Sunday, March 29, 2009
Well the great Twitter experiment of 2009 was a resounding success. I am still analyzing the Tweets from the conference to give some more insightful feedback on the potential impact. One major milestone is this medical conference was the first one to be covered by multiple Twitter users with a significant degree of interaction and reach. Early use of Twitter at medical conferences covered were done by pioneering individuals reporting from a conference with occasional but minimal interaction. With the growth of Twitter in the past three years and the relatively slow adoption of social media to health care, this is a significant step.
Some basic stats:
Tweets During the Conference (Tue 3/24-Sat 3/28 using #AAHPM tag): 224
Unique users tagging Tweets with #AAHPM: 30
Here are the great people who Tweeted!
DrLaura04, laikas, ctsinclair, palliativecare, jeffreybeane, SanDiegoHospice, justfab, lyfe20, daitpcg , AAHPM, Pallimed, MedicalNewsNet, knwachter, pwendl, mchwistek, denisefulton, aliciaault , rabob, MatthewBrowning, cvongunten, johnmulder, lou21, marachne, earlmd, doclake, SWHPN, drmomphd, lesmorgan, Bugo30, HospiceChicago
Throughout this week I will be posting ways in which Twitter was used successfully and also had a few stumbles. Thanks again to all who participated. I expect this will be a growing way to communicate at/from a medical conference.
Sunday, March 29, 2009 by Christian Sinclair ·
Pallimed has never been the official voice of anything. Our writings have really represented just our own thoughts on whatever topic happened to cross our interest that week. We have even disavowed our employers AND former employers in our disclaimer at the bottom of the page (a fun read compared to most disclaimers). But now something is different I was elected to the AAHPM Board of Directors by the membership, so I must ask myself what will change about what I write here on Pallimed.
My hope is that nothing really changes. I plan on writing about the same sort of topics I have discussed over the past three years. I still plan on doing the annual pre-assembly preview as I did before joining the Board. I do not plan to highlight everything the AAHPM does so this will not become a platform for AAHPM activities. But when there are certain AAHPM projects meriting some discussion in the larger context of our field, I hope to bring you a forum here to discuss it. I do not plan to be overly gushing about the Academy but I do hope to bring up some issues to the Pallimed readers to help give me additional insight as many of you are also members of the AAHPM.
So if anything really changes, I hope all of you understand you now have more immediate access to the leadership within the AAHPM. Thank you very much for electing me. I am glad to be your representative. Comment here on the blog or email me at ctsinclair @t gmail d0t c0m.
Email me anytime about anything.
by Christian Sinclair ·
Monday, March 23, 2009
...is the snappy title of a recent publication on public perception of resuscitation outcomes in Resuscitation. The data come from a survey of ~1800 people administered in Ohio & Pennsylvania in a 'variety of community settings' (airports, bus stations, and clinic waiting rooms). They don't give any further details as to how these people were found/screened; that said, there does not appear to be even an attempt to get at a random cross section of a population.
Median age of the subjects was 40 years, 55% were female, 17% African American, and 72% had education beyond high school (more than the US average). Respondents' mean estimate of survival with good outcomes (returned to the life the arrestee had before) from cardiac arrest (they asked about both in-community arrests and in-hospital ones) was 50%. As in 5-0. Not 1-5, which is a generous figure for this outcome (and actually is the approximate chance of survival-to-discharge after an in-hospital arrest; survival to baseline status is worse although less well defined in the literature; survival of an out-of hospital arrest is much lower).
They also inquired about decision-making about when to do CPR; 87% rated patient preference as important & only 54% rated physician prediction of outcome as important. To an extent, those who had more realistic expectations for resuscitation outcomes were less likely to endorse wanting it.
The most curious findings were about what resuscitation procedures subjects would be willing to undergo. Of those who said they themselves would want efforts to 'restart their heart' if they had an arrest, they went on to list (in lay-terminology) certain common aspects of CPR and asked them if having that done to them would be 'acceptable.' Many subjects then actually went on to say they wouldn't want these things: only 74% said they'd want chest compressions, 61% shocks, 54% IV medications, 48% endotracheal intubation, 42% mechanical ventilation, 31% a central line.
This, to me, is where the SciFi aspects of the paper really come out. It's no shock lay people don't understand likely outcomes of resuscitation - what's surprising to me is that these people then rejected in large numbers routine aspects of resuscitation, which makes one wonder just what the subjects thought resuscitation entailed. The phrasing in the questionnaire talks about arrests, and about 'restarting the heart;' most subjects generally thought this was a good idea, especially for themselves. But when asked if this happened to them, if they'd take a 'large IV in their groin or neck' 70% say that wouldn't be acceptable to them?
Given that just a little over a half of the subjects thought physician prediction of outcome was important for resuscitation decision making, then a good half of the subjects went about saying they wouldn't want endotracheal intubation, I'm reading this wondering if I've been thinking about 'code status' discussion incorrectly all these years. I've always thought the much-practiced 'gory description' approach in discussion CPR was misguided (e.g. 'we pound on your chest, break your ribs, stick this pipe down your throat, hook you up to a breathing machine, and stick central lines in you wherever we can find a big vein). Instead, the fundamental question is one of outcomes: if such procedures would restore someone to their previous state of health in a timely fashion then, well, who should care about the details - it's better than death (assuming the previous state of health was good/acceptable). Of course, it usually doesn't, and hardly ever does for otherwise dying patients, which is the whole point of not doing it in those situations, with the 'gory' details being just that (details). Thus, the main goal in having these discussions (at least in otherwise dying/poor prognosis patients), is to disclose the outcomes (and recommend alternative plans).
These data would suggest otherwise: screw the outcomes, focus on the gore, and people are going to say 'No thanks!'
Despite these data, I have a hard time believing that is actually a good idea. Ignoring the issues around subject selection (not random, not representative of any population, geographically limited)...and I think we can ignore them because it is likely that a truly random sample would have found generally similar figures...I wonder if one of the phenomena going on here is one to do with the youth and healthiness of the subjects. You get the sense that these people are saying "Sure restarting the heart is a good idea. Why wouldn't it be? I'd want my heart restarted if it stopped in the ER! Who wouldn't? Stick a tube down my throat? I don't know about that. That doesn't sound fun - no thanks."
