Monday, August 31, 2009

Haven Hospice Gets Medicare to Return Money from Cap Payment

Logo of the United States Department of Health...Image via Wikipedia

The National Alliance for Hospice Access has issued a press release stating the Department of Health and Human Services/ Center for Medicare Services has been ordered by a California Judge to repay with interest the Hospice Cap Overpayment to the Los Angeles area Haven Hospice.

You can read the Judge's summary order here and the NAHA press release here. The NAHA notes the California judge has also barred HHS from using the current cap calculation to reclaim overpayment to hospices. It is not mentioned in the judge's summary order (or I can't read legal-ese) but this is likely to be either just in California or challenged at a federal level I would think. I imagine the NAHA and any member hospices who have had to pay Hospice Cap overpayments will bring this argument to other states.

The NHPCO has made no formal statements on the recent Haven Hospice ruling nor does any of the NHPCO's current legislation reform effort include the NAHA supported legislation recently introduced to re-tool the Medicare Hospice Cap. There is also no mention of the actual monetary amount to be repaid, but from some numbers hospice cap overpayments average $1milllion.
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Monday, August 31, 2009 by Christian Sinclair ·

Top Comments & Posts for August 2009

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

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

Featured Commentary from Pallimed Readers:

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

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

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

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

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

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

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

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

Thanks for all the comments and keep them coming!

by Christian Sinclair ·

Why You Should Comment on Blogs and How to Comment

For the many readers of Pallimed who have not commented on the any of the blogs (Main, Arts, or Cases) I would really encourage you to break your silence and be proud to say 'long time listener, first time commenter.' Here are some of the reasons why you should comment on blog posts:
1. Comments Are Peer-Review: Discussing a counter-argument to the original post helps balance the viewpoint and encourages the writer and other comments to better define the original point.
2. Comments Make a Community: By contributing you now are part of a small network of Pallimed commenters which provides a foundation for a growing community. Often times the commenters answer each other's questions before any Pallimed writer gets a chance to reply.
3. Comments Guide the Content: Sure blog topics are what we decide to write on, but how we decide to write on is influenced by great comments which open up new areas of interest.
4. Comments Are Currency: Comments help any blog writer realize they are not talking into thin air, which is what it feels like when you first press 'publish post.' And that currency can be cashed in as goodwill from any of the blog writers. If we get a request for more info or a favor from someone who comments often, we will be much more likely to reciprocate.
5. Comments Make a Better, Smarter Blog: Comments often lead to new resources, new links and new insights making the blog a better resource for everyone. Also like a huge crowd sourced editors desk, if you find a broken link, a misspelling, poor grammar, tell us. We'll fix it, then thank you for helping all future readers.(Edit 9/8/10: Found two errors, but no one told me. *Sniff*)
6. Comments Make you a Pallimed Author: Drew started this whole thing, but Thomas Quinn, Lyle Fettig and Christian Sinclair (me) all started out as commenters before becoming formal contributors.
Barriers to Commenting:


"I didn't know I could make a comment"
-Well now you know. And knowing is half the battle.
"I don't know how to comment"
-See below.
"I don't have anything important to say."
-A comment doesn't have to be a long counter-point, it can express general agreement, a variation on a theme, a new question, a request for blogging on something different, etc.
"I am concerned about putting my real name online"
-Comment anonymously. Don't say anything inflammatory. Say anything you would be willing to defend on the radio or in court. Talk about things more generally. But using your own name may actually establish you as a thought-leader and for continuity purposes lets us know who is doing the talking. Is anonymous one person or 45 people?
How to Comment on a Blog Post:
Pallimed has a comment function (at the bottom of each post) that allows you to give us feedback on each post. Just click on the "comments" link at the end of each post (the link usually tells you how many comments have been left so it says, e.g., "0 Comments" or "1 Comment").  If you usually see the posts via email or RSS subscription there is now a link added to 'Post a Comment.'
You do NOT need a Gmail account to post a comment it is just one of the options in addition to OpenID and anonymous.  The wiggly word check is to help reduce spam commenters which should be a minor hurdle for a great relief.
Comments Policy: The editors of Pallimed reserve the right to remove any comments we deem offensive/hateful, mean-spirited, commercial, or in any other way inappropriate. This blog is intended to foster collegial, well-informed discussions about research and news relevant to clinicians working with patients facing severe/life-limiting diseases: it is not a forum for discussing individual cases or airing complaints or concerns about specific cases (whether from the clinician, patient, or family perspective). Such comments will be removed at the discretion of the Pallimed editors. Any posts older than 14 days are moderated to reduce spam.
We ask that you refrain from providing specific details about cases because of HIPAA restrictions. But if you want to discuss a case more broadly, that would be more appropriate.
Our full comments policy is here.

