Welcome to Pallimed: A Hospice & Palliative Medicine Blog!
Pallimed FAQ
Updated: July 29, 2008
We are glad you found us and hope you enjoy the information and commentary we provide. If you are here we presume you have a basic understanding of the field of hospice and palliative medicine, and are likely part of the professional field. (Here is a good description of palliative medicine).
Our target audience is the professionals (MD, DO, RN, LPN, LVN, Home Health Aide, ARNP, SW, Chaplain, Administrators, PT, OT, Speech, Pharmacy, etc.) working in hospice & palliative medicine, but we welcome all readers to this blog, including patients, families and other medical professionals outside of this field.
Our goal is to review current palliative medicine, hospice, end-of-life research with a particular focus on publications not from the major palliative care journals. We also highlight important events in end-of-life care from the news media and entertainment arenas. Pallimed is not intended to replace the patient-physician relationship.
Who is Pallimed?
Drew Rosielle, MD
drosielle (at) gmail (dot) com
drosielle (at) gmail (dot) com
Christian Sinclair, MD
ctsinclair (at) gmail (dot) com
Thomas Quinn, APRN, CHPN
tquinn152 (at) gmail (dot) com
Click here if you want to know more about us.
ctsinclair (at) gmail (dot) com
Thomas Quinn, APRN, CHPN
tquinn152 (at) gmail (dot) com
Click here if you want to know more about us.
You, the readers!
Please email Drew, Christian or Tom to let us know about things we may have missed but should blog about, or to give us general feedback on the site.
What About Your Day Jobs?
We do this in our spare time, for fun and for the pursuit of knowledge and truth (sounds noble!). We have a standard disclaimer that the views we express here do not represent the views of our employers or former employers or institutions that we are affiliated with. Please see the disclaimer and copyright information at the very bottom of our homepage. Our effort here is not to provoke but to inform and have open conversation about some potentially thorny issues. Our clinical care is enhanced by being able to comprehend as much information in our field as possible, which is part of the reason we do this blog. We use our real names and not pseudonyms, because we feel it imparts credibility and responsibility for our words.
How To Make Pallimed Work For You!
So what is the big deal about these blogs I hear so much about? If you are new to blogs the first thing to do is 'bookmark'/'add to favorites' this site in your browser (Ctrl+D in most browsers). You can even add the bookmark to your toolbars in your browser (Firefox, Internet Explorer) so that you can access Pallimed with one click. This is a great start, but the main problem is you have to actively seek the site to get the information. Wouldn't it be nice if the information just came to you?
To get the information to come to you we have a two different options to subscribe to Pallimed:
1) Email
Using a service called 'Feedblitz', Pallimed can provide you with posts as they are written directly to your email box. Just type in your email and click the button and you are done. No signing up for a new account or anything. Give this a try and if it does not work for you then just unsubscribe.
2) RSS/Atom Feeds
If you are a little more tech savvy you can make use of the RSS/Atom feature present on most blogs or news sites. RSS (Really Simple Syndication) and Atom are very similar. You may be familiar with the orange button on many sites that looks like this:
or the icon that looks like this:
Here is a very helpful 3 minute video to explain RSS.
Basically RSS and Atom are computer languages for universal formating of information. It can be read using a RSS/Atom Reader. Many readers exist as separate programs or add-ons to your browser, but you can use Firefox 3.0, Safari or Internet Explorer 7 to do the same thing (links go to those sites tutorials). Those of you on IE6 need to upgrade to IE7 to get the RSS benefit.
Ours is located in the right column and is supported via Feedburner. If you click on this link it will take you to their site to pick your feed options.
Christian recommends Google Reader (especially if you have a Gmail account). It is very intuitive as are most other RSS readers. If all this talk scares you, it really is not that bad, just try it. You will not break your computer.
3) The articles
Most of these articles are not available in free full-text online. Consult your institution's library for online availability. On an individual basis we should be able to provide .pdf's of most articles - email Drew or Christian. You can always find abstracts at PubMed. In time, some of these links may no longer work - let Drew know if you find any dead ones.
4) Navigating Pallimed
We have a search bar located in the left sidebar under the label cloud.
Each post is labeled by common topics we cover here at Pallimed so you can quickly find other similar posts. On the left hand column you will also find a 'label cloud' which lists all the topic labels associated with our posts. Click on a link and see what you find! Many older posts do not yet have labels.
