Sunday, May 31, 2009

Hospice Cap - Opinion Poll

For those Pallimed readers wanting to discuss the hospice cap controversy you may be interested to know about a redesign to the National Alliance on Hospice Access website which now allows for more interaction and commentary. The past site was very static and only gave out information and now with a blog as a central anchor the NAHA is posting with some regular frequency about why the Medicare Hospice Cap should be reformed.

So far the comments have been scattered and have been mostly people agreeing with the position the NAHA is taking. I was surprised to see the general negative view towards the NHPCO as noted in this post "Entrenched Hospice Interests Oppose Hospice Cap Reform, And Any Hospice Reform." Dave Daucher writes:

"Why do large urban hospices oppose reform that would improve access, save money and help independent rural hospices? Why does the NHPCO, which solicits dues from over 2,000 hospices, lobby solely on behalf of a relatively few large urban hospices? Why do NHPCO “talking points” say they need to “collect data” and “study things”, when there has been no data collection, no real study and no reform for the past 10 years? And what are the “unintended consequences” they’re worried about?"
Perusing the blog I did come across a CBS News story on the hospice cap from just a few days ago. Tell me what you think about the coverage. Does it match your understanding of the hospice cap? (Video player embedded below - text link from CBS here)



The Hospice Foundation of America describes the press coverage as misleading here. Even if you are not affected by the cap directly I do not think it will be good for the hospice movement as a whole if this divides us, nor if it makes the American public misunderstand what hospice is about like this one of 42 comments from the CBS news site:
I "used" to work for a Catholic run hospice program. The way they got around this was to start upping the morphine doses before the six months were up. The patients that were allowed to linger longer were those who had substantial wealth and paid their own way.
Posted by grammawhamma at 5:17 PM : May 31, 2008
I really hope that is not the perception of a 'solution.' If that is happening, posting an anonymous comment on a website is not living up to your obligation to report inappropriate care. Since I think it is likely a gross misrepresentation of what hospice staff do everyday, I think that is not the case.

So back to the hospice cap...we will have for the first time ever a poll here about a hospice issue.

What is your opinion on the hospice cap?

Look in the top left hand column for the poll. you have one week to vote in this extremely unofficial look at opinion here. Feel free to comment on this post if my choices did not leave you with enough options!

Sunday, May 31, 2009 by Christian Sinclair ·

End of Life Care in NY Times (Again!)

I am beginning to believe a tweet i saw a few months ago that mentioned the New York Times becoming a great End of Life Care textbook with all the recent articles and editorials.

Dr. Pauline Chen, author of Final Exam: A Surgeon's Reflections: (interviewed on Pallimed in march 2008), and columnist for the NY Times wrote an excellent piece for her Doctor & Patient column which starts off with reflection on the recent death of her mother-in-law.

"In the days since her death, I have often thought about the many conversations my mother-in-law and the family had with the doctors and nurses about the dying process. There was the initial discussion over two months ago that she was likely to die soon and would benefit from hospice, and then there were also the many daily conversations about her comfort, about what she wanted and what she did not"
She interviewed Dr. Alexi Wright and Dr. Holly Prigerson from the Coping With Cancer study and featured this article from last October's JAMA.

Nothing spectacularly new to this crowd, but a good well-written piece highlighting what we do. As always with Dr. Chen's editorials, the Tara Parker-Pope's NYT Well blog hosts the 63 + comments which are worth a read.

by Christian Sinclair ·

Thursday, May 28, 2009

(Not) Discussing hospice with lung cancer patients

Archives of Internal Medicine has a paper about hospice discussions with patients with lung cancer. The data came from a large, US, multicenter/regional study which involved phone surveys of ~1500 patients diagnosed with lung cancer (who, among many other items, were asked if a health care provider had discussed hospice care with them). The surveys occurred 4-7 months after diagnosis, this analysis only looked at patients with metastatic cancer, and charts were also abstracted to see if there was any documentation of discussing hospice care. Surrogates could answer for patients who weren't able or who were already dead and in fact over half of the respondents in this analysis were actually surrogates. Response rate was ~50% for the original telephone survey. A bunch of other items were collected as well. (As a minor side note they talk about coding patients' responses to questions about their prognosis and including 'it's in God's hands' as one of the potential codes - along with different timeframes and 'I don't know.')

There's a lot of data in this paper, and I'm just going to focus on what seems most relevant. Only 53% of patients (or their surrogates) reported and/or had medical records indicating that they had discussed hospice with a health care provider. There were a variety of modest (generally 5-10%) but statistically significant differences in reporting that discussion between different groups (whites more likely than African Americans or Latinos; patients with Medicare more likely than those with Medicaid; older more likely than younger; those who received chemo vs. those that hadn't, etc.).

Time to death had a major impact on who had had a hospice discussion as you'd expect, but the results weren't heartening. Surrogates reported that for ~80% of patients who were already dead there had been a hospice discussion; this drops to 54% for those who died within 2 months of the interview; 34% for those 2-4 months, and 26% for those who died 4-6 months after the interview.

When they looked only at the patients who completed the interview themselves these rates were even lower (43% for those who died within 2 months, 27% 2-4 months, etc.). Patients' self-reported expected prognoses impacted the likelihood of having a discussion: of those who expected less than a year it was ~45%, for those who thought it was likely to be greater than 5 years (which, not-shockingly-but-still-kinda-sobering, was over a fifth of the cohort - remember these were all patients with stage 4 lung cancer which has a 5 year survival of under 5%) it was 12%. 16% of the 'In God's hands' patients reported a hospice discussion. Of the "do not know" patients, which were 40% of respondents, 18% had had a discussion.

Notably, half this patient responders said they prefer 'pain relief over life extension.' That preference did not predict having a hospice conversation.

The low response rate to the survey may is a concern with these data, however my suspicion is that a 100% response rate would likely have altered the numbers a bit, but would not have altered the trends seen here. In addition, surrogates probably aren't terribly accurate reporters of what has happened to a patient; that said the differences in what the entire cohort demonstrated and the subgroup of patient-themselves responders likely reflects the reality that the surrogate responder patients were sicker (or of course already dead) and so the reported rates of conversations were higher in the entire group.

That aside the findings here are quite clear: for this group of patients with dismal prognoses hospice discussions were happening late (if at all), patients overall admitted ignorance or inaccurate perceptions of their likely futures (time-wise), those that did have a decent understanding of their prognosis were more likely to have had a discussion, although still at low rates, and half of these patients straight-up reported that life extension was not their preeminent goal.