by Christian Sinclair ·

Thursday, August 27, 2009

A Detailed Look at Euthanasia Accusations During Hurricane Katrina

“Katrina is comparable in intensity to Hurrica...Image via Wikipedia

ProPublica (in conjunction with the New York Times Magazine) has published an excellent analysis of the conditions in Memorial Medical Hospital in the Hurricane Katrina aftermath and flooding. Dr. Sherri Fink reviews the system issues as well as the human factors in an in-depth analysis. It is gripping reading which makes you feel as if you were in the same horrible conditions Dr. Anna Pou and the rest of the care team faced. It was clearly a tragic situation where 45 people died in awful conditions, the least we could do is learn from this awful story. Interestingly there was a physician named John Thiele who is a pulmonoligist but apparently trained in palliative care as indicated by this passage:
"Thiele practiced palliative-care medicine and was certified to teach it. He told me that he knew that what they were about to do, though it seemed right to him, was technically ‘‘a crime.’’ He said that ‘‘the goal was death; our goal was to let these people die.’’"
Topics covered in the article particularly relevant to palliative care include:
  • the role and varied meaning of DNR orders
  • the administration of morphine and/or versed as a potential cause of death
  • the role of medical professionals in civil emergency and potential liability
  • patient centered care and the difficulty of informed consent in emergencies
  • the ethics of rationing medical resources (medicines, personnel, technology) in emergency
  • the role of the chaplain and others for staff support
  • the meaning of dying with measurable opioids in your blood
  • the selection of a triage protocol when mortality risk is high
  • the difficulty of prognostication and it's role in every medical decision
  • the role of double effect
Here is an excerpt that will probably make any palliative care clinician cringe:
"Doctors, nurses and clinical researchers who specialize in treating patients near the ends of their lives say that this ‘‘double effect’’ poses little danger when drugs are administered properly. Cook says it’s not so simple. ‘‘If you don’t think that by giving a person a lot of morphine you’re not prematurely sending them to their grave, then you’re a very na├»ve doctor,’’ Cook told me when we spoke for the first time, in December 2007. ‘‘We kill ’em.’’"

See I told you that you should read it. Read the whole article before casting any judgments on the above quotes please.

We have covered the case of Dr. Anna Pou at Pallimed in the past here and here.


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Thursday, August 27, 2009 by Christian Sinclair ·

Pal-Pourri

A few things featuring palliative care themes this week:

1) American Public Media's Marketplace radio program broadcast a brief article Thursday on 15 Chicagoland Jewell-Osco pharmacies pilot program to make hospice-friendly medications available. The article does not have a lot of detail but it lead me to find out more about the program. The connections of how the program came to be is interesting as covered in this article from DrugTopics.

I too have run into the challenge of finding common hospice medications from local pharmacies, especially liquid formulations and methadone. While I am very lucky to work for a hospice with a local hospice specialty pharmacy, not all insurance companies cover their services. The article interestingly describes hospice patients as high maintenance and therefore not something chain pharmacies want to get involved with. Also mentioned is that this is a specific partnership with Passages Hospice in Chicago and not necessarily available to other hospice agencies.

2) For those who cannot get enough of the 'death panel' meme, I came across a very interesting slideshow of how it has evolved over the past few weeks at Talking Points Memo, a liberal blog.

3) Patrice Villars at Geripal discusses the cliches used when discussing the death of people with cancer. He uses the recent death of Sen. Ted Kennedy as the background on which to pick apart the hidden meaning in such words. Go leave your least favorite phrases in medical/palliative care at Geripal.

by Christian Sinclair ·

Sunday, August 23, 2009

Krauthammer on "The Truth About Death Counseling"

May_30_Health_Care_Rally_NP (453)Image by seiuhealthcare775nw via Flickr

The Pulitzer prize winning columnist Charles Krauthammer (MD*) wrote an intriguing op-ed the day after the NY Times piece on palliative care and breaking bad news we discussed last week. The article is behind a sign up free wall although you can also connect with your Facebook account.

The column starts by a request for civility. No death panel talk here. But also don't claim that HR3200 is benign since:
'government reimbursement to any doctor who gives end-of-life counseling -- whether or not the patient asked for it -- is to create an incentive for such a chat.'
First to correct this statement, doctors are already paid to discuss goals of care with patients. The payment structure utilizes time-based visits where 'greater than 50% of the time was spent face to face (or floor time)** with patient and family in education and counseling.' But the reimbursement for time based billing is minimal compared to regular visits and time-based billing has been reported to be more likely to be denied or coded wrong and there for not be paid. If I could see 4 inpatients in one hour and make lots of complex changes and bill at the highest code 233 for each (x4), the reimbursement would be less*** more than two 30 minute family meetings which would each get a 232. So the system already incentives heavily towards testing, adding medications and procedures versus cognitive/communication activities.

But the point he does indirectly raise is what would this 'new' reimbursement look like? Does anyone know? I am guessing if it is being considered to be part of Pay 4 Performance it is likely to be minimal and many physicians may not even think it is worth it to learn a new billing code (which would likely be required) which they would use infrequently.
"Do you think the doctor will go on and on about the fantastic new million-dollar high-tech gizmo that can prolong the patient's otherwise hopeless condition for another six months?"
The language in the bill does not determine the outcome of

Dr NickImage via Wikipedia

the conversation. If this is the argument, the assumption is you are working with Dr. Julius Hibbert or Dr. Nick Riviera who are in it for the money, then why wouldn't the greedy doctor offer the advance care planning counseling (get paid for it) and encourage/nudge the patient towards the hope giving procedure/surgery/medication (and get paid for that too?) So basically this logic falls flat with a better understanding of the whole system.
"Then consider the actual efficacy of a living will. When you are old, infirm and lying in the ICU...the doctor will ask you at that time what you want for yourself -- no matter what piece of paper you signed five years earlier."
I am glad to see someone bringing up the efficacy of living wills as I have seen a trend in the palliative care community to start shying away from the actual living will but rather focus on the conversations. I think this is a fair point but to pretend a patient will always be able to make a decision when doctors start thinking mortality risk is rising and goals need to be clarified is a little optimistic. Often times it is not until a patient is unconscious or delirious that everyone (family and medical staff) start wondering if things are heading in the right direction. Pallimed has covered advance care planning impotency here, here, here, here, here and here for starters.

"Well, as pain and diminishment (sic?) enter your life as you age, your calculations change and your tolerance for suffering increases. In the ICU, you might have a new way of looking at things."

