Monday, August 31, 2009

Top Comments & Posts for August 2009

Top Blog Posts from August 2009:
1. Krauthammer on the "The Truth About Death Counseling"
2. Palliative Care Featured (again) in the New York Times
3. Palliative Care Grand Rounds 1.7
4. A Detailed Look at Euthanasia Accusation During Hurricane Katrina
5. Minimally Disruptive Medicine

Top Commented Articles from August 2009:
1. Palliative Care Featured (again) in the New York Times - 13 comments
2. Public debate Over Reform Spilling Into Family Meetings - 9 comments
3. Minimally Disruptive Medicine - 7 comments
3t. Krauthammer on the "The Truth About Death Counseling" - 7 comments
5. Pal-pourri: Vertebroplasty and the QTc - 4 comments

Featured Commentary from Pallimed Readers:

Drew Heyding on Minimally Disruptive Medicine: During my training, I spent time working in an academic medical center and a VA hospital. The contrast really highlighted some of the issues you brought up in your post. The integrated VA-wide medical record gives health care providers a big head start on accomplishing principles 1 and 2. It's easy to recognize which patients are starting to become overwhelmed with multiple meds and visits and to find out what's been happening at those other visits. That said, I think principle 4 is crucial to all of this; and just like discussing EOL preferences, finding out patients' perspectives on treating their chronic illness takes perseverance.

hospicephysician on Krauthammer on the "The Truth About Death Counseling": I decided to give my 2 cents here. Since the mass hysteria and hyperbole has been exposed this is a very clever and sly tactic to continue to smear HealthCare Reform and the Bill. There are no lies in what Dr. Krauthammer states, but he plays to the drum of the smear tactics. By undermining Advanced Care Planning and Living Wills he accomplishes his goal of raising concerns about the Bill especially for the lay person. The one thing that people don't realize is that Advanced Care Planning would be quite different if they went to their doctors instead of their lawyers.

Anonymous on Methadone and QTc monitoring: I'm of the camp that routine ECG monitoring of patients on methadone is burdensome, costly, impractical, and given the underwhelming evidence of harm, unnecessary. For patients that are actively dying, on hospice with prognosis less than two weeks, who may benefit from methadone because they were on higher doses of opioids or for ease of administration (SL route), I never get an ECG. In the hospital setting, chances are at some point they have had one anyway. For patients who are more walkie/talkie, maybe older with a good functional status, I only recently started getting a baseline ECG if I start them on methadone. Again, many of the patients we see in our practice have so many co-morbidities that concern over prolonged QT seems almost trivial.

Jay on Free Spinal Cement Injury Legal Consultation: As far as VP/KP I have never been thrilled with it and it's difficult to access in our system, so I doubt this will change my practice pattern much, and I wouldn't expect it to change the practice patterns of anyone who likes it because, as you point it, it's still reimbursed. Evidence, schmevidence.

Phil Rodgers on Palliative Care Featured (again) in the New York Times: I would encourage folks to read the Comments too, as much as their time allows. I browsed the first 100 or so and found not only lots of validation and support, but also some thoughtful feedback about common issues in Palliative Care practice, like the size of the 'team' in the room during consultations, the noticeable lack of primary or continuity physicians in many hospitalized patients' care, etc. Very good reading.

Tim Cousounis on Palliative Care Featured (again) in the New York Times: Every one of your points is well made, and taken. Very thoughful, indeed. We tend, nonetheless, to read and evaluate articles on palliative care from an insider's view (we are "insiders", after all) and as a result we do pick nits. Stepping back to view the article from the perspective of a layperson reader (who is the intended audience, of course) I find the piece to be informative, illuminating, and edifying, which is just what the general public needs to read about palliative medicine.

And also Laurie Mallery's comment on Palliative Care Featured (again) in the New York Times which is too long to repost here but has some excellent points!

jbrobinson on Public Debate on Reform Spilling Over Into Family Meetings: Our hospice and palliative care intake department has actually had an increase in informational calls from family members calling to discuss their loved one's declining condition and inquiring if hospice would be appropriate now, or how to initiate it when the time comes. Many of them have advanced directives in place, but the subject had not yet been brought up by the attending physician. One referral came from a PCP for a hospice evaluation based on a call from the patient's wife, letting him know that her husband did not want aggressive treatment or hospitalizations. When the intake RN contacted the wife, she explained her husband did not want services yet (nor was he appropriate), but she just wanted to make sure the PCP was aware of her husbands wishes!

Thanks for all the comments and keep them coming!