I'm personally mostly interested in data about patients' perceptions of prognosis. To me, that's the key breakdown here. If you have a patient who is thinking they'll likely live for more than 5 years, a discussion, even info sharing, about hospice doesn't particularly make sense. If they understand it's likely to be less than a year, that discussion makes much more sense. More than that, we're doing our patients a disservice if we are telling them/allowing them to believe (by not correcting or never even addressing) grossly over-optimistic prognoses. I think I'd make different choices in my life (and my health care decisions) if I understood my likely time left was less than a year vs. 2+. (One also wonders if that fifth who thought they had over 5 years to live thought their cancer was curable.) Not all patients want to talk about time, of course - that's fine (although not making sure they understand that their cancer is incurable and any treatment is given with the hope of life-prolongation but without cure is not fine). But half these patients were already saying life-prolongation wasn't their top priority; if we're not even discussing time and all the treatment options with them we're doing them a disservice. This is not just a problem in oncology, although it's probably the most well-defined there as it's relatively well-studied.

Sometimes I feel that the Great Big Dirty Secret of 'palliative care' that's really of course out in the open if you cared to look at the literature or, you know, talk with patients is that many and indeed most of our patients facing life-limiting illnesses want to talk about this stuff. (To some extent of course, not necessarily all the gory details). And they are in fact deeply grateful to be able to talk about it. More frightening, worrying, not to talk about it. They thank me all the time for bringing it up, actually. And it's usually pretty easy to do.

Thursday, May 28, 2009 by Drew Rosielle MD ·

Physician bereavement practices

Archives of Internal Medicine also has a fascinating survey of physician bereavment/condolence practices. The study involved a national survey of Canadian medical & radiation oncologists and palliative care physicians (mailed to members of the 3 main professional societies). There was a 71% response rate, which is good for these type of studies.

Basically, bereavement practices were generally spotty: about a third of respondents 'usually' did something (card, call, attend a service - phone call being the most common of the 3), about a third 'sometimes' did one of those, and the other third rarely did. Palliative docs were more likely than oncologists to do condolence actions. In fact, being a palliative doc was a strong predictor of doing some bereavement practice; however working in a setting without a palliative care program also was a predictor - suggesting that these activities are being delegated/transferred to palliative care clinicians.

They also asked some revealing questions about physicians' attitudes towards patients' deaths, the role of family members, etc. There was one (literally) palliative doc who 'strongly disagreed' with the statements they 'like to meet patient's family members' and they 'like to treat patients as part of a family unit.' A very few oncologists disagreed with these statements too, but who is this palliative doc? Didn't they read the WHO definition of palliative care? Actually in the discussion they mention it was a palliative doc from Nova Scotia, so watch out if you're heading Halifax way***.

Anyway - there were some striking differences in some of the questions between palliative docs and others. One was whether the docs felt a sense of failure after a patient's death: literally none of the palliative docs did (and 92% disagreed with that statement). Only ~50% of the oncologists disagreed with that statement. In some ways I was surprised it was that high, and it reminded me of a friendly discussion I have with an oncologist colleague of mine about who has the tougher job (emotionally speaking). He thinks I do because I spend most of my time working with dying/soon-to-be-dying patients. I think he does because even when I've known a patient for a long time, even years, I rarely am in a position in which that patient expected/hoped of me to 'cure them' or help them live as long as possible. I'm always happy to oblige that when I can, but most of my patients understand/accept I do something else. This is not true of oncologists who have to go through the transition of being for (many) patients in the role of being an 'agent' of curative treatment or at least life-maximizing treatment to one in which they can longer be that agent. Even if they've given impeccable, excellent medical care (which is all we can and should ask of ourselves as physicians) that transition is inevitably difficult for many oncologists. Feels like failure, feels like you've let this person down. Oncology training ideally should be structured to explicitly address and 'prevent' this but I don't think it often does. Anyway: I think that's much tougher than what I do (most days).

I'm curious as to what readers' condolence practices are, if any?

(Image by Ian Britton/freefoto.com.)

***This is a joke (about Nova Scotia, there was in fact one palliative doc who apparently hates patients' families) - sorry to PM, RH, DH, LA - I know you're reading this.

by Drew Rosielle MD ·

A couple for the prognosis-completists

For the completists, because while intriguing these aren't particularly clinically helpful.

1)
Cancer has an interesting paper about the role of number of metastatic sites in non-small cell lung cancer and prognosis. Interesting because it provides some general prognostic information, as well as looks at tumor burden/volume and how it relates to prognosis.

The data come from a single institution's cancer registry (MD Anderson) and looks only at patients with documented metastatic disease within 3 months of being registered (~1200 patients, median age 62 years). (This means it's impossible to know for sure how far out from diagnosis these patients were; certainly many were initially diagnosed with metastatic disease and registered basically at the time of diagnosis, however some were likely diagnosed substantially prior and were only registered at the time of referral to this tertiary cancer center - we don't know from what's presented here. That is, these data describe survival from time to presentation at MD Anderson as opposed to necessarily time from diagnosis of metastatic cancer, which makes practical interpretation more difficult.) They looked at number of organ sites of metastases, presence of absence of brain metastases, and tumor burden, and how this all related to survival.

Gross survival was terrible: median 8 months overall, 7 months with brain mets. For patients with solitary organ spread (other than the brain), having brain mets made things worse (6 months vs. 10 months without brain mets). For patients with multiple organs with metastases (3 or more) brain mets didn't make much difference (~7 months).

They then looked at patients with only either brain mets (n=32) or lung mets (e.g. the only site of metastasis was to other areas within the lung parenchyma, n=137) to see if the actual volume of tumor at the time of registration correlated with survival. They only included patients for whom they could get decent volumetric data. Basically: size mattered and the greater tumor volume/burden the worse the survival.

While it's nice to know that this is the case (size matters), it isn't much of a surprise and I'm not sure this is of anything other than academic interest at least for palliative clinicians. The data would be more helpful if they were presented as time to death from time of diagnosis with metastatic disease as opposed to presentation at MD Anderson, but such are the limits of their dataset. 7 months vs. 10 months, at least to me, is all basically terrible

2)
Annals of Internal Medicine has a study about the prognostic importance of kyphosis in older women. The data come from prospective, long-running study of osteoporosis in older women (mean age ~72 at time of enrollment, for some frustrating reason only white women were studied, mean follow-up ~13 years) in which the degree of kyphosis was measured. Basically, more pronounced kyphosis was linearlly associated with worse prognosis (hazard ratio of death approaching 3 for those with the worst kyphosis) for these women, even after adjusting for age, smoking, self-reported health status, and other confounders. The authors speculate it is a combination of kyphosis being a measure of general frailty, increased risk for other osteoporotic fractures which can increase mortalilty, as well as respiratory compromise.

by Drew Rosielle MD ·

Online Radio and Palliative Care Grand Rounds coming up

Two quick notes:

1)

I will be interviewed by Viki Kind (of Kind Ethics) on Blog Talk Radio on the topic "How do I know when it is time for hospice?" The show is at 4pm Central and you can listen live (or later if you miss it) by clicking here.

If you do listen live, feel free to call in at: 347-945-5152

Viki may be looking for other guests so feel free to contact her through her site, Kind Ethics. There is a lot of good content on the site supporting hospice and palliative care.