(Added 2/7/7) Also in the left hand column is a feature from Google reader that allows us to share Hospice & Palliative Medicine related stories that come across our desk, but have not yet or may not ever write about.
In the right hand column we also have a link to the Pallimed Archives (where you can browse blog posts by date).
5) Comments
Pallimed has a comment function (at the bottom of each post) that allows you to give us feedback on each post. Just click on the "comments" link at the end of each post (the link usually tells you how many comments have been left so it says, e.g., "0 Comments" or "1 Comment"). Tell us your opinions and thoughts. This can be a great community for discussion. You can even add comments anonymously, especially if you want to say something controversial. Even something as pithy as 'great post' or 'what are you talking about?' helps us to keep working at the blog day in and day out for you.
We ask that you refrain from providing specific details about cases because of HIPAA restrictions. But if you want to discuss a case more broadly, that would be more appropriate.
If you comment we almost always will comment back. The comment function has a simple verification system to prevent spammers from clogging the site (it has already happened!).
You can find recent comments in the right hand sidebar. (Added 10/4/7)
Comments Policy: The editors of Pallimed reserve the right to remove any comments we deem offensive/hateful, mean-spirited, commercial, or in any other way inappropriate. This blog is intended to foster colleagial, well-informed discussions about research and news relevant to clinicians working with patients facing severe/life-limiting diseases: it is not a forum for discussing individual cases or airing complaints or concerns about specific cases (whether from the clinician, patient, or family perspective). Such comments will be removed at the discretion of the Pallimed editors.
Our full comments policy is here.
6) What Can You Do For Pallimed?
Read the posts, make a few comments, tell others about it. Thanks for reading!
7) Confidentiality/Privacy
Feel free to email us directly at our emails listed above. Subscribers (via RSS or email) are kept private and the information will not be distributed or accessible to anyone but Drew or Christian. Website stats for visitors are tracked by Google Analytics, but no identifiable information is kept which could identify a user. Pallimed uses 'cookies' to track returning visitors, but again this data will not identify a individual user, nor is it kept over time.
32 comments:
Christian thank you so much for the redesign of Pallimed. Readers let us know what you think of the redesign--we are very open to ideas to make Pallimed more user-friendly, readable, navigatable, etc. etc.
Drew
Hello Drew and Christian,
Do you have a "contact us" link anywhere on the blog? Thank you!
Lori
Gilbert Guide
Lori you're right--I updated my profile to contain my email. I'm going to get spammed a lot but oh well. It's drosielle at gmail dot com.
Good stuff. I've linked to my blog.
Is there anyone who wants to share information on "how" you use your hospice employed nurse practitioners? Are you having them see GIP patients or home care patients? Are you having them listed as the "attending of record" for patients? Or are you using them to triage patients and collect data then perform all physician visit/physician billing yourself?
Melinda,
Thanks for your post. I will make a post in the next day or two about NP's and hospice and I will make sure to include your questions.
keep an eye out for it on the front page.
I read a recent blog regarding the use of atypical antipsychotics and dementia in the elderly. I am seeing an increase use of these medications by one palliative care physician not related to dementia. My question is....are palliative care physicians trained in the diagnosis and treatment of psychiatric disorders or are the symptoms they are seeing related to the terminal diagnosis? These are costly medications used in end of life care when patients are experiencing terminal agitation and anxiety that can instead be managed with lorazepam or haloperidol. Wondering if anyone has any other experience with this.
Hi Guys! Your pallimed is so neat!!!
Say, a question for you. Do you have any insider info on the AAHPM conference, like when the precons are (1/30 or 1/29?) and also, what about the fellows' case conf?
thanks!
BLOG ON!
Laurie Lyckholm
Richmond, VA
Fascinating and intelligent blog. I'm getting linked up.
I am new to your website, but not new to hospice care and would like to ask you what are your thoughts on textbooks,etc related to taking the board certification exam. The Oxford Textbook is like an encyclopedia! Help! Dr. Shaughn Bennett, D.O., Miami, Fl.
do have any comments/articles regarding re-certification of non-cancer terminally ill patients that have survived > 1year? shaughn bennett, d.o., miami,fl.
Laurie,
Sorry for the delayed reply.
The AAHPM has the info up on the front page to submit for the fellows case conference.
http://www.aahpm.org/pdf/caseconferenceform.doc
Hope to see some submissions soon!
