Thursday, December 16, 2010

Opioids on the Chopping Block

Having a healthy level of respect for opioids is critical for any physician. For those of us who prescribe or recommend this class of medicines on a daily basis, this statement rings all the more true.Recent events and research reinforce this reality.

“Oxycontin, Other Opioid Painkillers Tied to Higher Health Risks” was the title of a recent Businessweek article that references a study in Archives of Internal Medicine about opioid safety in patients with non-cancer pain. In this study, 6300 patients taking one of five analgesics for chronic (non-cancer) pain were followed between 1996-2005.

Rus Portenoy, Chair of Pain Medicine and Palliative Care at Beth Israel Medical Center in NYC and former President of AAHPM responded to the study with caution, recognizing the confounding factors that could influence the data – including clinician knowledge of effective and safe opioid titration rates.

In the same journal, Daniel Solomon and colleagues evaluated the safety of opioids compared with NSAIDS and coxibs in elderly patients with arthritis, and finding that patients on opioids had higher incidence of falls, cardiovascular events, hospitalizations and all-cause mortality.

picture from www.outcomeresources.com


Oxycontin new formulation – MedAlert:


The study was released 9 months after Purdue announced its reformulation of Oxycontin, a move made to attempt to prevent abuse. The new forumulation makes crushing the pill difficult: instead of turning to a fine powder, it gelitinizes. Despite its release in April, patients have only started to routinely receive this new formulation in the last 6 weeks or so. Since that time, a Medwatch alert has already been released, announcing:


The following events have also been reported, potentially due to the swelling
and hydrogelling property of the tablet: choking, gagging, regurgitation,
tablets stuck in the throat and difficulty swallowing the tablet.


Furthermore, alive on the webchats, patients have discussed lack of efficacy of the new formulation, increased side effects – including GI symptoms and new headaches. As a physician prescribing Oxycontin, I have had patients whose breakthrough opioid demand increased dramatically with the change in formulation, with or without the other stated side effects. My approach has been to convert the long-acting oxycodone to another opioid in each case: to methadone or morphine extended release, based on patient's pain pattern, history of opioid side effects and using principles of opioid conversion.

I wonder whether others of you have had any recent experience with this and how you are addressing the concern.

So far, my experience with these problems has only been related with patients whose Oxycontin requirements were exceptionally high (>1g per day). My concern with what I am starting to see is the risk of undertreatment of pain – the potential assumption that patients who have been on higher doses of Oxycontin for a longer period of time might be labeled as “drug seekers” if they suddenly have an increased need for breakthrough pain medication due to lower efficacy of Oxycontin.

Pain and Palliative Care physicians may be increasingly under the gun to teach our colleagues, make our EDs, oncology and primary care centers aware of this possibility, educate about safe opioid conversion practices, and alert the FDA of observed side effects or change in efficacy through the MedWatch mechanism.





Thursday, December 16, 2010 by Suzana Makowski ·

Wednesday, December 15, 2010

Rationing: the debate is back on the table

Driving home tonight, as usual, I was listening to NPR. This time, the voice on the radio was honestly confronting the controversial topic of rationing – specifically, rationing in England. In recent evaluation of palliative care and end-of-life care around the world, England was ranked #1 – and as a result many countries healthcare leaders have visited the UK to learn from them. One of these countries was the United States – and as pointed in in Public Radio International (PRI) – this dialogue between England and the US was stopped after controversy about the “death panels” hit the front pages.

Around that time, Time Magazine published a story putting the pricetag on life – adding to the controversy.

More recently, in April of 2010, PBS hosted a debate on the topic featuring Ira Byock, Physician and Director of Palliative Care at Dartmouth-Hitchock Medical Center, Ken Connor, Lawyer and Chair of the Center for a Just Society, who represented Jeb Bush in Terri Shaivo’s case, and Marie Hillard, Nurse and Director of Bioesthics and Public Policy at the National Catholic Bioethics Center.

PRI has put this story back on the news – and given our place in healthcare, we cannot hide from the controversy as inevitably, in one way or another, we live smack-dab in the middle of it all. Our views on this topic also differ – and so I invite a discussion here.