In real-life, as we sit at the bedside of ill, suffering patients, afraid of death which they know is approaching, desperate for any way out - a femoral line or a little 'cardiac massage' can seem like a small price to pay to forestall death a while. For these patients, it's the unfortunate reality that we can't forestall death in that way (resuscitation) that is the 'message' that counts - that matters for 'decision-making.' That said, maybe I should not dismiss more detailed descriptions of what is actually involved (what I've glibly referred to above as the 'gore') as unimportant/unhelpful.
I'm curious as to how detailed, or even how frankly gory, others approach these conversations (ones in which the patient is dying, and your clear recommendation is not to attempt resuscitation due to dismal outcomes)?
MARCO, C., & LARKIN, G. (2008). Cardiopulmonary resuscitation: Knowledge and opinions among the U.S. general public - State of the science-fiction Resuscitation, 79 (3), 490-498 DOI: 10.1016/j.resuscitation.2008.07.013
Monday, March 23, 2009 by Drew Rosielle MD ·
My guess is the blog will be quiet (other than the twitter sidebar) until the AAHPM convention in Austin is over. Please stop me and say Hi if you see me. Christian and I are talking at the awards lunch on Thursday - we're looking forward to a chance to talk about the blog publicly, and to thank all who continue to support it. I remain amazed, and humbled, and grateful for the support and enthusiasm many Pallimed readers (including in the Academy) have shared with us about the blog - thanks.
And of course - please join us Friday night at Pete's Dueling Piano Bar after 7:30 (see here).
Cancer has published a paper about neoplastic meningitis (whose findings supplement these which I blogged about a couple months back). This study provides some further prognostic data for (treated) neoplastic meningitis, and suggests that patients with negative CSF cytology do a little better in the short term.
The purpose of the study was to compare outcomes/survival in patients diagnosed with neoplastic meningitis who have positive CSF cytology (cancer cells which can be detected in the CSF) vs. those who don't (for whom the diagnosis was made on imaging, clinical findings, and/or abnormal CSF findings short of positive cytology). The data come from a single US cancer center and involve 84 patients (median age 47 years). Importantly, all patients had Karnofsky performance statuses of 70 or greater, and were treated with intraventricular cathethers and intraventricular chemotherapy (explaining the better-but-still-crummy survival in this series than the last one I blogged about).
Median survival was in the 18-20 week range for both groups, with 3 and 6 month survivals better in the negative cytology group (this was not statistically significant, although the numbers here are low): 90% vs. 40% for 3 month survival in the negative and positive groups, and 80% vs. 33% for 6 month survival. 12 month survival was 10% in both groups.
NEJM has published the polling results about how to proceed in a case involving a protracted conflict about treatment goals in a brain-injured patient (free full-text here; my blog post about this here). Overall, most readers 'voted' for withdrawing life-prolonging treatments in the patient - with notable geographic variation. This is obviously not a scientific sample, but the geographic variations are not too surprising, with lower rates of readers endorsing withdrawing life-prolonging treatments in Asia and South America than Europe or North America. There's a handy interactive map for country-by-country results, too (click on the map).
Mayo Clinic Proceedings has a concise, practical review on shingles and post-herpetic neuralgia (free full-text here). It's pretty basic, but a good one for the teaching file. It seems to stumble a bit on its discussion of opioids in the treatment in PHN, playing up The Controversy, despite the fact that there's good data supporting their use (as good as opioid data goes which means solid efficacy/safety data for up to a couple months).
by Drew Rosielle MD ·
Friday, March 20, 2009
Age & Aging has a fascinating research paper on changing attitudes towards CPR in older patients in Ireland over 15 years. This study is a follow up to one done 15 years ago in the early 1990s which evaluated attitudes towards CPR in hospitalized but stable, older (over 65 years) patients who were approaching discharge (delirious, demented, and - curiously - depressed patients were excluded). The 1990s study was in a single hospital in Dublin; the current one, which deliberately used similar methods, was done in a couple hospitals in Galway, and involved 150 patients. Patients were read a description of CPR and then asked if they'd want it if they arrested in certain clinical scenarios (severe physical disability, severe dementia, terminal illness with a prognosis less than 6 months, critical illness with uncertain short term prognosis).
What was not disclosed to the patients, as far as I can tell from the paper, were likely outcomes of CPR. This strikes me as the most important bit of information in CPR decision-making, but who am I to say that? Anyway - the results between 1990s and today were dramatically different to the point of being shocking. The percent of patients wanting CPR in all clinically scenarios was dramatically increased in the contemporary cohort than the 1990s one. For instance - 74% said no to CPR in their current health state in 1990s vs. 6% today; for terminal illness - 96% vs 31%; for severe dementia 100% vs. 41%. There were some other findings and subanalyses (older patients in both cohorts were more likely to refuse CPR; many more 2000s patients thought doctors should discuss CPR with patients; most patients in both cohorts thought doctors should unilaterally be able to 'withhold' CPR in patients with poor prognoses).
Looking at the numbers, what's surprising to me is not so much the percentages of patients in the 2000s who didn't want CPR but it's the very low fraction of the 1990s cohort who didn't: 74% of those in their current state of health? Either a seismic shift has occurred in Ireland or something deeply flawed (research-wise) was occurring then. The authors opinion is that, in fact, a seismic shift has occurred in Ireland which explains the results. Interestingly they note that Ireland is generally wealthier than it was in the early 1990s (this study predates the current Global Economic Collapse of course) and wonder if that has anything to do with it (interesting because in the US increased wealth, or at least education which tends to track with wealth, is generally associated with relatively less interest in 'aggressive' end of life cares).
In addition they actually throw out that TV may be implicated as medical dramas have apparently become very popular in Ireland and they wonder if that has inflated patient expectations for CPR!
I would be personally very interested to see two things in follow up to this, although I know I won't. First is a similar study with a US/North American population to see if a similar trend has occurred although I doubt there was ever a US study which showed anything similar to the 1990s findings. Second would be to take the same group of patients and re-ask them the questions after being given survival-to-discharge data for in-hospital arrests - that would at least give us some semblance of what these patients would say when 'truly' (or at least 'more truly') informed...not that many real-life patients are given that information when having 'code status' discussions.
(Thanks to Dr. Robert Arnold for alerting me to this.)