Drshaugn,
I apologize to you as well that none of us have answered your requests for assistance.
As far as board certification, the Oxford textbook is a good reference book, but not is probably too in-depth to be a good study guide for an efficient use of your time. The AAHPM web site has a couple of conferences that could be helpful, but the UNIPAC series is a start if you are a beginner as it covers some of the basics, but if you have been practicing for more than a couple of years or did a fellowship, you may find the UNIPAC less helpful.
The Primer of Palliative Care is a quick short read with lots of info, and is now in its 4th edition, so that would be good as an overview.
Of course reading lots of Pallimed is entertaining and informative so that would probably help too, although no guarantees!
Drshaughn,
Regarding the certification of hospice patients who have been on service over a year.
There is not a lot of guidelines out there in the medical literature. I would suggest you talk to your LRMP (or is it LMRP?), and find out what criteria they are looking at. Something too find helpful may be looking at some studies looking at PPS and life expectancy with hospice patients. There were a couple in the JPM from 2005 and 2006, but I do not have the links right now as I am on vacation.
This is a great website... so glad you're doing it! I'm a surgery resident; most of my attendings shudder when they see the palliative care specialist hovering over their patient's chart. But I'm always appreciative of the immense help they usually are. :-)
Thanks for the comment Lights n steel. It is nice to see surgery residents with an interest in palliative care. I really like working closely with surgeons because many palliative options are surgical/procedural. Not just morphine and ativan.
To Lights and Steel - Great to see your interest in palliative care! The American College of Surgeons is very supportive of palliative care initiatives and there are many of us older surgeons out there who see the wisdom of this, so don't be discouraged by push back from surgeons who are afraid of the concept of palliation.
Best regards,
Geoff Dunn, MD, FACS
Wow. What a great blog. It's a tough topic but it's going to become more and more necessary to discuss/confront these issues both as medical personnel and as laypeople.
By the by... on the topic of competence and making decisions, please check out: http://mentalhealth.samhsa.gov/publications/allpubs/NMH05-0195/default.asp. It's an interesting summary of findings regarding competency as it relates to people with psychiatric issues. It ties in nicely with your discussion. Keep up the good work.
Chistech,
thanks for the feedback and the link. I also put the link on the recent post on competence.
Here is the link in a clickable form.
I hope that this blog is still active. I am not in the medical field, I have a MA in Theology and am studying for the diaconate in the Catholic Church.
I'm not sure how to frame my question, but please understand I truly believe that hospice and palliative care are very important and I respect the work that your do. The information I have received is anecdotal. In the area that I live, Northern Colorado, it seems that people enter into hospice and die within a week. Is this a normal situation? What is the average length of a stay in hospice.
Thank you
Richard,
Thank you for your query. Yes, we are very active--latest entry is Christian's, posted today.
I'm going to have to guess at what your underlying question/concern is. Yes, hospice stays tend to be much shorter than we would hope, but the national average is longer than you cite, closer to three weeks I believe. It has been slowly increasing in recent years. A major frustration of hospice supporters is that patients are often referred to hospice very late in their illness, so that much of the benefit of hospice care for patients and their families becomes a missed opportunity. Sometimes the physician is reluctant to make a referral, sometimes the patient/family are reluctant to accept a referral. The reasons are varied, and more complex than I can go into in one comment.
The goal of hospice is to provide the best supportive/palliative care (generally not "disease-modifying" treatments) within the time the patient has left to live. Hospice does not try to either extend or shorten life, but to make it as comfortable and fulfilling as possible. Bereavement services are provided to surviving loved ones.
There are local and regional differences in how hospice is used. I know nothing about hospice in Colorado (knowledgeable readers, please chime in!). There are those who are concerned that the use of opioid analgesics to control pain hasten (and are intended to hasten) death. There is not only no evidence to support that concern, but several studies have shown that hospice patients who receive opioids and sedatives do not die sooner in hospice than those who do not. A couple of those studies showed a slightly longer survival trend, I believe.
I hope I'm addressing your question. I welcome further questions/comments, and invite other readers to comment, as well.
The latest/largest/best study along the lines of Tom's last comment is here.
I am very interested in the Methadone topic. As a hospice nurse I am very familiar with the use of Methadone for pain control. I have had mixed results in regards to adequate pain control. Cost effectiveness has been brought up as a rational for converting to Methadone. I have an ethical objection to converting based on cost alone. Also we have never really discussed a patients "appropriateness" for Methadone. Would really like more info on who is appropriate and who is not.