Excellent point about the dynamic nature of goals when related to one's health and symptom burden. I bring this point up often when teaching residents and fellows as well as discussing goals with other medical staff, families and patients. This doesn't make the living will or the advance care planning process inadequate, just imperfect and why these documents should reviewed upon every hospitalization or major health change to make sure they reflect the values and goals of the most current 'you.'
"And if I'm totally out of it, my family will decide, with little or no reference to my living will. Why? I'll give you an example. When my father was dying, my mother and brother and I had to decide how much treatment to pursue. What was a better way to ascertain my father's wishes: What he checked off on a form one fine summer's day years before being stricken; or what we, who had known him intimately for decades, thought he would want? The answer is obvious."
But without a 'living will' or at least a conversation about your wishes and values these decisions are some of the most difficult things to do for families. Imagine trying to buy someone a birthday present without having any clue what their hobbies or interests are? You might buy them something you like or something generic, giving you have a much higher risk of an unappreciated 'gift.' Now multiply the birthday gift decision x infinity minus one and you get an idea of the difficulty of these decisions.
"The one time (a living will) really is essential is if you think your fractious family will be only too happy to hasten your demise to get your money."
If only life were a soap opera since money is rarely the basis of any of these decisions. After several hundred (more?) family meetings I have rarely seen this be an issue. Maybe a handful of times. Families get fractured over many many more things than money. Emotions, relationships, jealousy, mis-communication, distance, willingness to assist in care, religion, politics, you name it and I have seen it at least 50x more often than money being the cause of family tension in critical illness.
"But it is subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it's intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release. "
The hyperbolic and unnecessary accusation of care at the end of life being about pushing someone into a corner where it is implied they will be neglected, forgotten, dirty, and be left without dignity is an affront to hospice and palliative care. And again the idea that end of life care is always cheap is going to really surprise people when they realize there will probably not be a huge cost savings from more people choosing hospice earlier. The high quality care given by hospices and palliative care teams has a lot more to do with increased human capital and not as much technology.

* Yes Charles Krauthammer is an MD, although he doesn't flaunt it or reference as far as I can see. Thanks Wikipedia for the first source which I backed up with a quick PubMed search to find his Archives of General Psychiatry article.
**See this CAPC forum for more discussion of the particulars
*** Late night writing and editing fixed after pointed out by a studious reader. 8/24
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Sunday, August 23, 2009 by Christian Sinclair ·

Public Debate Over Reform Spilling into Family Meetings?

But I'm Still Just a BillImage by cafourek via Flickr

Can you tell I missed not having a soap box to talk about the (mis)representation of advance care planning in the House of Representative Health Care Reform Bill? Regardless of your politics on the whole reform matter, if you are an advocate for good palliative care you have to be aware of the public discussion getting out of hand, because if 'palliative care', 'hospice', 'advance care planning', 'living wills' get tied as buzz words to 'rationing' or 'Obamacare' our field will have to fight even more stigma to even have the ability to care for patients.

Have any of you had the discussions with patients or families that referenced/connected your work to 'death panels' or other 'government intrusion' type comments? If so please leave them in the comments.

I have had not heard many, but the one I recall was an out-of town relative who was having trouble accepting the patient's progressive illness in general who asked if the palliative care team was part of 'big brother watching' because 'it is all about money.' The other family members were able to redirect and make a cogent argument about quality not necessarily equaling money spent if the goals were not right.

Some physician peers have commented they hope we (palliative care and hospice) don't get too beat up over this. But I have not had any other staff

What have you heard? Or not heard? Form patients, families, other medical staff?

Do you feel the AAHPM, NHPCO, and other organizations are doing the right things with this recent controversy? What else should we do as a community?
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by Christian Sinclair ·

New Palliative Care Blog: GeriPal

Two physicians from UCSF (Eric Widera and Alex Smith) have started a blog covering the intersection between palliative care and geriatrics called GeriPal. They have been off to a great start with frequent content and insightful analysis. The format is a team blog with open contributions if you are interested.

So far the team consists of : Lynn O'Neill, Bob Arnold (aka rabob), Dan Matlock, Rebecca Sudore, Mike Steinman, R. Sean Morrison, Helen Kao, Cari Levy, Patrice Villars, Bree Johnston, Ken Covinsky and Nate Goldstein.

The writing is smart and approachable. The posts are generating some interesting conversations although for now much of it is from the other bloggers so get over there and add to the discussion. It is great to see more physicians writing openly (as opposed to anonymously) because it is helpful to collaborate and break down any information asymmetry by discussing these things in a public forum.

We look forward to sharing some interesting topics and expect to be linking to some of their coverage more often in the future.

Check them out and other hospice and palliative medicine blogs in the right hand column.

by Christian Sinclair ·

Thursday, August 20, 2009

Palliative Care featured (again) in the New York Times

I recall someone saying that the New York Times has started to produce enough articles on end of life care to become a palliative care textbook. It is wonderful to see such high profile coverage of our field which is generally very complimentary. Just type in Pallimed and "New York Times" into Google and you will get a sense of how many times we have covered at least the big articles here.

Today's feature article (6 web pages as opposed to the usual 2) follows the palliative care team at Montefiore Medical Center and centers around a couple of patient stories. The story, "Breaking Bad News," is part of a year long series called "Months to Live" which seeks to "explore the promises and challenges of extending, or ending, the lives of very ill patients." The articles are on a monthly basis and the two previous stories are "Gently into the Night" and "Quest for a Miracle". (Did I use enough quotation marks? Or did I need more parentheses? Here is a semi-colon; just for kicks)

Obviously having a feature story on talking about end of life care is timely given the heated discussions about HR 3200. But in reading the article there were a few things I found concerning and maybe I am being overly critical. It was just after reading it, I wasn't running around to show the article around as a good representation of palliative medicine work.