Cotter, P., Simon, M., Quinn, C., & O'Keeffe, S. (2008). Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study Age and Ageing, 38 (2), 200-205 DOI: 10.1093/ageing/afn291
Friday, March 20, 2009 by Drew Rosielle MD ·
JAMA has published two Perspectives on Care at the Close of Life pieces in the last few weeks. A young pregnant woman develops a fatal cancer and dies before her daughter reaches her first birthday. Her partner cannot bear the thought of her dying. The suffering experienced by this patient, her partner, and the health care team suffuses all of the care providers' descriptions of this case. The deep sadness here is universal. What is also clear is the profound influence of culture and immigration on this young woman's experience at the end of her life and on that of her partner.
The first is a review on palliative care for Latinos. With all due respect to the consistently excellent PCCL series I have to say this has been my favorite, perhaps for the simple reason that my own content-knowledge in this area is lower relative to the other ones. (This is despite doing my medicine training in Denver - I did not however learn about aspects of care particularly relevant to death and dying). Perhaps also because it is contains such well-written prose:
The paper discusses important cultural norms/narratives such as familismo, fatalismo; barriers to care from language/interpretation (this is one of the best, short, practical discussions of using medical interpreters I've seen anywhere), and issues regarding religion and immigration status. This is now at the top of my teaching pile for cultural issues.
The second is about self-care for physicians caring for dying patients. It focuses on burn-out and compassion fatigue, but also devotes a large amount of space for positive coping/responses to workplace stress, grief, and loss, and on the 'best-practices' of clinicians who thrive/endure in stressful environments full of loss.
The physician who formed the case for the piece made a comment which I really appreciated:
'The stuff that burns me out has nothing to do with loss. . . . It's fighting insurance companies . . .'I think many who don't do palliative care assume the major stressor is the death/loss - for me and most that I've spoken with about this issue this is not the case (it's there of course, and there can be individual cases which are devastating, although routinely caring for dying patients and their families is invigorating and a source of great satisfaction). It's the grind of documentation, patient-load overload, administrative-academic-clinical duties pulling at you at once, etc. etc.
Along these lines, they discuss the enriching aspects of caring for the dying:
Posttraumatic growth is characterized by positive changes in interpersonal relationships, sense of self, and philosophy of life subsequent to direct experience of a traumatic event that shakes the foundation of an individual's worldview. Posttraumatic growth is not uncommon and may occur concurrently with negative sequelae of trauma. The term vicarious posttraumatic growth describes the phenomenon of clinician growth that results from witnessing positive sequelae of other people's experiences of trauma. This may include the clinician's feelings that his or her own life has been enriched, deepened, or empowered by witnessing the patient's or family's posttraumatic growth. When patients experience meaning and peacefulness in relation to their approaching death, this enriches the lives of the clinicians involved. This phenomenon appears similar to the "healing connections" identified by Mount and colleagues.
A young pregnant woman develops a fatal cancer and dies before her daughter reaches her first birthday. Her partner cannot bear the thought of her dying. The suffering experienced by this patient, her partner, and the health care team suffuses all of the care providers' descriptions of this case. The deep sadness here is universal. What is also clear is the profound influence of culture and immigration on this young woman's experience at the end of her life and on that of her partner.
by Drew Rosielle MD ·
Wednesday, March 18, 2009
I'm expecting a lot of discussion about this study in the current issue of JAMA, "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer." Religious coping is defined as "how a patient makes use of his or her religious beliefs to understand and adapt to stress." Previous studies have shown that people with high positive religious coping are more likely to have preferences for aggressive life-prolonging treatment and less likely to have advance directives. "Positive" religious coping employs reliance on faith to promote healthy adaptation. "Negative" religious coping tends to see illness as punishment and may indicate existential crisis. Positive and negative religious coping are not mutually exclusive, but negative coping is uncommon. This is the first study to look at actual outcomes in patients with high vs low religious coping.
The subjects in this study were enrolled in the Coping with Cancer Study, a multi-institutional, prospective, psychosocial study of patients with advanced cancer. The Coping study is funded by the National Cancer Institute and the National Institute of Mental Health. Data was collected in a 45-minute interview. Both English and Spanish-speaking subjects were enrolled. In addition to patients, caregivers completed separate questionnaires, although caregiver religiousity was not a focus of the current study. Caregivers were approached a few weeks after the patient's death for information about the death (post-mortem chart reviews were also done). The instrument used was the Brief RCOPE, a validated 14-item questionnaire that assesses religious coping. Seven positive and seven negative types of religious coping are included, answered with a 4-point Likert scale. 92% endorsed a least one positive coping scale item, while only 43% endorsed any negative item. Patients were designated as having either high or low religious coping depending on whether they scored above or below the median. In addition, the Structured Interview for DSM IV Axis I to identify patients with panic, anxiety, or posttraumatic stress disorders or depression. Finally patients were asked to characterize their health status and whether their religious/spiritual needs were being met by the medical system.
A total of 664 patients participated in the overall study. Data were available on 345 of the 385 patients who had died at the time of the analysis. Death came a median of 122 days after the patient interview. The primary findings were that "a high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared to patients with a low level;" and with "intensive life prolonging care in the last week of life." Nonsignificant differences were found for CPR received, death in the ICU, and hospice enrollment. In addition, a high level of religious coping, compared to low, was associated with the following: use of negative religious coping, active coping, greater acknowledgement of terminal illness, greater support of spiritual needs, preference for heroic measures, less advance care planning in all forms.
The findings persist when adjustment for various psychosocial factors are included. "These results suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death." The authors characterize this as a possible negative outcome for religious copers "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment." This is a problematic statement for me. It seems to contradict a previous statement that these patients see themselves as "collaborating with God to overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the end of life." In addition, some patients see prolonging life as an essential acknowledgement of the sacredness of life. It seems to me that the task of spiritual care with this population is to support, to the extent possible, the patient's expressed beliefs and values while maintaining informed decision-making and consent. It is also important for patients who belong to an organized religion to receive adequate teaching and counsel in the teachings of that religion in order to clear up misunderstandings and misconceptions that may impact their decision making.
The authors recommend earlier spiritual assessment and support and inclusion of clergy/chaplains in the care team. A follow up research recommendation is to study the "mechanisms by which religious coping might influence end-of-life care preferences, decision making, and ultimate care outcomes."