Note: PRI has created a series about healthcare rationing in England, South Africa, Zambia, and India. Additionally – for all you TweetChatters: @PRITheWorld, @SheriFink and @dhbaron are also hosting another tweetchat on Thursday 1pm EST with the hashtag #rationinghealth.

Wednesday, December 15, 2010 by Suzana Makowski ·

Monday, December 13, 2010

Mediastinal Lymphadenopathy in Lung Cancer

Pop Quiz:

  1. What is the sensitivity and specificity of a CT scan of the chest for detecting mediastinal involvement in a patient with non-small cell lung cancer?
  2. What about a PET scan? 
Palliative medicine practitioners frequently see patients with stage IV lung cancer.  Usually the stage has been fully elucidated prior to the initial palliative care consultation, but not always.  Admittedly, this biased my assumptions about the sensitivity/specificity of these tests and I would have guessed much higher than the actual answers (even though I knew neither was 100% sensitive).
Lung cancer cell dividing.  Source: Wellcome Images

Read more »

Monday, December 13, 2010 by Lyle Fettig ·

Letters to the Editor on the NEJM Palliative Care in Lung Cancer Trial

The trial published earlier this year in NEJM on early palliative care in metastatic non-small lung cancer remains highly publicized after the initial brisk response to the study.  As I review my Google Reader RSS feed that searches for the term "palliative," I still routinely come across references to this study, most which highlight the survival advantage seemingly conferred to the palliative care group.  (See our initial reactions to the study herehere, and here.)

NEJM recently published four letters to the editor regarding the study and yes, almost everyone is focused on the survival result and how to explain the survival advantage.  Points made about the survival result included the following:

  •  Could the palliative care wing have received more chemotherapy (not less as I hypothesized), thus resulting in improved survival?  Could the mechanism of improved survival have been that palliative care leads to improved performance status, thus leading to more chemo, thus improved survival? (Authors respond that a preliminary analysis suggests that the number of chemo regimens did not differ between the groups.  They highlight some logistical challenges in measuring PS independently in this study over time. )
  • Could the palliative care group have had fewer comorbidities? (Authors acknowledge this possibility but also point out that randomization which resulted in similar pt characteristics between groups should have negated this possibility.)
Only one published letter tried to poke holes in the HQROL conclusion, with the letter writer suggesting that the statistically significant results might not be clinically relevant or perhaps borderline.   In response, the study authors point out that results for the the FACT-L and TOI scores differed enough to be considered clinically significant but did agree that the Lung Cancer Subscale (of the FACT-L) difference was not clinically significant.  This is one of the most challenging aspects of HRQOL research, and those of us who are not researchers need to be aware of meaningful cutoffs.

The letters do nothing to change the evolving significance of this study but should be reviewed by those developing future research to examine similar interventions (perhaps especially the co-morbidity issue). 
 

by Lyle Fettig ·

Tuesday, December 7, 2010

How Much Does a Palliative Medicine Doctor Make?

Well besides just putting down some rampant speculative numbers here, I suggest if you really want to know the answer,you have to be a CEO or CFO of a hospital or hospice organization, department chair, a palliative care/hospice doctor, spouse of said doctor, or in a few months time you will be to see the results of the AAHPM's brand new survey on palliative medicine and hospice physician compensation.

The deadline was extended until Wednesday December 8th, so if you have procrastinated thus far, you better ask your billing department to collect a few numbers and head on over to the survey.

Here is the link to the AAHPM page with more info about it

Hopefully then the 1,466 of you that land here on Pallimed looking for some salary information will actually have some good info to work with!  (image below taken from keyword search data including the term 'salar*' from Jan 2007 to Dec 2010)



.