So let's start out with the PROS (with a few editorial comments):

"Part psychoanalyst, part detective, Dr. O’Mahony had to listen to the cues and decide what to do next."
Excellent description of the searching and complex conversational skills good palliative care staff have.
"But Dr. O’Mahony does not press hard for a written advance directive,"
Important to recognize that palliative care staff go where the patient is at psychologically, philosophically.
"But before leaving, he made sure that she had a health care proxy — her husband — who would make decisions for her if she became incapacitated. He knew it would be harder to get one later."
While at the same time recognizing important opportunities exist to get crucial questions answered or tasks completed.
"For about an hour, Dr. O’Mahony asked open-ended questions, looking for clues as to how much she knew and how much she wanted to know."
Good palliative care takes time and active listening!
"A student named Paul (most asked to have their last names withheld for fear of harming their careers) told Ms. Telcher that her mammogram had revealed a “finding.”"
Choosing the right words is a skill learned with time, experience, and good mentoring.
"Two doctors on Dr. O’Mahony’s team listened quietly, and she seemed relieved just to be able to talk things through."
Listening is therapeutic. Write it down on your medical plan.
“Many clinicians don’t want to send the message that they’re giving up on their patients,” said Dr. David Goodman, a co-author of the Dartmouth Atlas. “They see palliative care as diminishing hope.”
A statement I can generally agree with BUT in publishing it does it also reinforce the false belief that palliative care is about 'giving up.'
"While there is nothing in the House bill to suggest that such panels would exist, the end-of-life language became so radioactive that several members of the Senate Finance Committee said they would not include it in their version of the bill."
Yes, please correct the misinformation! And realize misleading statements do have consequences.
"But some of these [palliative care cost savings] studies have been conducted by advocates,"
Good to fairly acknowledge a potential bias.
"“It’s just sort of letting them die completely naturally. It’s hard to explain to a lay person, because we know we need food and liquid to live. But we don’t need them to die. We’re just feeding whatever is killing them.”"
I feel sort of mixed about this one. This issue needs wider discussion, but in my experience the difficulty lies not in the explanation but in accepting emotionally what lack of feeding means.
"Asked how she deals with the death of her patients, Dr. Shaiova said, “I play the harmonium.”"
Yay self-care! Needs more press for people in tough occupations.
"She would return from the [radiation] treatments — administered every day for 29 days, her husband said — in a stupor."
I am not sure why radiation treatment side effects always seem to get downplayed, but they do. So it is nice to see some of the total impact addressed including the stamina/cognitive effects of radiation.
"“During these times when her thinking is impaired, you are her voice,” Dr. O’Mahony replied."
I really like this statement. I use variations on the theme many times when helping surrogates figure out how to make tough decisions.
"He had several conversations with her before she died, a luxury that other types of doctors might not have."
This is one thing that makes palliative medicine unique. "Luxury" is a very interesting choice to describe this. Does time=money?
"“Patients sometimes will be very explicit about wanting that information very, very clearly delivered,” he said. “Whereas other people don’t.”"
The simple act of listening to the needs of a patient goes a long way into personalizing treatment.

And here were some of the cons: (Disclaimer: I don't know the docs mentioned in this article and I realize some of their words are taken out of context. This is not a knock on their practice at all but maybe how the reporter portrayed them. I have had words misconstrued in reporting before which I think for our field will continue to be a frequent hazard given the nuances of our conversations.)
"[Palliative care] has also become a focus of attacks on plans to overhaul the nation’s medical system..."
Palliative care is under attack? Well not really. Maybe indirectly, but I have not yet heard hospice or palliative care besmirched. We need to be careful with words like this because this sentence effectively places a target on our field, which I feel has escaped harm thus far.
"They know who is more likely to suffer silently, and when is the best time to suggest a do-not-resuscitate order."
I have trouble with the wording of 'suggesting' a DNR order. I just don't think it fairly reflects how many palliative care teams approach DNRs. I would have preferred 'discuss' since it implies no agenda which reflects patient-centered care.
"A third of Medicare spending goes to patients with chronic illness in their last two years of life; the elderly, who receive much of this care, are a huge political constituency."
Are versions of this statement exhausting you? While a true statement, it starts to become a straw man fallacy regarding cutting costs. Good comfort care is not necessarily cheap and figuring out prospectively when the last two years of life are for chronic illness is extremely difficult given our lack of a Medical Prognostication Manhattan Project.
"Rather, Dr. O’Mahony and his colleagues were more subtle, cunning and caring than their own words sometimes suggested."
Oh please don't call palliative care doctors cunning. Skillful? Sure, sounds good. Wiley and deceptive? I'll pass.
"They are tour guides on the road to death, the equivalent of the ferryman in Greek myth who accompanied people across the river Styx to the underworld."
Ah mixed metaphors. Tour guides on the road to death (i.e before death) is much different than Charon (the name of the ferryman BTW) who guides the already dead. And besides palliative care is more than death & dying so please beware the pigeonhole. (But if you are reading this you probably know that already.)
"Dr. O’Mahony entered the field a decade ago, shaped by an almost messianic movement that began as a rebuke to traditional medicine but has become more and more integrated into routine hospital practice."
Huh? What? Messianic movement? You mean this has something to do with making sure Jesus is recognized as the messiah of Judiasm? Why did this get put into the article? Can someone explain this?
"His coolness is his armor. “I do not feel obligated to be sort of eternally involved with the experience of death,” Dr. O’Mahony said. “It’s not healthy to be there all the time.” But the danger is that “death gets to be banal,” he said. “Do you know that poem by Dylan Thomas?” Dr. O’Mahony asked with a faint smile. “After the first death, there is no other.”"
I have no problems with these statements in fact I agree with them. My problem is the poor follow-up and dropping of the subject of how to deal with high death acuity. Did the reporter have to include 'faint smile?' It leaves a lot open to interpretation which I don't feel is fair to Dr. O'Mahoney.