Andrea C. Phelps, Paul K. Maciejewski, Matthew Nilsson, Tracy A. Balboni, Alexi A. Wright, M. Elizabeth Paulk, Elizabeth Trice, Deborah Schrag, John R. Peteet, Susan D. Block, & Holly G. Prigerson (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA, 341 (11), 1140-1147
Wednesday, March 18, 2009 by Thomas Quinn, APRN ·
Thanks to the 128 people who completed the survey this year. We appreciate your time which this year averaged only 5min, 47 sec. You know how we appreciate your time! Still keeping the survey less then 6 minutes!
We got a lot of helpful input and will be poring over this in the next week or two. If you are coming to Austin you will get to see some of it during our noontime presentation. Otherwise you will have to wait until we get back and will post the results here with our analysis.
Here are a few juicy tidbits of info to whet your appetite:
- 93% or responders were in the medical field
- 72% of responders have used Pallimed for the preparation of educational materials
- 30% of responders have commented before
And thanks to all for the supportive comments! We will post some here as endorsements like you might see on the back of a really great novel.
You are providing a great service with this blog. Thanks for the heads up regarding publications, the information you provide, the reflections, and the links to other sources/blogs.With comments like these we may have to survey you once a month. And I don't think Drew stuffed the ballot box with these comments either. There were some more constructive/critical ones which Drew and I will take into account when we publish the full review of the survey.
It has given a huge insight into end of life care in the US. Your battles are very different to ours! I am finding the research articles interesting and it has introduced me to a wealth of blogs which are a welcome distraction from my essays.
The ARTS section gives an entirely new approach to my repertoire of articles to recommend to colleagues and laypersons.
Your site is superb--cogent, insightful, and timely. I especially appreciate your penetrating analyses of many of the articles that you review. The site is a fabulous resource for everyone in Palliative Care.
No.......thank YOU. again and again. Great Job! BTW, my son's name is Drew Christian. No kidding. My daughter's name is Amber Amytom. Kidding. My 2 cats are names Morphine and Ativan, and my dog's name is Narcan. No kidding.
Pallimed is an invaluable resource! I've been a reader since my fellowship, and I don't think I could practice successfully without it! Don't change a thing.
by Christian Sinclair ·
Saturday, March 14, 2009
This is the companion piece to Handy Hints for a National Meeting. If you are a presenter you may find this overview helpful. Feel free to add your own in the comments section.
Despite the frequent use of PowerPoint few people have ever been trained on how to use it effectively as part of a toolkit for presenting information. It is a tool to convey your message, much like a white board, a laser pointer, a flip chart, your verbal tone, your appearance, a video, the orientation of the audience to the speaker, etc.
PowerPoint can become a crutch which drags your presentation down instead of augmenting your speech. Getting caught up in all the ‘neat’ things PowerPoint can do does not always help in getting the message to your intended audience.
Many people put too much information on their slide. The only time to fill up a slide with scores of words is to demonstrate there is too much out there. If you put your whole talk on the slide, your audience will read it quicker then you can say it, and become bored quickly. Your slides should never be able to stand alone without you presenting. Otherwise, why are you even there? So to make sure you make the points and not your slides, use the 5-5-5 rule:
• No more than 5 words in your title for each slide
• No more than 5 bullet points on each slide
• No more than 5 words per line
With this rule you get a clean efficient look to your slides, enough reminders for the areas you want to talk about, and you become the focus of your presentation. There are times when you need to break it but in general it will lessen your dependence on the slides. If you NEED all those words on the PowerPoint slide and can’t slim it down, consider more practice giving talks WITHOUT the addition of PowerPoint.
Spellcheck is our friend, but please hand check the spelling after your computer does it for you. Eye now these form personnel experience.
No fancy fonts please, stick to the basics. There is no general consensus on which one is best, but make sure the fonts are legible from far away. Size of the font is important for your audience with poor eyesight.
Be consistent with your color scheme, and choose from a limited palette. Avoid red and green in the same slide for those members of your audience that are color blind.
Fancy backgrounds may seem creative but do not let them distract from your talk. Other common distractions are animated text (NO!), sound effects (double NO!). Include your logo on the first and last slide; a logo on every slide feels like an advertisement.
When giving your talk, try working with a remote control to advance the slides. If you give many presentations this should already be in your possession as it allows you the freedom to move away from your computer and engage your audience. You may consider pressing “B” during your presentation to turn the screen black to get more involved with your audience or to place the focus back on you.
Consider consolidating all of the information from your talk into a Word document instead of just sending the PowerPoint slides to be your handout. It may save several trees if we all did this.
Other quick tips on presenting:
* Start on time. Respect the people who got there to hear you speak.
* End on time. Respect the people who are still there at the end of your talk.
* Don’t cram a lot of data on one slide. The audience can’t read it. Consider making your own graph to highlight the important part as opposed to the journal provided version.
* MWSnap is great freeware to help you take screengrabs at high resolution.
* Repeat every question you are asked, because the whole audience likely missed some/all of it.
* Thank people who asked the question, even if it was a dumb/condescending/off-topic question. Your audience will admire your graciousness and know the questioner is an imbecile without you implying so.
* Don't take too long to answer the question. If you are covering it later, say so. If the answer will take a lot of time, give a short answer and ask those who are interested in the long answer to meet after the talk.
* If you are done presenting and you encounter the ‘know-it-all’ who wants all of your time, make sure to set limits, and let others ask you questions.
* Bring your power cord for your computer.
* Email your talk. Have it on a jump drive. And on your hard drive. And on the internet somewhere. Never be too cautious.
* Don't change your slides from the handout whenever possible.
* If the slides presented are different from the slides in the handout, mark the title of the slide with an asterisk to remind you to inform your audience.
* Turn off all unneeded programs on your laptop. IM, website alerts, weather alerts, CITRIX prompts, etc.
* Give credit to others who helped prepare your talk, especially if they are there.
* Put your contact information on the last slide if you would like people to contact you about your topic.
* If you are a presenter at this meeting or anywhere, take note of how other presenters are effective or ineffective. Think of how you may incorporate/avoid their style in any of your future talks.
* If you are doing a poster, keep it clean and simple -- put your take home message at the top, use large enough font, break things up with graphics.
* Have copies of the poster and/or related/expanded material available in handouts.
* If you have a poster session, unless it's an absurdly interminable length of time, stay with your poster. There are people who want to talk to you about your study, and if you did your poster right, it's only going to give highlights. You're there to give the details and answer questions.
but it gets you most of the way there!