Tuesday, December 7, 2010 by Christian Sinclair ·

Celebrities, Illness and Hospice

As our country mourns the death of Elizabeth Edwards who died today, many are recalling her legacy of health care reform and advocacy for hospice.  She was named NHPCO's 2009 Person of the Year. Her writing and her advocacy focused on bringing the humanity back to patients.  I was particularly struck by a blog post she wrote about the death of political commentator and Bush press secretary Tony Snow.  Despite being on opposite sides of the spectrum of American politics, they struck up a friendship as Edwards writes:

"We each chose to reach for something larger than the life and body with which we were saddled when we kept our course after the last diagnoses. We did it because we thought it was important and because (although it is chic to say that one detests politics) we actually loved the give and take it, the struggle to find what you think is right and the imperative to make others understand and agree. But what, in the end, does it tell us about what we each found to be really important? I am guessing it is not school vouchers or the expensing of stock options or class action lawsuits about salacious material in video games."

Any news hound will also realize that it was only yesterday, a day before she died, when it was formally announced that after a recent admission to the hospital, Edwards (with the advice of her doctors) would be forgoing any 'anti-cancer treatments.'  When I first heard the news yesterday about Edwards forgoing anti-cancer treatments, I casually wondered if there would be much discussion about palliative care or hospice.  I will tell you this is something I find hard to stop myself from thinking about given my interest in how hospice, palliative medicine, prognostication and medical decision making is portrayed and communicated in the news and entertainment media.  So my question to all of you is: Is this something you have wondered yourself too?

Now this is much different that wishing or hoping that someone does poorly or dies, that is not what I am talking about at all.  That is plain wrong.

I felt somewhat validated when I saw conversation on a different social media site about how this was a public example of a common challenge seen in hospice and palliative care: late utilization of the hospice benefit.  Someone mentioned we should capitalize on this story to highlight this challenge, which I do not think is appropriate, but I wanted to give a forum for rational discussion about this rarely discussed but (probably) often thought about topic for our community.

I'll leave with a quote from Edwards:

"Hospice and palliative care professionals support and care for people at a time when hope can be hard to find.  The professionals of NHPCO know more than I will ever know about providing that care; I know more than I wish I knew about receiving it and I am happy to share my perspective with them.”

NOTE: Eleanor Clift writes about hospice and Elizabeth Edwards here.

by Christian Sinclair ·

Tuesday, November 30, 2010

LVAD Advice and Talking About Palliative Medicine Boards

Two posts have recently received a little more attention and I wanted to bring them back to everyone's attention if you had not seen the discussions.

The first is a post called "Holiday Heart"  from August 2010 written by Holly Yang.  Anon posted this comment which i thought might get better attention if it got bumped up to a post:

My hospital began LVAD-DT procedures recently. Our inpatient Palliative Medicine Department has been invited by the CV surgeons to participate in their pre-op inter-disciplinary patient evaluation process.
Our discussions re the old adage of "Hope for the Best; Prepare for the Worst", a phrase I never like to use, seems to be now changed in a nuanced way in the process of goals of care discussions with these patients. They have already experienced years of frustrating medical care and are very aware of their limited treatment options. Thus, some are hanging on to a thin thread of hope of this procedure as their last and saving option.
I wish to ask about how do others approach the subjects of hopes, wishes, goals, fears, scenario planning and related topics in the context of the person facing an LVAD procedure? I appreciate any comments.

Any suggestions for our fellow Pallimed reader? Feel free to comment on the original post.

Also a few anonymous commenters have taken to my "Good Luck on Boards" post to start a conversation about board prep and the test. If you needed a space to discuss this it is available, but please do not disclose anything about the questions or answers directly. and keep the comments constructive.

Tuesday, November 30, 2010 by Christian Sinclair ·

Are You Glad Darvocet Got Pulled by the FDA? Are You Sure?

I know many palliative care practitioners were cheering the news that the world's least effective opioid propoxyphene (Darvocet (w/ APAP) /Darvon)  (similar efficacy to acetaminophen) is being pulled off the market by the FDA.  Along with meperdine (Demerol) I am not sure if a medicine exists that produces as much disdain as propoxyphene amongst palliative care clinicians.