"But Dr. Nicholas Christakis...has found that doctors are generally bad at making prognoses." --(later in article)--“Doctors are the worst predictors,” she said after the session."
Now I adore Christakis' efforts and work. But this constant harping of poor prognostication by doctors based on anecdotal experience and a few research studies really undermines our field. EVERY medical decision is rooted in prognosis. And if we are so bad at it, why are we not paralyzed by our inadequacy. And if we are so bad where is the Medical Prognostication Manhattan Project.

"The better they know a patient, the worse they are at prognosticating, possibly, Dr. Christakis has theorized, because they view death as a personal failure."
I used to believe this but I think it is the rare doctor who sees death this way. It makes for a nice story but is this really the cause of poor prognostication or is the fact we are working with dynamic complex open systems of biological tissue (aka a human) a much larger part of the degree of difficulty? You can guess my answer.

"The bill would help validate the work of palliative care doctors..."
No! This bill does not validate my work. Not one bit. Feedback from families and patients like those found in the 177+ comments to this article validates my work.

"Palliative care still goes against the core beliefs of many doctors."
Hmmmm...do you like good symptom management? Yes. Is it important for patients to understand and be involved to their best ability in their own care? Yes. I hope these two aspects are core beliefs of every doctor because simply that is what palliative care is.

"The receiving hospital, she believed, was part of the conspiracy of denial, only too happy to get the payment for accepting the patient, who ended up dying before he could be evaluated."
We as a field have to be very careful about statements of the intent of other doctors to make money. I have heard other palliative care and hospice staff make these concerns and have had them myself. But without more proof, this is dynamite. The more likely explanation...tertiary hospitals need to be seen as gracious recipients and so they accept many even if there is not a large difference in care options. If they started saying no to another hospital more often, they might not see any more patients.

""“I can’t give a definite response in terms of the number of days or weeks,”
Dr. O’Mahony said. Mr. Migliore said another doctor at the hospital had estimated four to six months." While the context and supporting statements from Dr. O'Mahoney may have been edited, I think the article shortsights a palliative care teams ability to give some prognostic estimates to help with practical issues surrounding caregiving, family obligations, and time for the patient to plan appropriately. This is one of the things we get commended for the most from families and patients.

"Dr. O’Mahony has not spoken to Mr. Migliore since his wife died, and he does not expect to."
Wit a high number of deaths for hospices and palliative care teams we should not expect to stay in touch with everyone, but the way the reporter worded it makes it sound like abandonment which was likely not the intent of Dr. O'Mahoney to convey. I don't expect this either, but the support for families often continues through grief and bereavement services.

"Once the ferryman has delivered his patients across the river, he rarely looks back."
Oh stop it with the metaphors already. It was bad to begin with.

So was I way off base or did you feel the same way?

Thursday, August 20, 2009 by Christian Sinclair ·

What I Did on my Summer Vacation

Hello Pallimed readers! I am back from my two month sabbatical so you can expect the volume of posting to pick back up. Did I miss anything big in the palliative care/hospice world since I was gone?

I have a lot of material saved up over the past month so I am excited to get back on the bike and start posting. Thanks to Drew and Lyle for posting as much as they did while I was on break. I am expecting to push Drew to take a little break here sometime soon. Help me encourage him will you?

I am planning on getting into the Cases blog again so for those of you have noticed it has been pretty dormant. It will be making a comeback.

Glad to be back and looking forward to some great conversations in the comments.

by Christian Sinclair ·

Tuesday, August 18, 2009

Minimally Disruptive Medicine

A BMJ article describes the concept of "Minimally Disruptive Medicine" which seems akin to the concept of "Slow Medicine" as previously mentioned on this blog. The authors (two from the UK and one from Mayo Clinic in Rochester) state the relatively simple case for the need of such a concept: Physicians expect patients to respond to an individual therapy for a chronic disease as if each patient embodies the "average" patient in the clinical trial on which the therapy is based. However, just as patients often don't offer a textbook presentation of disease, their response to therapies (or lackthereof) will be impacted by many factors that often exclude subjects from those clinical trials. The "burden of healthcare" may result in the best laid plans backfiring. Patients may become unwilling or unable to comply with an overwhelming number of medications or provider visits because of cost, complexity, or just a sense that what the physicians are asking them to do is absurd. And the authors put it well:
The work of being a patient includes much more than drug management and self monitoring. It also includes organising doctors’ visits and laboratory tests. Patients may also need to take on the organisational work of passing basic information about their care between different healthcare providers and professionals. In some countries, they must also take on the contending demands of insurance and welfare agencies. This means that although intensifying treatment often seems the solution to the patient’s problems, it adds to them. Advances in diagnosis and treatment thus have the paradoxical effect of adding incrementally to the work of being sick. Patients who cannot cope eventually experience iatrogenic outcomes and poorer quality of life, just as surely as do those who are affected by medical accidents or errors. Clinicians cannot respond adequately to this problem. They lack the tools to detect patients overwhelmed by the burden of treatment, and they lack strategies to lift these burdens.
The authors propose four principles of minimally disruptive medicine which should guide health services research:
  1. Establishment of tools to identify overburdened patients

  2. Encouragement of coordination in clinical practice

  3. Acknowledgement of comorbidity in clinical evidence

  4. Prioritization from the patient persepective
The overall concept has wide-reaching implications for the practice of medicine, but could these principles be any more aligned with the principles of palliative medicine? And what population might be more ripe for this type of research than a palliative care population? Consider a man who hasn't received much health care over the previous several years who is diagnosed with metastatic adenocarcinoma of the lung. Let's say his performance status remains good and he's expected to live for several months or even a year to two. He's in the hospital, and it's incidentally noted that his blood pressure is persistently mildly elevated as are his accuchecks. All of a sudden, he's not only faced with the prospect of chemotherapy, but he's also thrown onto a couple of meds to ensure tight BP and glycemic control. Of course, he's a little short of breath, and he may have a COPD component, so he's started on bronchodilators which are never stopped even though they may not be beneficial....and on and on. And then there's a palliative care consult to discuss "goals of care." Shouldn't the goals of care discussion include whether preventing stroke/MI or diabetic retinopathy over the next 10-20 years is really a realistic goal or whether this man (who is overwhelmed with a new diagnosis of cancer) and his family will really be capable or willing to take 6 other new pills throughout the day and monitor accuchecks?