As a hospice nurse I had an experience with a physician last year. He gave us many referrals but then refused to let us use Morphine for patient comfort, whether for air hunger or pain. Our medical director overrode his orders to make sure our patients did not suffer unnecessarily. When all was said and done this physician then accused us of euthanizing his patients. Requested an ethical review board meeting. Has this ever happened to any other hospice care providers?
Anon (7/14),
This is a tough situation that hospice medical directors occasionally have to deal with. Trying to have open communication is probably the best answer, and his request of an Ethics review is hopefully a chance for education on everyone's part. Working with community physicians with different approaches towards hospice care is probably one of the more difficult tasks for the nurse case manager. A proactive medical director may be able to head some of these issues off with direct MD-MD communication, but sometimes that does not work.
As far as the prevalence, it would be a good quick survey/research study.
Well now, humour me if you will, as I go slightly off-topic here for a minute.
Ah, pain is such a great leveller. Oh, how the mighty are fallen!
What exactly can a dying atheist do to achieve immortality?
S/he can do what I am doing right now: leave faint footprints in Cyber space.
I am the ghost
in the machine.
I yet live on
in coldest Cyberia
Cogito, ergo sum ... cogito.
Blog on, good folk, blog on.
This comment is in response to Anonymous, the hospice nurse who asks about choosing the appropriate patient for methadone. Most of us would agree that cost as a sole reason for switching to methadone in not appropriate. A perusal of the literature suggests the following considerations (in no particular order): pain uncontrolled, especially with escalating doses; unacceptable refractory side effects from the current regimen; pain with a significant neuropathic component; prognosis of at least a week (because it may take that long--or longer--to complete the switch); consideration of history of cardiac arrythmia and how much it should count in decision-making for a particular patient; concurrent medications, due to wide range of drug-drug interactions; capacity for daily monitoring of the patient, including reliabilty of patient and lay caregivers, availability of telephone; availability of methadone in the community.
We are sometimes asked to see patients specifically because the referring clinician thinks they should be on methadone, often because of high doses of opioids or complex regimens or both. Careful evaluation is important. How functional is the patient? Is s/he satisfied with the current balance of pain and side effects? Is the regimen unduely burdensome? Is the patient afraid to rock the boat if the regimen is a burden, but pain is stable? Making a major change when the only obvious deficit is an unnecessary complexity and change could bring unplanned negative consequences, switching to methadone may make sense only on paper.
Switching to methadone is unquestionably a situation requiring individualization of assessment and care.
Tom
Thank you to Thomas Quinn for your insightful and helpful answer to my question about determining the appropriateness of patients for Methadone for pain management in the terminally ill. It was very informative. I am going to show it to my medical director and discuss it further with him.
A thank you to Dr. Sinclair for your response to my situation with the physician who believed using Morphine to control pain and air hunger at the end of life was akin to euthanasia. In response to your comment, the medical director and I both tried to be proactive and discuss the use of Morphine for his patients. Offered information about studies that indicated that the use of Morphine at the end of life does not hasten death. In the end we were unable to educate this physician and unfortunately for his patients had to decline any further referrals from him. My question at this point would be, if all else fails and the referring physician is unwilling to order Morphine to ease the suffering of the patient, is it ethical to have the medical director order what is needed to provide relief for the patient?
To Anonymous, who is in difficulties regarding referring physicians who won't allow their patients morphine:
You ask, is it ethical to have the director (of the institution) override that decision and order morphine.
I know naught of medical ethics. I do know that what you are proposing is merciful, humane, caring and seems entirely appropriate. It is the decision of a civilised person in a civilised society.
Is it civilised to rely on methadone if there is a more effective form of pain relief available? (That's a purely rhetorical question, Anonymous).
Is the meaning of 'ethics' hidden somewhere in those words above?
I write as a person who hopes desperately that I have someone like you looking after me in the hospice.
To Anon,
I think I will try and address your issue of the ethics of medical directors taking primary care responsibilities in another full post.
I will try and do some background reading on current literature first to back up any of my own assumptions/experience.
Basically, yes it is ethical as Mr. Quinn has pointed out, but there are right ways and wrong ways to go about it.
To RQuinn,
I am puzzled and impressed by your prose. Thanks for leaving it here as it has given me something to ponder. Is it a quote from some work of art or fiction or is it your own?
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