (in the moment) who are holding on to this falsity as their hope and sanity, it is equivalent to pulling the chair out from under them.When you hear, "God doesn't give you more than you can handle," how do you respond?
H/T to Rick Bauer (@nvrflycoach) for posting the original blog to Twitter
Photo Credit: Not attributable after using Tin Eye Reverse Image Search
Friday, October 4, 2013 by Christian Sinclair ·
Tuesday, September 24, 2013
Back to the Sanderson’s study and article. Sanderson and her colleagues David Zurakowski and Joanne Wolfe wanted “to identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients.” Literature exists for adult populations, but this was the first specifically targeted at the pediatric realm.
Sanderson A, Zurakowski D, and Wolfe J (2013). Clinician Perspectives Regarding the Do-Not-Resuscitate Order. JAMA Pediatrics PMID: 23979224
Other cited works:
Birds: Audubon "Illustrated Birds of America"
Bridge: Emily Riegel Personal
Child: Emily Riegel
*Links are Amazon Affiliate Links. Any proceeds from sales using these links support Pallimed outreach efforts.
Tuesday, September 24, 2013 by Emily Riegel ·
Friday, September 20, 2013
Patients attending an ambulatory consulting service in Adelaide, Australia were queried regarding their feelings about stopping medications, and the results were reported in JAGS recently. The subjects, age 71 on average, were taking an average of ten medications. Most subjects thought they were taking a "large number" of medications and 92% said they'd be willing to stop one or more medication "if possible."
Big shocker for Pallimed readers, I'm sure. Who wants to take ten medications?
This survey included a geriatrics population and was published in a geriatrics journal. But if you practice palliative care or see patients with limited prognoses, you should take heart in the notion of slashing medication lists, especially when you can see no clear indication for the medications. I'm looking at you, primary and secondary preventative medications.
A few hypotheses for why it's so difficult for some physicians to discontinue medications:
- Inertia: It's easier to continue with the status quo.
- It may require a discussion about overall prognosis: "Wait a second, doc. My doctors have been telling me for years to take that orange pill. Are you sure it's OK to stop now?" In other words, patients want to do the right thing, even if that means being burdened with taking a boatload of meds. This is evidenced in the JAGS study by the fact that 71% of patients said they'd accept taking more medications, if necessary. However, if a prognostic discussion has occurred (e.g. related to advanced cancer, etc), it's then easier to say "I think that medication has done it's job, I admire your commitment to taking it, and now it's OK to give it a rest."
- Overestimation of actual benefit of medications: "He had an NSTEMI five years ago. What if we stop the simvastatin and he has another MI? Sure, he's probably going to die from lung cancer in the next several months, but I don't want him to die from an MI. No, he's not having any coronary artery disease symptoms now, but I think it's best just to continue it." Look at a meta-analysis of several studies evaluating the benefit of statins for primary and secondary prevention of cardiovascular events. The number needed to treat to prevent one major coronary event was 28, which isn't horrible. Yet it's not exactly dooming your patient to angina/MI before he dies, especially if you consider that the five studies evaluated in the meta-analysis followed patients for 5-6 years to look for the outcomes.
Use a shared decision-making approach with patients. Even though it's OK to discontinue meds, it's also OK to not be dogmatic about it if the patient prefers to continue the med (as long as it's not harming them).
As hard as it is to stay on top of the deluge of new research (just even in your own specialty), it also never hurts to remain aware of research regarding the indications for primary/secondary prevention. A good example would be a recent cohort study from the Annals of Internal Medicine which suggests the optimal BP in patients with chronic kidney disease may be 130 to 159/70 to 89 mm Hg, with patients in that group having lower mortality rates.
If you're reading this, you're probably part of the choir already. If so, here's a pat on the back to you for being vigalant about polypharmacy!
For more related to this topic, see my post from a few years ago about "Minimally Disruptive Medicine" (and some other related links in that post).
Edit 9/22/2013: Also, I just found some recent American data published in Journal of Palliative Medicine on statin use near the end of life in patients with cancer (along with a letter to the editor on the JPM study). Bottom line: Statin use common in this population right up until time of death, unclear how appropriate the use is in each individual patient, but opportunities to deprescribe were likely missed.
Friday, September 20, 2013 by Lyle Fettig, MD ·
Thursday, September 12, 2013
JAMA Internal Medicine (JIM, you'll always be Archives of Internal Medicine to me) has published a study of an outcome prediction tool for in-hospital cardiac arrest. Specifically, a tool to predict the rates of neurologically intact survival after an in-hospital arrest. The developers of the tool call it GO-FAR (Good Outcome Following Attempted Resuscitation).
One could imagine ways of re-titling it FORe-GO, if one chose to spend one's time imagine such things.