2)
Palliative Care Grand Rounds is coming up next Wednesday June 3rd at About.com's Palliative Care page hosted by Angela Morrow, RN. So if you have any blog posts you think should be included from May from any site (not just ours of course!) please email her soon at dying.guide@about.com.

by Christian Sinclair ·

Friday, May 22, 2009

Palliative care & eating disorders

The International Journal of Eating Disorders has a case report and discussion of a patient with refractory anorexia nervosa who died receiving hospice care. This is one fascinating case report. The case, to summarize briefly, involved a young woman with a long history of anorexia nervosa, refractory to all attempts at treatment (including involuntary/forced treatment) who apparently also was not deemed a candidate for forced guardianship (the hospital's legal counsel advised she would not meet requirements to be declared incompetent).

This is how they describe the ethics committee's response to the case:

The committee’s members struggled to understand how one could die from a psychiatric illness (other than by suicide or unintentional overdose) and were not sure how to proceed. Although they could delineate the differences between acute mental health risks such as suicide, drug overdoses, psychosis or self-neglect, they had no points of reference regarding how to manage a patient who was chronically a danger to herself, unwilling to engage in further treatments, and unresponsive to all prior attempts to treat her involuntarily. The only examples the committee raised for comparison concerned drug users who received heart valve replacements, yet continued to use, knowing that such ongoing use would kill them. In such cases, if a high risk of ongoing subsequent IV drug use was suspected ahead of time, the decision was often made not to provide valve replacements, but there was no forced treatment.
This is how they presented what palliative care for anorexia nervosa would look like to the patient (italics mine):
If she chose to pursue treatment she would be assisted, but the staff would not force her into any involuntary placements or impose any treatment she did not want. There would be no weigh-ins, no calorie or exercise monitoring, no IM medications and no required therapy sessions. She would be offered outpatient therapy only as she felt desirable and necessary. Psychiatric medications would be prescribed as the patient deemed necessary to help manage depression, anxiety and insomnia. The patient would receive weekly visits from a palliative care nurse, who would work with her to manage her symptoms and keep her comfortable. The patient agreed to no further hospitalizations, but did not fully agree with the plan for ‘‘palliative care’’ since she did not believe she was going to die.
The patient basically continued her illness behaviors, got weaker/sicker, and was eventually enrolled in an inpatient hospice where she died.

Some observations.
  1. AN is clearly at times a terminal illness, refractory to all attempts to reverse it.
  2. In this case it was clear that the patient's life could have been prolonged although only with forced treatment. It was the opinion of her physicians that such forced treatment, while life-prolonging, would not 'cure' her AN (for some patients a trial, or many trials, of forced nutritional treatment along with psychiatric care gets them to the point at which they are willing to continue with voluntary treatment and can have a durable response; it was felt this would never happen with this patient). Thus the decision came down to trying to force further involuntary treatment vs. letting the disease run its natural course with her inevitably dying.
  3. I found it interesting that they did not feel there was enough of a chance she'd be considered incompetent that they didn't even put her through the court process. Her statement that she did not think she would die (and it seems she continued that belief until the end, and persisted at least until she was enrolled in hospice in saying that she in fact wanted to live) seems to me to indicate such a fundamental lack of insight into her condition that I'm not sure I believe that. Granted, I'm not too familiar with criteria for declaring someone incompetent on psychiatric grounds, but I assume it has something to do with one's mental illness being such that one cannot even take in basic medical information.
  4. That said, and even if she was legally stripped of her decision-making rights, for situations in which even involuntary treatment would not work long-term, is it right to force patients to do that? In this situation they concluded No, and made plans accordingly, which seemed to work as well as could be expected under the circumstances.
I have had, thankfully, only minimal involvement as a palliative doc with patients with refractory eating disorders. And while #1 is certainly true, these cases stick in your gut a little more than, say, refractory CHF or whatever. Part of that has to do with it being psychiatric illness, as opposed to medical, and the at least visceral differences that creates. I think it also has to do with the very fact that the illness precludes a patient from from having 'normal' insight and ability to make decisions, etc.: that's the very nature of the disease.... Youth, potential loss of decades of vitality, and the fact that there's a tiny chance that stripping a patient of all rights and forcing treatment for a long time might end up working, make it all the more distressing. I wonder how the hospice providers handled her care, emotionally?

And what if this was refractory depression, and a patient was suicidal? Depression can certainly be a terminal illness, and it certainly can become refractory to all treatments (drugs, involuntary committment, electroconvulsive therapy, etc. etc.); we are not offering them hospice care or 'palliative care.' Which I'm fine with (I'm not really sure what that would mean anyway other than not forcing treatment or stopping a patient from committing suicide), and part of this comes down to the difference between 'active suicide' from one's refractory depression vs. 'passively "allowing" oneself to die from an eating disorder.' But I think these cases really push these distinctions we make - make us really examine them. If the choice was permanent involuntary committment and ongoing ECT, when do you decide enough is enough? That rarely happens of course because patients either get better or commit suicide (given that long-standing involuntary committment is rare/unrealistic/often unable to be provided for financial or regulatory reasons for depressed patients).

Much more commonly than eating disorders I care for patients with other mental illnesses (such as schizophrenia with refractory symptoms/inability to comply with treatments despite efforts to control the schizophrenia) which preclude them from receiving what would otherwise be life-prolonging care (e.g. chemotherapy, dialysis, whatever). In these cases I tell my trainees what the patient is really acutely dying from is the schizophrenia, as it is precluding them from receiving life-prolonging treatment. That aside, while these cases are tough and tragic, I'm quite comfortable with them as long as everyone is in agreement that there's no reasonable alternative to providing life-prolonging treatment other than forcing it upon a patient who cannot understand it and could not receive it without ugly/inhumane restrictions (forced hospitalization, restraints, whatever). I'm asking myself why these eating disorder cases feel different to me and I wonder that, despite my flippant statement above that the patient is 'really dying of shizophrenia,' the difference to me is that they're also really dying of cancer, or renal failure, etc. as opposed to this case in which this young woman was dying, solely, of her mental illness...?

Friday, May 22, 2009 by Drew Rosielle MD ·

Prescription drug abuse

National Drug Intelligence Center (part of the US Department of Justice) has released its 2009 'National Prescription Drug Threat Assessment' documenting the ongoing rise of prescription drug related deaths in the US. Key findings:

Current nonmedical use of these drugs, collectively referred to as "controlled prescription drugs (CPDs)" for the purposes of this report, remained relatively stable from 2003 (6.5 million) to 2007 (6.9 million); however, the number of deaths and treatment admissions involving CPDs, particularly prescription opioids, increased significantly. According to the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, unintentional overdose deaths involving prescription opioids increased 114 percent from 2001 (3,994) to 2005 (8,541), the most recent nationwide data available.
The report also squarely blames legitimate prescribing for this...
Increases in legitimate distribution of prescription opioid pain relievers (the most commonly diverted and abused CPDs), amphetamine, and methylphenidate have expanded the amount of these drugs available for diversion and abuse.
...which will likely provide further impetus to the movements afoot to, in some way, further restrict legitimate prescribing of these drugs (cf here). I am skeptical this can be done in a way that will ensure timely access to these drugs for patients who responsibly use them and benefit from them, particularly those without cancer. If any policy-mavens reading this have ideas as to how this could actually be done well, feel free to share your thoughts on the blog.