If you have any other tips, please email me at ctsinclair @t gmail d0t c0m
How to Give a Great Presentation is archived online at www.pallimed.org
Requests for use/modification should be directed to ctsinclair@t gmail d0t c0m
Saturday, March 14, 2009 by Christian Sinclair ·
The American Academy of Hospice & Palliative Medicine / Hospice and Palliative Nurses Association (AAHPM/HPNA) Annual Assembly is right around the corner (March 25-28th) and after that Pallimed will return to the usual posts with maybe some small additions or changes based on your input to the Annual Readers Survey (over 105 so far! only a few days left to take it!)
One growing trend in the Twitterverse and Blogosphere is the live 'reporting' from conferences by the attendees, so with the growing list of Twitter users in Hospice and Palliative Medicine (now including Bob Arnold and Diane Meier!), I wanted to try this at the AAHPM/HPNA Annual Assembly. If you need to know more about the basics for Twitter check out this previous post.Why would Twittering from a conference be a good thing?
1. Social media is the newest and fastest growing influence source on the web.So before reading further you may want to classify yourself in one of the following categories and follow the directions.
2. More hospice and palliative medicine content on Twitter raises the profile of the field.
3. Tweets may be passed on in the form of Re-Tweets and reach networks far beyond your own.
4. Highlights of the conference and key themes and memes will be featured and reinforced.
5. Lowlights of the conference will be noted and can be transparent and immediate feedback for the speaker or organizers.
5. Those not attending the conference may get a sense of being there and possibly participate.
6. Finding/Networking with other Hospice & Palliative Medicine professionals.
1. I don't know about this Twitter thing, I really I don't care to no more. -> Read no further!If you have a Twitter account and want to participate, make a Tweet using #AAHPM so we have a running list of potential participants.
2. This Twitter stuff is interesting but I don't really have time to start something new -> Read no further because I will post highlight Tweets (posts on Twitter) after the conference.
3. Twitter...Hmmm...Kind of interesting, I think I might get an account and try it out for myself. -> Keep reading!
4. I am a Twitterholic and this sounds awesome. -> Read on for the goals and organizing principles.
If you do not have a Twitter account, but want to participate, go to twitter.com and signup (it's free). Go to the list of HPM Twitter people and start to follow several of them. Watch what they Tweet about, and post a few of your own so you get a feel of it. Do not feel you HAVE to read every tweet from everyone you follow. That is not the point. It is like a river on a hot day, get in when you want but you don't have to spend the whole day in there.
If you do not plan on getting a Twitter account (now or ever) then you have a few ways of following along.
- Wait until the post conference post in early April on Pallimed to see what the Twitter fuss was all about.
- Use search.twitter.com and enter #AAHPM to see what the day to day Tweets are about.
- Subscribe to the RSS feed (using Google reader or other service) from search.twitter.com
- Follow along at Pallimed using the new right hand column widget "#AAHPM" (limited to the last 5 Tweets)
- Widen the conversation about palliative care themes in online social networks
- Collect important facts and key themes from the conference for reference and ongoing discussion
- Network with your peers
- Hashtag for the conference is #AAHPM. Include this in any Tweet (post) about the conference.
- Tweet about interesting phrases/facts heard at the conference.
- Give credit for the speaker when possible.
- Do not tag content with #AAHPM if you are only describing how good your coffee is.
- Consider using phone based Twitter clients like Twitterberry, or TwitterforiPhone or Tweetie or TwitterFon.
- If you feel clicking away on your phone is too distracting during the conference, Tweet after each session.
- If your phone has a camera, consider posting pictures using a service like TwitPic.
For further reference here are a collection of great resources on the power of Twitter and using Twitter at conferences.
- Evan Williams (co-founder of Blogger and Twitter) at TED giving an 8 minute talk on Twitter. (Good info, not a very confident speaker surprisingly.)
- Twitter Glossary find out what these twords tweeple are tweeting mean.
- Comprehensive guide on how to Twitter effectively.
- Presentation Zen coverage of Evan Williams TED talk above.
- Two examples of Twitter at medical conferences from Ves Dimov, MD at the NEJM Horizons Conference and Theresa Chan, MD at the Management of a Hospitalized Patient conference (via Kevin MD)
- Ves Dimov, MD at the AAAAI conference
- And for presenters here are tips on how to present while people are Twittering from Tamar Weinberg of Pistachio Consulting. (via TED Blog)
- Health Affairs live tweets a Health IT conference
by Christian Sinclair ·
Wednesday, March 11, 2009
A new study just published online in Cancer by the MD Anderson palliative care group asked this question of medical oncologists, nurse practitioners, and physician assistants at their institution in an anonymous web-based survey. Interestingly, there was a 70% response rate to the questionnaire among the 200 practitioners to whom it was sent.
The impetus for this study was apparently an observation that palliative care service referrals continue to be made late in the illness trajectory, despite efforts to encourage clinicians to use PC services earlier. The authors cite 2 studies, one in Japan (patients, families, physicians, and nurses) and one among US pediatricians and parents. These studies found that the name "palliative care" had a negative image and was a barrier to referrals (Japan) and evoked negative emotions and was less favored than "supportive care" (US). The authors decided to conduct a similar study in a large US cancer center with a well-established Palliative Care Service.
When asked what term they preferred using when discussing the referral with patients and families, only 19% preferred 'palliative.'
Fadul, N., Elsayem, A., Palmer, J., Del Fabbro, E., Swint, K., Li, Z., Poulter, V., & Bruera, E. (2009). Supportive versus palliative care: What's in a name? Cancer DOI: 10.1002/cncr.24206
Wednesday, March 11, 2009 by Thomas Quinn, APRN ·
With the AAHPM Annual Assembly coming up, I will post the 6th edition of Handy Hints for a National Meeting. Later this week I will feature How to Give a Great Presentation, 2nd edition.
* If you are bringing family or a significant other, spend some time with them.
* Bring business cards, lots of them. Make sure they have your email on them. If they don’t, write your email a number of the cards so when you hand them out, you are not trying to find a pen to add it.
* When receiving a business card, immediately write down the topic of interest you were discussing with that person. If the time isn't right, then do it soon afterwards. When you get home, you will have met so many people, you won't remember who that person was. Opportunity lost.