This should be a routine but for some reason, I think I blush more easily when recommending that the recently added third antihypertensive be stopped when it's clearly not meeting the patient's goals of care than when I recommend that a patient be extubated because invasive ventilation isn't meeting their goals. Why? I think it gets back to the wishful thinking that clinical trials provide guidance for every clinical scenario. And so this orthodoxy leads to polypharmacy when perhaps the appropriate orthopraxy in this scenario should be minimally disruptive medicine.

Additionally, I can recall at least one time when a resident rotating with our team expressed reluctance about recommending the reduction of antihypertensive and diabetic therapies because the resident thought this was unrelated to the reason why we were consulted. I think we were able to adequately explain why this may be an appropriate PC recommendation, but I may pull this article out if I'm confronted with that scenario in the future.

The palliative care world has already put some thought into this issue, including an article
co-authored by Christian and the aptly titled session at AAHPM 2008 Ending Prevention: When and How to Stop the Statin, Ignore the Blood Pressure, and Give the Patient a Cookie.

See Mayo endocrinologist and article co-author Victor Montori, MD describe the rationale in the video below (and also see their
new blog).



Thanks to Dr. Greg Gramelspacher (Twitter: @ggramels) for alerting me to this article.

Tuesday, August 18, 2009 by Lyle Fettig, MD ·

Friday, August 14, 2009

Free Spinal Cement Injury Legal Consultation

As I mentioned briefly last week, NEJM has published two blinded, sham-procedure controlled trials of vertebroplasty for painful osteoporotic vertebral compression fractures, both of which indicated VP was no better than the sham procedure (article 1 here, which I will refer to as Buchbinder, its primary author's last name; article 2 here, Kallmes). (Supporting editorial here.)


Buchbinder was an Australian multicenter study of ~70 patients with non-malignant, painful VCFs less than 12 month old. Everyone, including all the investigators were blinded to treatment group (only the radiologists who did the procedures were unblinded; they weren't involved in data collection, patient care afterwards, etc.). Patients were randomized, brought to the procedure suite, and underwent identical procedures with the exception that the sham patients just had their vertebral bodies lightly tapped with a blunt instrument and obviously no 'cement' inserted (for the sham patients the cement was opened and mixed in the room, the patients had local anesthetic, etc. etc.): they did a very careful job of blinding the patients to which procedure they had. The study was powered at 24 patients in each group to show a 2.5/10 point reduction in pain in the active group over sham.

A lot of outcome data were generated that's not worth belaboring: at no point (1 week to 6 months) did the active group patients have superior pain relief to the sham group: both groups reported rapid and durable pain relief (on the order of 2/10 in their overall pain ratings). Notably, the results were the same just looking at those with the freshest fractures (less than 6 weeks of symptoms) - although the study was not adequately powered to determine a difference just in this subgroup. Secondary outcomes about quality of life, etc. were similar between groups.

Kallmes was a multinational trial involving similar patients (N=131, all with fractures less than 12 months old, pain at least 3/10, not cancer related VCFs). A similar protocol was used, including anesthetizing the periosteum of the vertebral pedicles, face activity to suggest they were actually doing the procedure, etc.; blinding was similar as well. The study was powered at an N of 250 to find a 1 point difference in pain outcomes; when they had accrual problems they changed their targets to an N of 130 with '80%' power to detect a 1.5/10 difference in pain at one month.

The results for pain and disability were basically negative at all times, with some notable caveats. Baseline pain was ~7/10 in both groups; both active and sham groups had an immediate reduction in pain down to ~4/10 at 3 days, which continued out to 1 month (active was 3.9, sham was 4.6 - not statistically significant).

Kallmes allowed cross overs after one month (both ways - those who had real VP originally were crossed over to the sham procedure). By 3 mo 43% of sham patients had crossed over (asked for and received the alternative treatment - all of this was still blinded to the patients), compared to 12% of the VP. By one month after the repeat procedures there was no difference in pain outcomes between groups either. Overall, all of those who sought cross over did worse at all times than those who didn't. Interestingly, 63% of the control group patients correctly guessed at 14 days that they had received the control intervention; only 51% of active VP patients had.

Kallmes notes in the discussion:
These results suggest that factors aside from the instillation of PMMA may have accounted for the observed clinical improvement after vertebroplasty. Such factors may include the effect of local anesthesia, as well as nonspecific effects, such as expectations of pain relief (the so-called placebo effect), the natural history of the fracture, and regression toward the mean. The possible role of the placebo effect on outcomes in this trial remains unclear. Previous studies have documented pain reduction in placebo groups, on the order of 6 to 7 mm on a 100-mm scale. The treatment effect in our trial was substantially larger than those in previous studies, even though the previous studies included both pharmacologic and psychological interventions in addition to physical interventions.
Compare this to the unblinded, randomized, conservative therapy controlled trial (of balloon kyphoplasty) I blogged about a few months ago which showed marked benefit of KP over conservative treatment.