One interesting part of the report is a massive table listing street values of different prescription drugs - they are listed by drug & dose, as well as where the info was collected. E.g. 4 mg tabs of hydromorphone can go for up to $40; MS Contin's street value wasn't grossly less than OxyContin's overall.

Thanks to Dr. David Weissman for alerting me to this.

by Drew Rosielle MD ·

Wednesday, May 20, 2009

Anniversary for Arts and Cases blogs; Top 5 Lists

This is the anniversary week for the two sister blogs for Pallimed and we just wanted to wave some colorful flags, toot some horns, and shower some confetti on these endeavors. If you do not know about these two blogs you are missing out on some great content. An easy way to find them is to click on the graphic map at the top of the page for Arts or Cases. You know you are on Arts when the trim and colors are red, and Cases when the trim is blue.

Pallimed: Arts & Humanities is co-edited by Amy Clarkson, MD and Amber Wollesen, MD. Updated every Monday they have done an excellent job covering a wide range of artistic genres. They have drawn over 500 subscribers and 11,000 visits in the past year with their 59 posts. Way to go!

If Drew, Lyle, Tom and I get a little dense over here some times with the academia, jump on over to Arts where the tone is much more personal and experiential. Have you ever read a book, seen a movie or listened to a song? Well then you are more than qualified to jump in the discussion at Pallimed: Arts & Humanities.

Top 5 Visited Posts from the last 12 months at Arts & Humanities
1. "What Sarah Said" by Death Cab for Cutie
2. Postmortem Photography - Lost Art?
3. Top 10 Palliative Care Films
4. Bird Hits a Window
5. You're Going to Die

Top 4 Most Commented Posts from the last 12 months on Arts & Humanities

1. Top 10 Palliative Care Films - 25 comments
2. "What Sarah Said" by Death Cab for Cutie - 23 comments
3t. Scrubs (TV) and Palliative Care - 7 comments
3t. Isle of the Dead - 7 comments
Multiple posts with 5 comments

Pallimed: Case Conferences is (usually) posted twice a month and is focused on a single topic title. The cases are contributed from staff and faculty at the Institute to Enhance Palliative Care at the University of Pittsburgh Medical Center. I am sure when you start reading through the cases you can say, "I have seen this situation before!" So if you have insights or questions about singe topics in a case based way, head on over to Case Conferences.

Top 5 Visited Posts from the last 12 months at Case Conferences
1. "Do you have something stronger than this Dilaudid" A Case for Opioid Rotation
2. One Man's Journey Towards Deactivating His Implantable Cardioverter-Defibrillator
3. "Am I Really going To Have To Live Like This?" The Role of Octreotide in Patients With Persistent Nausea and Vomiting after Venting Gastrostomy
4. Music Therapy
5. Palliative Sedation Therapy

Top 5 Commented Posts from the last 12 months at Case Conferences

1. An Isolated Patient Who Wants to Die at Home - 7 comments
2t. Coordination of Care for People at the End of Life - 4 comments
2t. Using Cultural Specific Music to Alleviate Symptoms of Anxiety and Depression - 4 comments
Multiple posts with 3 comments

Wednesday, May 20, 2009 by Christian Sinclair ·

Nurse Practioners and Prescribing Controlled Substances

Just came across a post from HospiceNP and anonymous blogger in Florida who discusses the recent dismissal of an attempt to get nurse practioners the ability to prescribe controlled substances. I have heard about this happening in other states (including Missouri) and I profess to be somewhat ignorant about the whole situation despite the obvious impact to my own practice.

Maybe ignorance is too strong of a word. I am aware of the growing calls for nurse practioners to get prescriptive authority for controlled substances, but I have not followed the situation with great zeal to understand all the arguments. The one consistent argument I hear from the pro-NP side is that doctors are pushing hard to stop NP's because of turf, pride, power, or money. The thing I do not understand about this argument is how prescribing controlled substances is a task that gives power or money or pride or turf to physicians. There is a prevailing notion that physicians often may want to avoid prescribing controlled substances and if someone else could do this in their place (even with the doctors overseeing responsibility) they might freely share the right with adequately trained NP's.

Anyway, the real reason I write this post is to give a shout-out and soap-box level of support to all the NP's, ARNP's, CNS's I have worked with in palliative care and hospice. They have all been extremely professional, with a high level of knowledge about opioids and other controlled substances and the potential risk and benefits of the medications, and they have also demonstrated a immense concern for prescribing within their allowed guidelines. Now some outlaw NP's may be out there but I have not yet come across one.

If any one has some more info to share about this issue please enlighten me and the rest of the readers. Does anyone know what states NP's have prescriptive authority for controlled substances?

by Christian Sinclair ·

Congratulations to the NPCRC Grantees for 2009!

The National Palliative Care Research Center and the American Cancer Society announced the recipients for a total of $1.5 million in grants this week. It is wonderful to see a growth in research awards for palliative care, because as the NPCRC tagline says:

"Without research, palliative care is an art, not a science."


Here are the brief reviews of the grantees and their projects. Check the NPCRC for more details.

Kyle R. Allen, DO Summa Health System

Study to test the effectiveness of an in-home interdisciplinary care management intervention for improving global measures of quality palliative care

Jane L. Givens, MD, MSCE Hebrew SeniorLife

Study the mental health of family members of nursing home residents with advanced dementia.

Scott A. Irwin, MD, PhD The Institute for Palliative Medicine at San Diego Hospice

Dr. Irwin will assess the feasibility of conducting a randomized, controlled, safety and efficacy trial of rapidly treating major depressive episodes with methylphenidate monotherapy in patients receiving hospice care.

Jennifer W. Mack, MD, MPH Dana-Farber Cancer Institute and Children's Hospital Boston

Evaluate the relationship between hope and prognostic disclosure among parents of children with advanced cancer.

Ramona Rhodes, MD, MPH Brown University

Examine racial differences in the perception of the quality of hospice care by examining hospice-level variability associated with African American perceptions of the quality of hospice services and to identify processes of care that can reduce these disparities.

Alexander K. Smith, MD, MS, MPH University of California, San Francisco

Investigate emergency department use at the end of life.

by Christian Sinclair ·

Monday, May 18, 2009

Denied Access and Info for Dying Patients: Is it just about sexual orientation?

Image representing New York Times as depicted ...Image via CrunchBase

Tara Parker-Pope writes in the New York Times today about a Federal Case from Florida in which a same-sex partner holds that she was denied access and information about her partner who was dying based on their sexual orientation. Hospitals and other health care organizations are invested in the outcome of this case because it could greatly alter medical staffs interaction with the friends and family of patients.