* If you get someone's business card, and you don't care if you ever interact with them again, make a special symbol that only you know on it, so you know to throw it out when you start going through all the business cards. Not everyone you meet is going to be a hub of a network you need.
* Turn in session evaluations in a timely manner.
* Find someone who is organizing the event and let them know they are doing an excellent job. They don't hear it enough. They are probably pretty exhausted from putting out everybody's "EMERGENCY!" They have put in a lot of hard work and seldom get recognized.
* Also find the conference chairs and thank them. While likely celebrities in the field, they don't always get personal recognition for the months of work put into coordinating the activity.
* Reconnect with old friends.
* Try and get out and see the city you are in, since you never know when you will be back there or if it will be devastated by a major hurricane or flood or earthquake or killer tomato.
* Ask other attendees what talks they are going to or avoiding. You may find something interesting you had previously overlooked.
* Bring your CV (multiple copies, and UPDATED), regardless of whether you are looking for a job. Many people may want to know more about you for networking reasons, not just job offers.
* Don't sit by yourself unless you are the first person in the room.
* Talk to people.
* Sit next to someone and then introduce yourself.
* Don't stay in your hotel room too much, you'll miss too many opportunities
* Stay in your hotel room sometimes. Take some time to unwind and be yourself.
* There is usually a bulletin board in a central place where people post messages: Look there for any messages regarding you or get-togethers you are interested in.
* When you go out with other people, you do not HAVE to talk about your field. (The people at the table next to you may appreciate that).
* You should make lunch/dinner plans with people outside the group you came with, but invite your group along too, if appropriate.
* Connect with attendees before you go through social networks like Facebook, LinkedIn or Twitter.
* See if people are Twittering about your conference on search.twitter.com
* Put something colorful or interesting but not too noticeable on your name badge. People will ask you about it and then you can tell them what it signifies. Note: Do not say, “It signifies something to get people to talk to me.” Although that would be pretty funny.
* Try to ask a question in at least one session that strongly interests you.
* When you ask a question, introduce who you are, and where you are from (quickly). This helps calm you down if you are nervous to ask your question. It also lets the audience know if they want to talk to YOU after the session if they have similar interests.
* Ask your question succinctly. Other people have questions too.
* When you come back to work, schedule an educational session with interested parties to share everything you learned there. You business may let you go to the next conference if you educate others.
* Don't just depend on your notes during each session; chances are you will never look at them again. Write down key facts you have learned towards the end of the day.
* Go to the poster sessions and talk to the people who made the posters. A lot of hard work went into most of these, and everyone likes to hear when they have done a job well.
* Go to at least one paper session. The concurrent sessions are great but you can find out some interesting up and coming things in the paper sessions.
* Don't be afraid to introduce yourself to any of the 'celebrities' in the field. Most of the well-known people are very friendly and willing to talk, just make sure they are not in a rush for somewhere else. If you don't read the situation right, they will cut the interaction short, and you will think they are a big jerk. Remember, a lot of people would like to have their attention.
* After a session, if you talk with a speaker, make your point or ask your question, and then allow others to interact. Nothing is worse than the know-it-all who wants to take up all the time of the presenter without regards to other people's interest.
* If you don't like a session, leave. Make the most of your time at a conference.
If you have any other tips, please email me at ctsinclair @t gmail d0t c0m
Handy Hints for a National Meeting is archived online at www.pallimed.org
Requests for use/modification should be directed to ctsinclair @t gmail d0t c0m
by Christian Sinclair ·
This offer is open to any Pallimed reader who wants to grow the knowledge of hospice and palliative medicine professionals. We have recently ordered from Moo.com (highly rec!) some new business cards with the Pallimed logo (including the Arts, Main and Cases blog) and some 'P' stickers in the Pallimed font (Algerian if you were interested.)
The Pallimed cards are great to hand out to members of your hospice or palliative care team or peers you see at regional and national meetings. The 'P' stickers are great additions to any name tag while at a conference to help you find other readers of Pallimed thereby creating a bigger sense of community. And when someone asks you about the 'P' you can tell them about Pallimed.
Our intention is to grow the readership so the knowledge can grow and the discussions about contemporary issues in palliative care are informed. If you want some please email ctsinclair and I will send you a packet of 10 business cards and 6 'P' stickers. (If you really want more ask, but supplies are limited.) If you want them before the AAHPM Annual Assembly email me (ctsinclair @t gmail d0t c0m) by Wed March 18th so I can get them in the mail to you.
Why use these viral or guerilla marketing techniques? Our biggest growth has always come from word of mouth from our readers which is so appreciated. And we have never and will never take any advertising so we have no budget! If you want to help...great! If this is not your gig, then that is OK too!
And lastly thank you to all the people who have already completed the 2009 Annual Pallimed Readers Survey. In only two days we have more surveys completed then we did for the whole week of the 2008 survey. The 2009 survey closes next Tuesday! And we will share the results with you as a thank you for taking it.
by Christian Sinclair ·
Monday, March 9, 2009
Many news sources are picking up on the March 9th article from the Archives of Internal Medicine* titled "Abandonment at the End of Life From Patient, Caregiver, Nurse, and Physician Perspectives: Loss of Continuity and Lack of Closure." The headlines place the blame squarely on the physician, but for those who work in hospice it is easy to see the many reasons why contact breaks down between physician and patient after hospice enrollment. The blame does not rest solely with the physician but more with the system in general.
*Which has five, count 'em five palliative care related articles and an editorial. Some of which we will highlight this week.
1. Shifting the contact person
Once someone enrolls in hospice, the nurse for the hospice team makes a full assessment of the patients needs and medical issues. There is an initial flurry of Medicare required paperwork faxed/mailed between the hospice and the doctors office. The hospice nurse becomes an extension of the doctors eyes and ears and calls the office when problems arise, a task once left for the family or patient. This may get more immediate results since the call is coming from a medical provider instead of a patient or family thus resulting in quicker symptom control.
2. Return visits are coded differently
Some people in the comments section of the USA Today argued doctors 'don't make money on dying patients.' This is somewhat true but not in the evil, money rules the world way it is made out to be. Physician visits under hospice care have a slightly different coding system to get billed and since doctors may not see a lot of patients on hospice they may not get those bills paid if they are not coded correctly. I have rarely heard this as a reason from doctors and it is one of the educational points hospice staff should help doctors offices understand.