But let's look a little closer as to why this happened.  The FDA cites the increasing cardiotoxicity and risk of heart arrythmias in a post-market study conducted by Xanodyne.  It is a little difficult to find out more exact information since the study is not published but lets do a little Scooby Doo-like sleuthing.


  • Propoxyphene is a synthetic derivative of methadone.
  • Methadone causes QT prolongation of questionable clinical significance in palliative care patients.
  • QT prolongation is a risk factor for ventricular arrhythmias.


Searching beyond just the press releases and news articles I found this FDA memo from Dr. Sharon Hertz *(Deputy Division Director Division of Anesthesia and Analgesia Products) noting that Xanodyne was asked to do a Thorough QT study. Never heard of that before? Well all new drugs since 2005 have had to pass through one before being approved. Given this increased risk of QT prolongation and the fear of resulting ventricular arrhythmias, the risk of the drug started to overwhelm the very minimal benefit it offered.
Interestingly the FDA has no evidence of QT Prolongation Adverse Event related deaths with Propoxyphene. Here is a quote from the memo: (emphasis mine)
At the 2009 advisory committee meeting, FDA staff shared postmarket data that have been suggestive, but inconclusive, about the risk for propoxyphene-related cardiac toxicity when used at therapeutic doses. No cases of torsades de pointes (TdP) causally associated with propoxyphene have been reported despite extensive use for many years. In an analysis of serious adverse events reported to the Adverse Event Reporting System (AERS) covering the period from marketing to February 2, 2005 (approximately 33 years), there were 91 U.S. deaths associated with Darvocet, the most commonly dispensed formulation of propoxyphene.  Most of the reports identified opioid drug overdoses in individuals with profiles of drug dependency, in which there was coingestion of multiple medications, or in those attempting suicide.
What is really interesting about this memo is section 1.2.1.1 on page 20, where they discuss QT studies of other opiate agonists. 6 lines of the report are redacted and in the whole 20 pages there is not one mention of methadone despite nearly all other opioids being mentioned. Redaction? Should we call Wikileaks founder Julian Assange?

So in the end I am not sure if propoxyphene being removed is really about cardiotoxicity and QT, minimal effectiveness, abuse and overdose potential or a combination of all of the above.

Well all this may be a whole lot of nothing but my real concern is that methadone may be a drug in the crosshairs of the FDA soon. It already has four strikes against it:
1) documented QT prolongation
2) stigma of heroin treatment programs
3) accelerating percent of all deaths related to opioids
4) methadone could be considered an orphan drug

And evidence of  methadone being a very useful medication is possibly not strong enough to overcome these issues. So while we can cheer propoxyphene disappearing we should also be cautious and gather better evidence for the medications we wish to keep in our arsenal to ensure good pain control for years to come.


ResearchBlogging.orgBeaver, W. (1984). Analgesic Efficacy of Dextropropoxyphene and Dextropropoxyphene-containing Combinations: a Review Human and Experimental Toxicology, 3 (1 suppl), 191-220 DOI: 10.1177/096032718400300118


Collins, S., Edwards, J., Moore, R.,  McQuay, H. (1998). Single-dose dextropropoxyphene in post-operative pain: a quantitative systematic review European Journal of Clinical Pharmacology, 54 (2), 107-112 DOI: 10.1007/s002280050430


Ripamonti, C., Bianchi, M., Bruera, E. (2004). Methadone: An Orphan Drug? Journal of Palliative Medicine, 7 (1), 73-74 DOI: 10.1089/109662104322737278

** Yes the Deputy Direcotr in charge of pain medicine at the FDA is Dr. Hertz. Ha!

by Christian Sinclair ·

Changes at the blog

After 5+ years of doing this, and much deliberation, I am stepping aside from being the editor of Pallimed.  If you hadn't already noticed, Christian, Pallimed's co-editor, has really been the energy behind the success of the blog for well over a year now, and I am grateful he has agreed to continue to lead the blog.  Thanks, friend.  I plan on remaining a contributor.

For those of you who know me - don't worry - everything is fine.  Between my kids getting older and staying up later, and a whole set of new (& welcome, & engaging) challenges & projects with my move to Minnesota, I have needed to closely examine my priorities and for now stepping away from the blog makes the most sense. 