Many barriers to good patient-family-staff communication exist within medical facilities the greatest of which is lack of time. You add on top of that 'medical passwords for information', staff documentation, a lack of quality reimbursement structure to encourage better communication, an greater volume of clinical data and information, the loss of primary care representation in the hospital, the fractioning of physician specialists time on service, the presence of trainees, the micro-specialization of every service in the hospital, and the fact that medical staff have historically as a whole been poor communicators about the critically ill and dying patient, and you could see why lawsuits exists regarding communication.

So for health care staff to erect more barriers because of sexual orientation of the partner seems almost ludicrous, especially in these cases where health care proxy statements were completed. But as I read the story, I was wondering if this was just really more of a poor example of dying in American hospitals or outright discrimination. Not that I am trying to give the defense an argument. One might imagine in this outrageous defense: "Your honor, we were not discriminating based on sexual orientation, we were just providing poor communication about a dying patient per standard of care." Read the story and tell me if you see shades of both. Here is one example that just sounds like it is begging for a palliative care consult:
"The medical chart shows that the documents (ed. DPOA) arrived around 4:15 p.m., but nobody immediately spoke to Ms. Langbehn about Ms. Pond’s condition. During her eight-hour stay in the trauma unit waiting room, Ms. Langbehn says, she had two brief encounters with doctors. Around 5:20 a doctor sought her consent for a “brain monitor” but offered no update about the patient’s condition. Around 6:20, two doctors told her there was no hope for a recovery.

Despite repeated requests to see her partner, Ms. Langbehn says she was given just one five-minute visit, when a priest administered last rites. She says she continued to plead with a hospital worker that the children be allowed to see their mother, even showing the children’s birth certificates."

Palliative care teams do a great job at taking a social history and finding out who needs the information and help build trust and open channels of communication with family, patients and medical staff. But they can't be everywhere and until this issue is settled in a court of law palliative care will just have to keep doing the best when we are consulted.

In addition, there are studies showing no significant harm by allowing family members in the room during codes and trauma situations so this statement from the hospital:

“The primary legal point is that the amount of visitation allowed in a trauma emergency room should be decided by the surgeons and nurses treating the patients,”
doesn't necessarily hold well.

Read the 145+ comments and counting on the Well Blog at the NYT for more public opinion.

Monday, May 18, 2009 by Christian Sinclair ·

Hospice and the Stock Market

NASDAQ in Times Square, New York City.Image via Wikipedia

We don't cover the quarterly reports of hospice companies here, and to date have only blogged about the stock market happenings of these companies once before. But recently two of the publicly traded hospice companies have run into some speed bumps with the stock market. I follow the news feeds for the three well known companies (VITAS, Odyssey and Gentiva) to see if they have broader insights into how hospice is faring nationally. For example, the recent rollback of the wage index cut made all these stocks rise quite nicely. "Buy! Buy!" The market is listening to hospice providers apparently. They care what we do!

VITAS is the nation's largest hospice provider
and is one of two operating business of the Chemed corporation (the other business being Roto-Rooter). Last week the hospice portion of Chemed had a subpoena from the Department of Justice which requested patient records and administrative files back to 2003. With this news the shares of ChemMed dropped 10% so the market obviously think this is a big deal. I am not writing this to speculate about the meanings of the inquiry which will obviously be revealed in time. And to their credit, VITAS has stated a confident claim of being in compliance with Medicare rules. But I believe it is important to recognize the manner in which this inquiry is handled by the DOJ, VITAS and the media may have broader implications for the hospice field:
  • Does this affect reimbursement lobbying efforts?
  • Does this affect hospice cap legislative discussions?
  • To what degree do government inquiries have the potential to change the public's highly positive view of hospice?
  • How do hospice agencies support each other and the field when they may also be competing in local markets?
In addition to the DOJ investigation, ChemMed has been in the stock market news because of a challenge from some stock holders to elect new members to the Chemed board of directors. This motion has arisen because of a hedgefund feels splitting the hospice operations from Roto-Rooter would 'unlock value' for each.

Gentiva also was in the stock market news because it was recently de-listed from the NASDAQ stock exchange for not having the proper board structure. It looks like they will be able to rectify this and be re-listed, so this is not a big deal, but interesting that it came right around the time of the DOJ announcement.

We'll see how these issues play out over the next few years since I doubt review of records going back to 2003 is going to happen very quickly. Here's hoping for a quiet peaceful resolution.
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by Christian Sinclair ·

Friday, May 15, 2009

New Blogger: Pediatricians' Perceptions of Palliative Care

(Editor's Note: This is the first post from Pallimed's newest contributor, Dr. Lyle Fettig. Lyle is a palliative care physician at the Indiana University in Indianapolis. We invited Lyle to join the blog because of his well-written, erudite, and wise comments over the years, and ongoing committment to the use of new media and social networking to disseminate and discuss palliative care research, news, and policy. In addition, Christian was feeling a little lonely being the only Pallimed (mainpage) contributor with a full head of hair, so Lyle now tips the balance to 2-2. We are delighted to have Lyle join us. For those of you who think that we already post too much (I know you are out there), don't worry: we are planning on keeping our current volume of content steady (usually 2, and at most 3, rounds of posts a week). Please welcome Lyle to the blog, and comment away. --Drew.)

As a longtime reader and an occasional commenter, I’m honored and excited to join the crew here at Pallimed and I thank Drew, Christian, and Tom for the opportunity. I hope to contribute to the volume of posts while maintaining the quality that is well established. I’ll dive right in.

Pediatrics has a survey that assesses pediatricians’ perceptions of palliative care and their preferences regarding timing of palliative care consults. The study assesses how pediatricians define palliative care (and their view of the relationship of palliative care to hospice), what the pediatricians’ personal experience is with palliative care, and whether pediatricians agree with the Institute of Medicine’s recommendation to refer pediatric patients “before the end-of-life.” Pediatricians from Florida and California were surveyed. These states avail Medicaid waivers for pediatric palliative care services to eligible children. Of the 303 respondents, 76% were in private practice and the remainder practiced in an academic setting. Both generalists and subspecialists were included in the survey and there was an equal distribution of time in practice (with a third practicing less than ten years, a third between 11 and 20, and a third more than 20).

Of respondents, 41.9 % defined palliative care to be the same as hospice, 31.9% defined them differently, and the rest weren’t sure. Pediatricians at academic medical centers were twice as likely to define palliative care as different from hospice. About half of respondents had made a referral to a palliative care service previously, a percentage which wouldn’t have seemed high to me if they had surveyed pediatricians exclusively in academic settings, where I suspect most non-traumatic pediatric deaths occur. Since a significant minority equated palliative care with hospice (I'll call them "conflators"), I suspect that many of these referrals were to a hospice, not a palliative care program per se. Of those that had made referrals, the vast majority (83.7%) had referred two or fewer patients.