This is the best tool of its kind that I've seen, although one needs to be very clear about what it's actually predicting.
The paper mostly describes, in detail, the derivation and validation of the tool. I won't belabor this - they did a good job of it, used a large dataset, created a model, tested and validated it to get the best receiver operator curve, etc. The data come from the massive, US-based, 'Get With the Guidelines Registry' (which used to be called the National Registry of Cardiopulmonary Resuscitation). The GWGR collects standardized data on in-hospital cardiac arrests from 366 hospitals in the US (all types and regions of hospitals) (the national rate of CPR survival to discharge of 18% which most of us are aware of comes from the GWGR). The GO-FAR data come from arrests between 2007-2009 (51,000 patients).
Worth belaboring, because this is critically important in understanding if one chooses to use this as a tool to help patients understand CPR outcomes, is how they defined a good outcome: a Cerebral Performance Category (CPC) of 1. CPC of 1 means:
"The patient is conscious, alert, and able to work but might have mild neurologic or psychological deficits (such as mild dysphagia or minor cranial nerve abnormalities). Patients with a CPC score of 2 have moderate cerebral disability and are able to live independently and work in a sheltered environment. Disabilities may include hemiplegia, seizures, ataxia, dysphagia, or permanent memory or mental changes. Patients with CPC scores of 3 through 5 progress through severe cerebral disability, coma or vegetative state, and finally brain death."This is important because while I'll venture to claim that nearly everyone would agree CPC scores of 3-5 are dismal outcomes, I think there could be a substantial number of people for whom a CPC of 2 would be acceptable. Not welcomed, not a 'good outcome' (which is, granted, what the researchers here are trying to predict), but better than death for some. So to be clear, the GO-FAR tool predicts rates of survival to hospital discharge with a CPC of 1, every other outcome from a CPC of 2 to death are lumped together as bad outcomes.
GO-FAR is being explicitly developed to help inform discussions at the time of hospital admission, so they deliberately excluded patient/CPR characteristics which predict outcomes but wouldn't be available necessarily to the admitting clinician (such as initial rhythm after arrest, site of arrest as someone may be admitted to the floor then transferred to the ICU prior to arresting). The characteristics which survived their analysis and were included in the final index are below. They very nicely also mentioned what the overall survival to discharge with good outcome was in all of these categories (remember, this is not overall survival, this is survival with a CPC of 1). The overall survival with good outcome rate for the entire dataset (all-comers) is 10%.
- Neurologically intact/minimal deficits at time of admission - CPC of 1 (this predicted a better outcome; everything else here predicted worse outcome) (18%)
- Major trauma (reason for admission) (6%)
- Acute stroke (reason for admission) (3.7%)
- Metastatic solid tumor or any hematologic malignancy (5.2%)
- Septicemia (basically they mean active bacteremia here; not the sepsis syndrome) (3.6%)
- Medical non-cardiac diagnosis (reason for admission; ie, patients admitted with cardiac conditions did better) (5.6%)
- Hepatic insufficiency (bilirubin greater than 2mg/dl or AST more than 2 times the upper limit of normal) (4.4%)
- Admitted from a skilled nursing facility (3.2%)
- Hypotension or hypoperfusion (5.9%)
- Renal insufficiency (creatinine over 2mg/dl) or dialysis (6.4%)
- Pneumonia (5.2%)
- Age over 70; the older the worse the outcome (10.2% 70-74 down to 4.5% for over 85 years).
Thursday, September 12, 2013 by Drew Rosielle MD ·
Monday, September 9, 2013
Monday, September 9, 2013 by Christian Sinclair ·
We at Four Seasons and Duke University are asking for your voluntary participation in a research study questionnaire on work stresses and burnout. Similar to studies conducted in other fields like internal medicine and oncology, we aim to aggregate the responses of several palliative medicine and hospice colleagues in this IRB-approved survey to understand what our colleagues are experiencing in daily practice. These aggregated results will be used to comment on the state of burnout in our discipline currently and inform future strategies to prevent and address this.
There are 29 questions in this web-based confidential survey. We anticipate this short survey will take less than 15 minutes of your time. By completing this survey, you are consenting to participate in this study. No identifying information will be collected or reported. At the end of the survey, you may answer an optional question to provide your email address and indicate an interest in being contacted in the future for more in-depth thoughts on burnout in our field. Other than contributing to our field's knowledge in this area, there are no other benefits to participation.
We anticipate to publish the aggregated findings. The link to the survey is at: http://bit.ly/HPMburnout
Thank you for your time. We look forward to receiving your responses.
Janet Bull MD FAAHPM
Arif Kamal, MD, AAHPM Research SIG Chair
Amy Abernethy, MD FAAHPM, AAHPM President
by Christian Sinclair ·