Wednesday, April 1, 2009

The Best of Pallimed Comments: March 2009

Some readers on last year and this year's survey mentioned not being aware about the comments, so to highlight some of the great insights found in the comments section, I present to you a new feature, The Best of Pallimed Comments: March 2009. Come join us in the comments section.

My Favorite Comment this past Month was from Amy Abernethy regarding the Supportive vs. Palliative Care name:(an excerpt)

"So, in 2006, I conducted an e-mail survey of everyone I knew that might answer (N about 225 of medical and non-medical people) and they helped me rename the program to the "Duke Cancer Care Research Program." ( Referrals soared and our trials get completed; oncologists welcome us to hang out in their clinics and talk to any potentially eligible patient appropriate for our studies. These studies run the spectrum from pain and dyspnea to spirituality and caregiver distress. Our nurses also help out with clinical care needs, and palliative care patients are actively referred to my clinic by my colleagues for end-of-life care."
Other comments on this post are very rich with great information about this dilemma.

Two posts tied for the most comments with 13 in March: Hospice and Palliative Care Tweeple and Do Not Attempt Resuscitation vs. Allow Natural Death

On the Do Not Attempt Resuscitation vs. Allow Natural Death post, some of the great comments included Leigh:
"We are struggling mightily with the issue of goals of care vs. DNR "status" in my instution. Inappropriate (at times) inferences are drawn from the presence or absence of a DNR order. For example, I had a very difficult time getting a venting gastrostomy placed in a DNR patient because she was DNR ("we don't do procedures on these patients"). It happens on the other end of the spectrum as well, this is part of why patients, particularly those who are underfunded, are suspicious of DNR. We are working toward separating our processes--so that the code status orders pertain only to what happens at the moment of death, and there is a separate/ongoing process of goal setting to work out the rest."
Later she also added an important point about what The Joint Commission considers a 'sentinel event':
"Do-Not-Resuscitate patients who do not receive the same level of care that patients without Do-Not-Resuscitate orders receive."
And Paul McIntyre:
"I'd argue that comfort is a goal at each step. The problem with separating "comfort" as a separate category - may imply that sx control is less important in 1. & 2. Chest 2007;132 had a good point-counterpoint on CPR, one author arguing against autonomy/choice in pts with predictably poor outcomes."
A family member Gail Rae chimed in with a great question:
"What, exactly, in medical terms, does "curative" mean?"
And in the end Drew leaves us with a great comment to tie everything together:
"these sorts of goals-->care plans can be highly individualistic, and based in individual historical precedent (e.g. for whatever reason the TPN is staying on, or XYZ), and cramming them into one-size-fits all order sets or phrases is often not appropriate. That, to me, is ok, and frankly a good thing - where is it written that these things are supposed to be easy - as long as you have the time and institutional culture to put all this out."
In a post on Hospice Patients Feeling Abandoned by Doctors comments focused on the system:
"The perception of abandonment may be rooted in mismanaged expectations. In the generation of aged currently in the "python" there is a perception MY doctor, possibly a remnant from our previous health care system without DRG's and managed care. These people may need more expectation management than the next generation who are accustomed to THE doctor, THE nurse practitioner, and/or THE physician's assistant. We can remember that there is always with us another unhealthy client, the System."
And Gail Rae gives expands in her comment on this scenario:
"My mother did not forget about her former PCP but expressed, a couple of times, even though she liked him, that she was glad she "never ha[d] to see him again," because, inevitably, when we saw him, it always meant more of everything, rather than less.
Hospice care, as well, encouraged me to lighten my medical hovering over my mother, to her (and, finally, my) delight."
Drew and Tom have a great exchange fleshing out the post about the JAMA Religious Coping and Aggressiveness of Care study

And finally Lyle, David and Angela give their takes on the level of detail in CPR informed consent talks.

Feel free to join in the fun and belly flop in the Comments Pool! Maybe your comment will be featured next month.

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