Participants were asked to indicate their preference for timing of palliative care involvement for patients in the course of 13 different diseases. For each of the diseases, they were asked to indicate whether a referral was indicated “early” in the disease course, in the “middle” stage, or at the “end-of-life.” It’s unclear how “early” and “middle” were defined. Although it wasn’t explicitly stated, it’s implied that the “end-of-life” was defined as when “curative therapy is no longer the goal.”

Depending on the disease, 44 to 59 percent of respondents indicated that a referral was appropriate at an “early” or “middle” time during the course of the disease. Patients with diseases for which fewer disease modifying therapies are available or which are more commonly associated with death before adulthood (such as metabolic diseases, muscular dystrophy, and severe cerebral palsy) were thought to be better candidates for early referral than patients with other diseases such as sickle cell disease or a seizure disorder.

Although it’s not clear what time frame respondents had in mind when thinking of an early or middle course referral, I’m pleasant surprised that so many would consider ANY referral before the end-of-life. I would have guessed that the 41% that were conflators might have been more likely to make late referrals, but the multivariate analysis suggested that conflators were no more likely to make a late referral than non-conflators. Equally fascinating (or baffling?) was the finding that almost a third of respondents thought that home hospice care was “always or often needed” early in an illness but then only 75% thought it was needed at the end-of-life.There were certain other broad elements of care (which are likely focuses of a palliative care service) that pediatricians generally thought were always or often needed, including: support counseling (93% of respondents), pain management (74%), and other symptom management (87%).

In the discussion, the authors reference the importance of language as well as clearly defining what services are provided by whom and when they are provided:

Although the IOM stated that the end of life is too late for referral, physician responses showed that deciding to refer patients earlier, especially immediately after diagnosis, can be problematic and may be difficult to implement. Although approximately one half of respondents would refer patients before the end of life, few reported referring patients at diagnosis. In practice, early referrals may be even less common. The findings suggest that early timely referrals for children with diverse diseases may remain inequitable without a shift in the working definition of needed services or an agreement on terminology.

The National Consensus Project for Quality Palliative Care provides guidance for the uniform development and maintenance of palliative care programs, and I presume that the guidance applies to pediatric palliative care. There are several mentions of pediatrics in the NCP’s guidelines. It might be helpful to survey pediatricians about their perceptions of each of the NCP domains of care (which are more specific than the elements referenced in this study), how well they perceive themselves as managing those domains of care, and what role palliative care might have in each domain.

One advantage that adult palliative care programs may have over pediatric palliative care program is that prognostication is often times easier in adult populations (especially in advanced cancer). Thus, non-PC adult healthcare providers may conflate PC and hospice, but the impact to the adult PC service may be more on timing of referrals rather than on volume of referrals. The struggle upstream may be even more important for peds palliative care programs. The question, “would you be surprised if this patient died in the next year?” may not be as relevant in pediatric palliative care. Non-prognostication related criteria may be more relevant. For instance, the majority of pediatricians in this survey might be surprised that some have suggested incorporating palliative care into the treatment of sickle cell disease from the time of early childhood.

The language in the very first paragraph of the article may unfortunately be an example of how inappropriate use of terms can confuse providers (and subtly reaffirms the views of those providers who believe hospice and palliative care are one in the same):
The Institute of Medicine (IOM) emphasized a need for enhanced pediatric palliative care services in When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families; however, palliative care programs for children often mirror adult models, providing services only during the last 6 months of life, when reimbursement is available.
Of course, while almost all hospice programs adhere to the less than 6 month prognosis limit as mandated by Medicare, I'm not aware of an adult (or pediatric) palliative care program that deliberately restricts referrals as such.

I’d be interested in comments from pediatricians out there and also wish to know more about the Medicaid Waiver programs in these states.

Friday, May 15, 2009 by Lyle Fettig, MD ·

AAHPMLead

Quick & shameless announcement:

AAHPM has announced that applications are being accepted for its AAHPMLead program:

AAHPM LEAD is an innovative 3-year leadership development program designed to promote collaboration among hospice and palliative medicine junior faculty as they prepare to assume leadership positions at academic institutions.

The program is designed to teach key leadership and organizational management skills helpful to navigating the complex world of academic institutions. The program will focus on issues such as promoting organizational change, conflict negotiation, strategic planning, mentoring and networking, leadership and personality styles, directing effective teams, and setting professional or personal goals. Professional development and leadership skills will be fostered through longitudinal-exposure networking with other junior faculty, exposure to and mentoring from senior faculty, interactive learning, and structured educational sessions.

Participants will interact closely with both junior faculty colleagues and 6 to 10 senior faculty leaders each year during biannual retreats. The first retreat will take place October 6–9, 2009. Over the next 2 years there will be a 1-day retreat each spring in conjunction with the Annual Assembly of the AAHPM and HPNA and a 3-day retreat each fall (total of five retreats over three years).
Context & Disclosure & Why I am Blogging About This: This project grew out of a relatively informal Junior Faculty Leadership Forum that met in 2008 that led, with a lot of support from some 'senior' faculty and AAHPM, to the creation of this program. I have played a minor role in organizing this, and will be participating in it. That said, I am really excited about AAHPMLead, and think it will be a great opportunity for those of us who are stumbling into leadership positions, looking around, and saying to ourselves Now what?

So apply, or let your colleagues know who might be eligible/interested. It should be fun and I look forward to meeting some of you in October.

by Drew Rosielle MD ·

Monday, May 11, 2009

Physician-patient agreement about treatment goals


JCO has a fascinating and frustrating study about physician-patient agreement about treatment goals predicting having a discussion about limiting life-prolonging treatments.

The study was a prospective study of ~70 hospitalized patients with cancer (mean age 58 years, the full spectrum of solid and hematologic malignancies was represented, 65% had KPS of 60 or less, and 25% had KPS less than 40) at a single German academic medical center. (They were eligible for enrollment if 'questions about forgoing treatment options were being discussed'; what that actually means, how they actually identified these patients, etc. is not entirely clear - one gets the sense that several research staff actively collaborated with hospital staff to identify them.) Patients were followed while hospitalized until death or discharge. One of the main thing they were looking at was whether patients described having a discussion about 'decisions to limit life-prolonging treatment' (DLT) with their physicians.

Most of the DLT that were discussed were about code status and not transferring to ICUs, with a smattering of others (e.g. stopping antibiotics). The persistent, yet always shocking, disconnect between what I'll generously describe as 'what we physicians think we are talking with our patients' about and what they actually perceive, recall, and identify what we are talking about is demonstrated by this paragraph:

Physicians informed the vast majority of patients about their diagnosis (99%), treatment plan (98%), and course of disease (93%), but only 38 (55%) about life-prolonging treatment [Drew here - they mean here that this is what physicians reported about their conversations with patients]. As measured by patient inquiry, 51% of the patients knew about their diagnosis and treatment plan, 43% about their course of disease, and 33% (23 patients) about life-prolonging treatment.... Of the 47 patients who did not state that they knew about life-prolonging treatment, we were aware of patient wishes for end-of-life care in 28 patients; 15 patients preferred comfort care, and 13 patients wished to prolong their lifetime.
(They are vague about what exactly they mean by 'about life-prolonging treatment.' One assumes, as this is the only thing that makes sense in the overall context of the paper, is that they mean talking about LPT as LPT, framed that way, perhaps [but again not clear] as something that is 'optional'. Strictly speaking one could interpret this as a any conversation about antibiotics as being about LPT and I don't think that's what they mean.....)