3. What do you do on a return visit?
Patients and doctors may want to see each other and maintain contact, but the primary way that is done is for a problem based office visit. Well if your challenges are being managed well by the hospice team, you may not have a 'good reason' to make an appointment. The doctor may not want to ask a patient to come in because the patient may have difficulty getting to the office. The doctor also may not want to ask a patient to make an appointment, "just to say hi and catch up.' The classic paradigm for doctors in the past few decades has been to recede from the point of care at the end-of-life. With the growth of comprehensive end-of-life education a new breed of doctors may emerge to demonstrate more physician involvement near death is better.
4. "I have new doctors now."
Well I have a job as a palliative care specialist for some reason, and that is because patients with life-threatening illness may need a different type of doctor. With more hospice and palliative care doctors, our community doctors may feel more comfortable handing over the leadership of clinical care to us. Some prefer to maintain input, others hand it over gladly. Without the constant feedback that someone is on hospice, the community doctor may easily forget given the harried workload of most physicians. Not their fault, just the demands of the system. It is a misunderstanding that hospice requires the patient to accept their physician. The patient has the right to choose the physician of record. Hospice should be about choice.
5. Geographic distribution
A home visit would be a rare treat these days given the wide service area of most physicians. The doctor you have been seeing for 20 years even though you have moved 20 miles away, is unlikely to make a home visit. Again with the demands of the schedule and increased travel times, this becomes more and more difficult.
6. Lack of connectivity
It may be as simple as not realizing the impact of the connection a doctor has with a patient's family. I know this has happened to me when I have walked by a patient's room and the family chased me down the hall asking if I was going to see them today. When I replied someone else was covering, they acted disappointed. And this was a family and patient I did not necessarily feel a strong connection with. I am sure other health care workers have experienced this as well. I know I have been on the other end when I have disappointed a family because I was not one of my partners. (Eventually, I win them over!)
7. Phone calls get scrunched out of the day
Everyone knows a physician's office is a busy place, and even the most well-meaning physician may want to call a hospice patient at home to check how they are doing, but again the pressures of a packed schedule may make this item drop to the bottom of the list. Even though the physician desires more contact. In addition, phone calls are rarely reimbursed, so making time to do this is not encouraged by the smaller margins being seen in health care.
8. Who is the important doctor?
Is it the primary care doctor or the specialist who has been following the patient more closely over the years? When the patient identifies more with the specialist but the primary care doctor is the one managing hospice orders, it is easy to understand how the specialist may lose contact.
Efficient offices can manage to maintain contact during and after the hospice period. There are ways to overcome these and other barriers to non-abandonment for hospice patients and their families. But it takes a more systematic approach. One successful approach I have observed is a log of hospice patients that get calls every two weeks by a office staff member. With some creativity and structured format you can build a caring system.
Hospice agencies can help support this connection as well. For doctors with many patients on service, a list of patients with home phone numbers, key family members names, and a quick update could go out every few weeks to the office. If a patient and family highlight their relationship with the doctor give the doctors office a call and let the doctor hear the esteem they command and encourage the doctor to make an outreach.
Anthony L. Back, MD, Jessica P. Young, MS, Ellen McCown, BA, Ruth A. Engelberg, PhD, Elizabeth K. Vig, MD, Lynn F. Reinke, PhD, Marjorie D. Wenrich, MPH, Barbara B. McGrath, PhD, J. Randall Curtis, MD, MPH (2009). Abandonment at the End of Life From Patient, Caregiver, Nurse, and Physician Perspectives Archives of Internal Medicine, 169 (5), 474-479
Monday, March 9, 2009 by Christian Sinclair ·
SURVEY CLOSED WED MARCH 18, 2009
Results posted on Pallimed Main blog in April
Dear Pallimed Readers,
Thanks so much for joining us here at Pallimed. Last January we had our first annual survey to get some more structured feedback from the readers. (Here are the results from the 2008 Pallimed Readers Survey.) This year we ask you for a few minutes to complete this year's survey. (Last year the survey took less then 6 minutes on average.)
It is even shorter then last year's, since we took out some questions! Blame it on the economy, we cannot even afford more questions this year. Drew, Amber, Amy, Tom and I appreciate your feedback very much.The survey is open for just one week. Please complete it only once. It is the same survey regardless of which blog (Main, Arts, Cases) you access it from.
We will not sell your information. We pledge not to bombard you with survey pop-ups, or separate emails asking you to finish this. It is a voluntary survey.
We are expecting to provide our readers with some feedback from the survey by the end of March.
Christian Sinclair (on behalf of Drew, Amber, Amy, Tom and Pallimed)
by Christian Sinclair ·
If you're going to the AAHPM conference in Austin, the '3rd Annual Pallimed Happy Hour' will be at Pete's Dueling Piano Bar, (map here) Friday March 27th at 7:30PM until at least 8:30PM, probably later. Yes we realize this is during the Rounding with the Stars session, but no other night worked for both Drew and I. (Here is what we look like to help you find us! I am the smarter looking one.)
Last year we had a pretty good turnout of a little over 20 people and it was nice to put some names and faces together. Regardless, if no one shows up Drew, Tom, Amber (from Arts) and I will spend a decent portion of our Leadership Award on ourselves. If people show up...well I guess we will let them buy us drinks.
It will be simple, and casual, and done for mostly selfish reasons: we love to meet people who are part of the community reading this blog. If you want to come to give us a piece of your mind - feel free to - but remember Drew created this blog so he should if there is something that upsets you the Editor-in-Chief wants to know about it.
by Christian Sinclair ·
Thursday, March 5, 2009
The USA Today had a feature article this week highlighting the careful use of words to construct the order to no longer initiate CPR. (Don't miss the 170+ comments, very enlightening about how th epublic feels) The author focuses on the growth of the "Allow Natural Death" phrase as a compassionate alternative to "Do Not Resuscitate."
The prevailing medical order in the United States is "Do Not Resuscitate" and is usually abbreviated as DNR. It has been codified into law and etched in health care organization policies. The very direct nature of the command defines its usefulness. Do. Not. Resuscitate. Should be pretty clear with the precision and simplicity of the words. Some doctors would argue there are different aspects of resuscitation and a buffet approach could be approached. Chemical Code Only, Resuscitate but Do Not Intubate, Shock Only, etc. Specific changes to DNR orders should be written very clearly so as not to cause more confusion in an emergency, which is why I favor not making these changes unless absolutely necessary which is uncommon.