What does all this mean?

When it comes down to it I think it does mean that the marked pain improvements noted after VP are in fact not due to installation of cement, just as Kallmes remarks. It's complicated though, to say the least, and unanswered questions remain - which don't however invalidate these new findings which are by far the most rigorous investigations of VP.
  1. Why was the pain relief in Buchbinder half of that in Kallmes (2/10 vs. 4/10 on average)?
  2. There is a sense from the Kallmes trial (with the differences between groups in rates of guessing correctly which treatment they initially had and rates of seeking cross over) that real VP had some benefit over sham which wasn't noticable at all on pain and disability questionairres. Or pain 'really was' improved in the VP group compared to placebo and the study didn't have the power to show it. Even if that's the case it is not good news for VP - if the benefits (over sham) are so minimal (or rare) that you need more than 130 patients to demonstrate it - this is not a ringing endorsement of the procedure. Needing more than 130 patients to prove a treatment saves a few lives a year is fine (and typical in cardiovascular research); for an analgesic modality it means it's pretty worthless.
  3. It is possible the sham procedure is actually an effective, active treatment for VCFs which they inadvertently demonstrated in these trials. It seems physiologically unlikely (outside of the initial hours after anesthetizing the pedicle) but one could invoke some 'placebo' response explanation? Such as - patients think this will help; anesthetizing the pedicle gives them rapid and effective pain relief; patients now 'know' if fact this will help and despite the fact that nothing else has been done which effectively relieves pain (including, apparently, the installation of cement into the vertebral body); this expectation/belief provides the patients durable (months long) pain relief.
Unanswered questions:
  1. Balloon kyphoplasty, a related procedure, was not investigated and one can't conclude anything about KP from these trials (despite the compelling** non-blinded controlled research I cited above). However, these papers indicate the effectiveness of KP can no longer be assumed without properly blinded studies.
  2. It's possible that certain patients would receive benefit from VP over sham; patients with very acute fractures, specific anatomy, etc. (there has been for instance a clinical impression that more acute fractures respond better). Perhaps...but we can no longer assume that without it being demonstrated properly.
  3. Who knows about cancer patients? All I can say, and to join most of the world here, VP frequently seems to help. And in fact it does help, even if it's placebo - see below.
The clinical frustration of all this:
  1. These papers, if you accept their findings as they are (which I do - they are as good as you can get when it comes to this sort of symptom research), shouldn't actually lead us to conclude that VP is as good as medical/conservative management. VP is better than medical management, and has been shown to be so (as has KP). The results very specifically mean VP is no better than 'sham,' which is a different conclusion than no better than medical management. The difference is now we have reason to believe VP is better than medical management due to that thing called 'the placebo effect' as opposed to, eh, 'real analgesic effects' of instilling PMMA into a vertebral body. Real in quotes there because I don't mean to suggest that 'placebo' is not a real analgesic. It is, god knows, I just wish I had it in a bottle as opposed to a fancy fluoroscopy suite.
  2. I have thought VP and KP are pretty darn good things the last few years as I've seen many patients feel a lot better afterwards. It's frustrating and you wonder what would have happened if rigorous, blinded studies were done early on. E.g. the technique is developed and a few case series suggest a powerful treatment response to VP (this in fact happened). Next, a properly blinded trial was done which showed no benefit. Maybe this was repeated with larger trials - still no benefit - VP is never adopted and never became as wide-spread and accepted as it has now become. Instead we had large, unblinded trials; VP still looks great, everyone loves it, and then this. All of this makes a good argument (if we ever needed one, which we do, as we constantly forget) for remaining skeptical of unblinded treatment trials and also of doing blinded trials early, particularly with novel therapy.
  3. But coming back to #1 there, what do you do clinically given that it still remains that VP is 'superior' to medical management (at least in the short term) even if it's because of placebo. It's not ethical, supposedly, to prescribe placebos, right? But we do it all the time - at least I do with, for instance, lidocaine patches for pain syndromes highly unlikely to 'actually' respond to a lidocaine patch - I do it because it's almost ridiculously safe and a substantial minority of my patients report they feel a heck of a lot better. An invasive procedure is different though; while quite safe the tiny risk of a catastrophic adverse event remains. Frankly, for patients with disabling pain that I cannot effectively treat medically/conservatively without dose limiting side effects, I think I will continue to recommend this, or maybe kyphoplasty to make myself feel better.
  4. Please comment as to what your plan to do based on these studies. I'm also curious to the community's larger response and if this will in fact be the death of VP. As long as people get reimbursed for it though I imagine it will continue to be practiced.
  5. I Googled vertebroplasty to see if there were any open source images for this post and found this link (www.youhaverights.com/medical-devices/spinal-cement/) was at the top of my search (it was a paid link, and I am not embedding an actual link here because I don't want to improve this website's Google rank by doing so). Yes, people are already trying to cash in on this via litigation (thus this post's title). God bless America.
**I was compelled I have to admit.

(I am traveling next week and won't be posting. Christian is back [missed you buddy] and we should soon be ending our lighter, 'summertime' posting schedule.)

Friday, August 14, 2009 by Drew Rosielle MD ·

Wednesday, August 5, 2009

Palliative Care Grand Rounds - 1.7 - Risa's Pieces

Palliative Care Grand Rounds- the monthly collection of the best writing from blogs about hospice, pallaitive care and related topics is back again. This time at Risa's Pieces, a palliative care nurse practioner in Seattle. She is a great writer herself and has brought some great new blogs to attention. And she kindly included some of Palliemd Main and Arts posts.

Go take a quick enjoyable read and explore how rich the palliative medicine blogging community has become! And if you see soemthing you like leave a comment (Comments are like gold to bloggers!)