They then looked at the 51 patients who clearly articulated treatment preferences as they die (about 2/3 saying they'd want no life-prolonging treatments). Those who expressed more life-prolonging goals were more likely to diverge from their physicians' opinions about what the treatment goals should be (90% of physicians supported treatment limitations in the 'comfort care' group whereas only about 50% of physicians supported life-prolonging goals in those patients who endorsed those goals). Patients who wanted life-prolonging treatments were also less likely to be involved in a discussion about DLT (38% vs 75% for those with 'palliative' goals). Age, performance status, and duration of disease did not impact whether someone had had a discussion about DLT.

The authors express some surprise (if I'm reading them right) about the divergence of opinion, suggesting they thought they'd find doctors more commonly wanting life-prolonging treatments for their dying patients than they actually found. What I'll say to that is that it looks like in those circumstances the physicians were actually talking with patients about things, and perhaps were more likely to be accepting of their treatment goals. That said, there are enough vagaries about how the data were presented here that I'm not really sure overall what it is they were actually describing.

When I read this paper's abstract the first thing that went through my mind was relating this to the Coping with Cancer Study, and my musing a while back (we've written enough about the CWCS that I can't easily find that post) about what was going on with those patients who reported not having an EOL discussion with their physician (and who were more likely to spend time in an ICU prior to death, etc.): did the 'not having a discussion' lead to 'more aggressive' care as they died, or did the whole phenomenon point to something else (e.g. one scenario being patients who were more likely to want 'aggressive' care as they died being more reluctant to discuss death, the docs somehow read that, and therefore are less likely to discuss that with their patients in the first place)? With this paper, I was wondering if it would lead some credence to that speculation, and while it doesn't undermine that theory, I can't say that it provides sufficient info to support it either.

What remains clear, however, is that we (clinicians) remain frequently on 'different pages' than our patients, and do not do a good job of ensuring that they even understand what we're talking about....
ResearchBlogging.orgWinkler, E., Reiter-Theil, S., Lange-Riess, D., Schmahl-Menges, N., & Hiddemann, W. (2009). Patient Involvement in Decisions to Limit Treatment: The Crucial Role of Agreement Between Physician and Patient Journal of Clinical Oncology, 27 (13), 2225-2230 DOI: 10.1200/JCO.2008.17.9515

Monday, May 11, 2009 by Drew Rosielle MD ·

Pall-Pourri: TAL & a couple on prognosis

1)
This American Life (a public radio show) last week included a moving monologue by Dan Savage about his mother's death (you can stream or podcast TAL for free). We previously mentioned Dan Savage's column about his mother's death last year shortly after she first died. This piece expands some of the thoughts from that column and focuses on how her death effected his relationship with his former faith (he was raised Catholic, and his mother died devoutly Catholic), and is also just a deeply moving account of her death, his love for her, and his ongoing grappling with his loss. For those of you who don't know, Dan Savage is a sex-advice columnist, and basically nothing he writes could be considered 'Safe For Work' (even this - I think - I heard the unexpurgated version that was broadcast live to movie theaters last month and they may have edited it a bit for the radio broadcast) so don't go blasting this from your computer in insecure locations.

2)
Mayo Clinic Proceedings has a case-control study looking at the prognostic importance of acute kidney injury in non-(yet)-critically ill hospitalized patients. ('AKI' is a more general, and less threatening, term for what used to frequently be called 'acute renal failure' or 'azotemia' and is defined as a rise of .3mg/dl in serum creatinine within 48 hours.) This study takes a bunch of patients from one hospital who had AKI, matches them with age-matched controls, and compares outcomes. The study generates some good data, but is probably mostly only of interest for prognosis-wonks.

Basically: yes AKI is a profoundly important prognostic indicator for in-hospital mortality (those with AKI do much worse than those without); however taken alone it is probably not anything one can bring to the bedside. AKI was actually the most powerful prognostic indicator in the study - beat out age and number of comorbidities, for instance. Relative risk of in-hospital death was 10 for those with AKI (meaning those with AKI has 10x the risk of death than those without; again these were only age matched controls not co-morbidity matched); in a multivariate model those with AKI had an odds ratio of 8 for death compared to those without along with much longer hospital lengths of stay and transfer to ICUs. Overall hospital mortality was ~15% in those with AKI compared to 1.5% in those without; over 40% of survivors were discharged to other care facilities (not home) compared to 20% of those without AKI. So, bad, yes, but sort of in the category of hypoalbuminemia, hyponatremia, elevated uric acid, etc.: we know that those who have those findings do worse as a group than those who don't in multiple disease states, but doesn't help us much more, as individual findings, than adding to a gestalt impression....

3)

American Journal of Medicine
has a paper about mid-long term prognostication in patients with non-cardiac vascular disease. It's a multicenter Dutch study which looks at ~700 patients undergoing vascular surgery (e.g. endovascular grafting, arterial stenting, carotid endarterectomies, etc.), all of whom underwent preoperative cardiac evaluation and were risk stratified by the Lee Risk Index. The LRI stratifies patients' operative cardiac risk based on the presence of: high-risk surgery, ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, insulin therapy for diabetes mellitus, and renal insufficiency.
This study follows these patients out for 3 years and looks at whether the LRI predicted survival over that time-frame.

Those with 3 or more risk factors on the LRI had a substantially worse survival at 3 years (hazard ratio 3.3; 3-year mortality of ~40%; most of those who died did so within a year of the index surgery). This is compared to a ~10% mortality at 3 years for those with no risk factors.

While this does not give us helpful short-term prognostic data, this is on par with the sort of data we get from the BODE index for COPD, so I thought I'd mention it. I'm curious as to whether palliative clinicians are seeing PVD/vascular surgery patients in their practice outside of those who are imminently dying: pain consults, goals/care planning, etc.? I see a few from time to time; it's a patient population which by all rights is 'perfect' for palliative care: severe PVD is a chronic, debilitating, highly morbid/symptomatic life-limiting illness.

by Drew Rosielle MD ·

Thursday, May 7, 2009

Losing the Ability to Smell and Taste
Didn't Miss You, Til Ya Left Me

The Journal of Supportive Oncology (my favorite free journal with excellent practical palliative care articles) published a fantastic review of taste and odor dysfunction in cancer patients. If you read this article you could become a local expert because so few clinicians appreciate the implications or understand the treatment options for these significant quality of life markers. Obviously with this kind of endorsement it qualifies as a teaching file article.