I first noticed the Allow Natural Death order on transfer paperwork for a hospice patient a few years ago. Never heard of it before then. What did it mean exactly as a medical order? Is morphine natural? Are antibiotics natural? Does this patient consider artificial hydration or nutrition as natural (To some that is a contradiction but others would disagree)? It left too many questions for me to consider it a helpful or accurate medical order.
I don't think I would write an order: "Make this patient's hemoglobin normal." I would need to write to transfuse a specific amount of blood and maybe specify to initiate the action when the patients hemoglobin was below a specified threshold. Ambiguity in medical orders is a situation ripe for error. For this reason medical orders regarding such momentous life and death decisions should not be ambiguous. Exactly the same reason to avoid orders such as DNR-A, DNR-B, DNR-C.
The article itself covers the pros and cons of each order very well. The proponents of Allow Natural Death orders believe it to be more compassionate and better accepted by patients and families. Anecdotal evidence to be sure but not to be ignored. But maybe the source of compassion does not come in the writing of an order but in the communication of the medical plan once the goals have been delineated. Efforts should be made to explain the medical care as defined by the goals of care set in a shared decision making situation. That would be the ideal situation.
To highlight how intrinsically the goals of care and the code status (DNR v CPR) are tied, I have begun writing the following orders as a set for any palliative care consultation and at any change in goals or code status.
Goals: Curative, Restorative, Comfort (occasionally I will use a combination of two if appropriate)
Code Status: Full Code, Do Not Attempt Resuscitation
Do any of you use the "Goals:" as a medical order or as a special section in your plan? I began doing this when doctors started jumping ship once a palliative care consult was called. This way I could alleviate their concerns the patient was still focusing on curative goals and we were following along for support. The DNR-A, B, C system seems to address this as well, but the abbreviation does not make sense, and would it really throw someone off schedule to write a few more letters for something so important?
Also, abbreviating DNR as a medical order is a shortcut that does not reflect the gravity of the decision so I have recently decided to write it out every time. That is another reason why Allow Natural Death does not work as an abbreviation. Imagine the following order in a chicken scratch illegible black pen (which I have seen before)
xfer to medical floor
Once I saw that I quickly clarified a new order.
What are your pet peeves/concerns/thoughts about DNR orders?
I am just glad that no one mentioned DNR Commies in this article!
Thursday, March 5, 2009 by Christian Sinclair ·
Go check out the second edition of Palliative Care Grand Rounds at the Dethmama Chronicles.
Also be sure to check out her PCGR interview.
She did a fantastic job! Jessica Knapp at The Good Death is the next host so keep your eyes peeled for good posts to send her! The next PCGR will be posted Wednesday, April 1st.
Email ctsinclair @ gmail d0t c0m if you are interested in hosting an upcoming edition.
Subscribe to the RSS feed for each monthly PCGR so you do not miss it in the future!
by Christian Sinclair ·
There are many other hospice related people on Twitter but they may not post often or may have let their account fade away. If you find others please let me know and I will add them here. Please feel free to tweet this list to anyone interested.
I want to encourage any Pallimed readers going to the AAHPM conference to consider giving Twitter a try because I am hoping we can build some buzz by twittering from the conference. If we can grow a palliative care network on Twitter that 'leaks' out into other networks it can be pretty powerful. Even better then giving a talk at your local civic center for 10 people. Consider this a public education function of your HPM work. More on the AAHPM Annual Assembly twittering plans later.
** Updated Sep 2009
(@username is the proper syntax for noting a Twitter username)
@dethmama - Hospice RN and blogger
@angelamorrow - Hospice RN, CHPN and blogger for About.com The Palliative Care Blog
@marachne - Hospice/Palliative Care Nurse and PhD Student
**@sarahskiba - Hospice/Palliative Care RN, blogger for A Journal of a Hospice Nurse
**@abbrody - Hospice/Palliative Care Nurse Practioner and PhD trained researcher
@ctsinclair - Palliative care doc ("me"), talking about Pallimed and maybe some board games occasionally
@lyfe20 - Palliative care doctor, research focused.
@ESMenkin - Palliative Care doc and mother of "Go Wish" cards
@mchwistek - Palliative Care/Pain Doc
@DianeEMeier - MacArthur Genius Grant awardee and Palliative Care Doc and director of CAPC
**@DrSawicki - Palliative Care Doc, Medical Director Hospice
**SuzanaKM - Palliative Care Doc, Director of Palliative Care Program & Education- UMass Cancer Center
Other HPM related disciplines
**@GriefHealing -Marty Tousley, CNS-BC, FT, DCC Certified hospice bereavement counselor www.griefhealing.com
@hospicegirl - Volunteer Coordinator from Seasons Hospice Milwaukee, WI
@StAnnsHospice - Catherine Williams, fundraiser for St. Ann's Hospice in the UK
Hospice Agencies and Organizations
**@KCHospice - Official Kansas City Hospice and Palliative Care Twitter account
**@HMSPallCare - Official Harvard Medical School Palliative Care Twitter accoun
**@HospiScript - Hospice focused Prescription Benefits Management
@SanDiegoHospice - Official San Diego Hospice Twitter account
@palliativecare - Official Institute of Palliative Medicine (Education & Research arm of SDH)
@lesmorgan - Founder of Growth House, tweets about HPM and IT
@SBHospice - Twitter account for Hospice of Santa Barbara (Non-medical hospice)
@NHPCO_news - NHPCO news feed
@weldmar - Weldmar Hospicecare Trust in Dorchester, Dorset, UK
@hospicecarecntr - Twitter Account for Hospice & Palliative CareCenter - Winston-Salem, NC - That is where I did my fellowship. Way to go W-S!
@AAHPM - Official Twitter account for American Academy of Hospice & Palliative Medicine
@hfahospice - Official Twitter Account for the Hospice Foundation of America
@Pallimed - Official Pallimed feed and some other HPM stuff
@larryberesford - Blogger for Growthhouse
@daitpcg - Tim Cousounis from the DAI Palliative Care Group, blogger, general HPM info
@HospiceChicago - News about Hospice in Chicago from Rainbow Hospice
**@freshwidow - Blogger Supa Dupa Fresh of the blog Fresh Widow
Jeff Okazaki of @HospiceChicago also maintains a list on the Hospice Wiki
by Christian Sinclair ·