(I am not officially off hiatus yet, but will be soon, and I have a lot to write about!)

Wednesday, August 5, 2009 by Christian Sinclair ·

The PVS, fMRI, Radiolab, & 'Murder'

Journal of Medical Ethics has a discussion on the implications of functional MRI imaging on the withdrawal of life-prolonging treatments in vegetative patients (free full-text here; Pallimed posts on similar topics here, here, here, here for further context).

The authors make 2 main arguments, and make them specifically in the context of whether fMRI findings - which suggest some form of consciousness/awareness in some patients diagnosed as being vegetative - make it therefore unacceptable to withdraw life-sustaining medical treatments in those patients.

First, they note, as have others, that the state of the science is such that we don't really know what these fMRI findings mean, and certainly don't know that they mean patients have consciousness (capacity for thought, self-awareness, etc.) . Except for the most reductionist and overconfident neuroscientists, I think everyone agrees with that. It could of course, and completely 'negative' fMRIs would I think be taken as decent evidence these patients' cerebral cortices don't work, but we just don't know.

Second, and more saliently, they argue that even if these patients were actually in a minimally conscious state or in fact fully cognitively intact but also fully/completely locked-in, that doesn't necessarily lead to a conclusion that it is inappropriate to stop life-prolonging medical treatments and allowing them to die. And, in fact, the possibility that these patients can suffer/experience pain and have no way of asking for help etc. actually strengthens an argument to allow them to die.

Even ignoring that point, the question of consciousness or not is not what is fundamentally important about medical decision-making in these settings. The question is whether given what is happening, and their prognosis, whether they'd want their life prolonged medically; the exact same question that patients/surrogates face all the time in the setting of poor prognosis and available medical technology to prolong life but not improve quality of life. This is a point that I (see here) and others have made, and it's good to see it prominently in a journal.

The question of consciousness is important: it might have some prognostic implications, it might aid loving families in making decisions about what to do for a gravely brain-injured person (but not predictably one way or the other), but it doesn't fundamentally alter a surrogate's right to advocate for the cessation of unwanted medical treatment that is maintaining a patient in a way that would be unacceptable to that patient.

Coincidentally, Radiolab, a science-themed public radio show which I love (and still do), recently broadcast a new episode on 'the afterlife' (can be streamed/downloaded here). In it they talk about this very phenomenon, and one of the hosts says something like 'this means we are in danger of inadvertently murdering people' (ie - if someone is 'truly' vegetative withdrawal of life-prolonging medical treatments is not murder; if someone has some consciousness then doing the same thing would be murder). The scientist with whom he was discussing this, noted that 'it's complicated' but didn't challenge the host's characterization of this as 'murder.'

I can appreciate that people might be uncomfortable with this and that some families would find it impossible to agree to stopping life-prolonging treatments if there was a suggestion of consciousness, despite the possibility as well of unmitigated suffering (of course some families choose not to stop such treatments even with good evidence of permanent unconsciousness). But murder? *Sigh.*

I challenged the use of 'murder' on the Radiolab website's comments section (same link as above), and concluded with these comments:

Where fMRI may eventually help is to stratify patients into those who have virtually zero chance of ever recovering and those who have a small (but real) chance of actually recovering (most never will under any circumstances at least with current technology).

This may *help* of course, but it will do so by presenting families with some variation of this choice: your loved one cannot indicate any signs of consciousness, awareness, pain, or suffering. This scan suggests they may be aware of their surroundings in some way. They might be in agony and we'd never know it. There is a 10% chance that in a year they will have improved somewhat - not sure how much - but it's possible they'd regain the ability to communicate. Would the patient want to be kept alive with artificial medical support given those odds?

Yikes.

by Drew Rosielle MD ·

Pall-Pourri: Vertebroplasty & the QTc

1)
European Journal of Cancer
has a small case series about vertebroplasty for vertebral metastases from solid malignancies. The study involves all consecutive vertebroplasties (n=19, mostly breast and prostate cancer, mean age 70 years, 47% received multiple level interventions at the same time) performed at a single UK center. In a relatively loose fashion, pain relief was assessed afterwards and at at least 3 month followup. They report that 84% (16) patients reported 'immediate benefit' in pain and ability to ambulate, and that all 16 of those continued to report some benefit (although unclear how much) at 3 months. 15 reported decreased use of analgesics although how much etc. is not described. We talked recently about the large, randomized, unblinded trial of a similar procedure (balloon kyphoplasty) which included a handful of cancer patients. This study confirms the general clinical impression that these procedures are helpful for most patients but doesn't unfortunately add much to that (how helpful, how long, how much more than medical management, etc.).

Late entry 8/5- I'm adding this after I originally posted this earlier today so it will at least be up to date for those who read this on email: two people have already emailed me about tomorrow's NEJM which presents two randomized, sham-procedure controlled trials of vertebroplasty for osteoporotic fractures and found no benefit over a sham procedure (here & here). I've only read these in abstract at this point; but will blog in-depth soon. Exciting stuff. Thanks to Drs. David Weissman & Bob Arnold who let me know.

2)
Annals of Internal Medicine has published a series of highly critical letters about the recently published consensus guidelines on QTc prolongation and methadone (our original blog post here; letters here, here, here, here; authors' reply here; original article here). The major themes of the letters are that QT monitoring as suggested in the guidelines is impractical, actual rates of harmful events from QT prolongation in methadone are very low, for patients on methadone maintenance therapy there is often no effective alternative to help maintain abstinence, and the evidence one way or the other is crap. This latter point is the real one; there can be such widely-divergent, well-informed opinion about this because there is really very little practical data to guide us.

by Drew Rosielle MD ·

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