Some of you will remember when I claimed xerostomia as my 'favorite symptom.' Well taste alteration is probably in my top 5 favorite symptoms. (If you must know the others, they would be opioid neurotoxicity, delirium, and intractable vomiting. In no particular order. And yes, pain is not on there, but I know my stuff. OK back to the article, thanks for tagging along on my sidebar.) There are small things you can do to make a difference including: avoiding metal in silverware, serving cool foods, and my number one recommendation adding a sialogogue and/or saliva substitute.

I do not know why nurses and doctors can do so many other 'gross' things in medicine, but there is a severe and general aversion to writing for or administering saliva substitutes. It is more than just lack of knowledge, because even when informed, I have had nurses basically say, "I'm not giving that to them, That's disgusting!" Yet when I go in the room and have the patient try it, the patient exclaims (with a smile and a much louder voice) "My mouth feels alive again. Thank you so much."

Those mouth care kits that have the swabs and moisturizer really need to have the saliva substitutes in them as well. There is no reason artificial saliva needs to be a physician's order. And yes I know some patients really do not care for it, but try the different forms: spray vs. gel, or maybe add sugar-free gum (which contains some of the same ingredients as artificial saliva.)

Anyway, if I have not given you enough reasons to read this article, you should at least read it so you can say the following fun medical words: Ageusia, dysgeusia, hypogeusia, phantogeusia, agnosia, hyposmia, electrogustometer, umami, xerostomia, sialogogue, circumvallate papillae. But it really is not that dense of an article. It is very accessible lest these words scare you away.

And quick shout out to my oncology attending from residency at Wake Forest, Glenn Lesser with the senior author credit.
ResearchBlogging.orgJH Hong, P Omur-Ozbek, BT Stanek, AM Dietrich, SE Duncan, YW Lee, & G Lesser (2009). Taste and Odor Abnormalities in Cancer Patients Journal of Supportive Oncology, 7, 58-65

Thursday, May 7, 2009 by Christian Sinclair ·

Oncology Fellow on Palliative Care: "It's a Refuge (for me)"

HemOnc Today has a personal essay from Dr. William Wood, an oncology fellow at UNC, about why he likes palliative care. He is in a cohort of medical learners with an increasing exposure to palliative care from medical school to fellowship. The historical perspective on the slow culture change in medicine to accept palliative care demonstrates an increasing acceptance with earlier and consistent access to palliative care teams. Here he describes working with the pallaitive care team during his residency:

"I was lucky to be in a program where my senior residents and attendings were heroes. Their thoroughness, competence and compassion were widely emulated by interns, who tried hard to live up to their examples."
Later in the essay, he makes an impressive statement referenced in the title of this post:
"As an oncology fellow, palliative care is everything it was before, but it has taken on a new dimension for me now — it is a refuge.

Paradoxically, though the goal is no longer cure or prolongation of life, providing this kind of care can feel extremely satisfying."
It is these satisfying interactions between professional and patient which inspire so many clinicians to pursue a career in palliative medicine or at least embrace palliative care from within their specialty. I am glad to see so many medical learners with the opportunity to have these personally rewarding opportunities to 'comfort always.'

He ends with a few probing questions about health care policy and the structure of oncology as a business:
"Yet, I am still troubled. Why does providing good palliative care feel like a refuge to me now in ways that it didn’t before? And why are there so many palliative care physicians who no longer primarily treat cancer? Could the structural and institutional organization of our cancer care delivery system, and the incentives therein, present subtle barriers to the ability of good oncologists to deliver good palliative care throughout the disease continuum?"
These organizational challenges to ethics may start to emerge in many specialties as we have more doctors like William Wood who promote palliative care within their specialties. When a critical mass of gastroenterologists start challenging automatic PEG placement without a exploration of the appropriateness and efficacy they may change policy or even reimbursement mechanisms. Same issue for oncologists and chemo, radiation oncologists and prolonged fractions when a few may do, or nephrologists and offering dialysis to patients they feel will not survive regardless of dialysis. We may be on the cusp of small internal revolutions in other specialties as palliative care education becomes the norm. What do you see at your institutions?

by Christian Sinclair ·

Palliative Care Grand Rounds 1.4 Out Now!

Palliative Care Grand Rounds v1.4, the monthly blog carnival reviewing the best posts with palliative care themes is up at the blog, Medical Futility. Thaddeus Pope, my favorite law professor (and the only one I know) runs a great blog always coming up with tough cases regarding conflicts of goals of care, commonly around (obviously) futility decisions. He has nicely arranged the couple score of links so you can really narrow down to the areas you find most interesting.

Healthcare Provider Experiences
Family Experiences
Hospice
Communication
Policy
Arts
On The Lighter Side

There are a lot of blogs hitting on issues relevant to our field so check out the links and don't forget to leave a comment for Thaddeus for his efforts.

by Christian Sinclair ·

Monday, May 4, 2009

Top Posts and Most Commented for April 2009

From looking at the most commented and most viewed posts you can tell what was on the mind of palliative care clinicians this past month. In an upcoming post, I will highlight some of the best comments in April.

Top 5 Pallimed Posts for April 2009 (in case you missed them the first time):

FDA Shocks Hospice World: No More Roxanol

The Role of Social Networks in FDA Morphine Recall

FDA: Opioids need Risk Evaluation and Mitigation Strategy (REMS)

Lessons Learned Using Twitter at a Medical Conference

?FDA to rescind recall of 20mg/ml morphine solution
Most Commented on Posts for April 2009 (in case you don't read the comments):
FDA Shocks Hospice World: No More Roxanol - 20 comments

The Role of Social Networks in FDA Morphine Recall - 7 comments

A Painful Pall-Pourri; N/V, Industry; Pain Research Ramblings - 7 comments

?FDA to rescind recall of 20mg/ml morphine solution - 6 comments

Series of Articles on Grieving in Slate
- 4 comments
And don't forget about the Arts & Humanities and Cases blogs. You can access them via subscription (RSS or Email) or clicking on the 'Arts' or 'Cases' images at the top of the blog or your Pallimed newsletter emails. The Arts blog writers have contributed some outstanding and provocative posts recently.

Monday, May 4, 2009 by Christian Sinclair ·

Call for AAHPM Annual Assembly Closes May 5th

Cancel your Cinco de Mayo plans if you have not been on your game and forgot the first call closes for workshops and concurrent sessions for the 2010 AAHPM Annual Assembly Tuesday May 5th.

That came really fast this year. If you are still looking to polish your submission, you may want to look at this post from last year about "How to Submit a Presentation for a Medical Conference."

by Christian Sinclair ·

May 2009 Open Thread

We are going to reinstitute the monthly open thread post for you to comment on any topics you would like to see covered here at Pallimed.

Feel free to comment on this post and we will take the topics under suggestion. Sometimes as we search through tables of contents, RSS feeds, emails and blogs, we may come across something on the verge of becoming a post, but for whatever reason it fails to get to the write-up and publish stage. But if we know you care about a particular topic, we may be able to incorporate it into a later post. And at the least we may just foward you some interesting links or articles.

by Christian Sinclair ·