Thanks to all the readers and supporters of the blog for your generosity and wisdom over the years.  See you in the comments.

--Drew.

by Drew Rosielle MD ·

Monday, November 29, 2010

Palliative Care and Accountable Care Organizations - URGENT Call for Comments

With health care reform and Medicare budget cutting being the latest buzz in Washington DC, we need to be very proactive in making sure palliative care (including hospice) gets 1) included in a fair and professional manner  and 2) not let other people narrowly define us and misinform the public who we are or what we do.

But this is going to take some work, you must not just read this email/post and say, "Yeah! People need to make sure Palliative care is represented" and then wait for other people to do it for you.  So go to GeriPal and read Eric Widera's latest post on Accountable Care Organizations and how to advocate for palliative care issues to be represented.  After you are done commenting tell 4 other people about it and then follow-up to make sure they commented.

For some background on this, Eric and I had a conference call with Diane Meier, Alex Smith and Phil Rodgers. Some of the very enlightening things from Diane from her time in Washington was that all of these comments are read and carbon copied ones tend to not get as much value as the original well-crafted ones.  You are not just sending your words into some bureaucratic abyss.

Diane also shared that there will be many, many more of these opportunities to comment to all sorts of different committees and agencies so we should be prepared for a sustained response.  Knowledge of when and how to comment is not always reliable, so Geripal and Pallimed are working on someway to help our readers stay informed. Any ideas you have please share with us as we plan to have a more comprehensive solution in 2011 and will be looking for some input and volunteers to assist.

Some things that we brainstormed:

  • Website to direct people where/how/why to comment along with ways to share what you wrote so others could learn, critique, and support each other. 
  • Entertaining slides/videos/podcasts that help to explain the alphabet soup of the agencies receiving our comments
  • A way to report success to encourage people to continue to writing/advocating
Yes I know policy can be boring, but you may recall that the Medicare Hospice Benefit was once just policy discussion and now look where we are.  And FDA taking liquid morphine off the market was just policy but look what amount of change we were able to evoke.

Monday, November 29, 2010 by Christian Sinclair ·

Thursday, November 25, 2010

Engage with Grace 2010 - Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.


So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

theoneslide


We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.


Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.

Thursday, November 25, 2010 by Christian Sinclair ·

Sunday, November 21, 2010

Facing Death Online Community Viewing

(Welcome to viewers of "Facing Death" from Frontline PBS from the Sunday Nov 21 Community Viewing) (Transcript embedded below)

If you found the discussions and topics in this show provocative and interesting and want to learn more about medical decision making and palliative care, here are a few suggested links from us here at Pallimed to some of the best material on the web. (You can also find some good links at the official PBS Frontline page also.)

Organizations (Twitter profiles)
-For health care professionals


Organizations
-For the public



Excellent Palliative Care Blogs (Click here for a full list of updated hospice and palliative blogs)



Weekly Hospice and Palliative Medicine (#HPM) Tweetchat - Wednesday 9p ET

Key People in Palliative Care on Twitter



Support National Hospice and Palliative Care Month with a Twibbon on Twitter and Facebook.
Be a Fan of National Hospice and Palliative Care Month on Facebook to find other advocates.

Sunday, November 21, 2010 by Christian Sinclair ·

Saturday, November 20, 2010

Prognostic Tool in Pediatric Oncological Hospice



In the December 1st issue of Pediatric Blood and Cancer is an article that presents the validation of a prognostic tool in pediatric hospice care. The study was produced by a team from the Hospital A.C. Camargo, a large cancer center in São Paulo, Brazil. Their overall survival rate in the treatment of pediatric cancers is just over 75%, roughly on par with those in the United States at approximately 80%. At this institution, a nurse-led, multidisciplinary palliative care team was developed in 1999. Patients are referred to it when 3 pediatric oncologists reach a consensus that a particular patient has no chance for a cure.

Read more »

Saturday, November 20, 2010 by Brian McMichael, M.D. ·

How much is enough? Dartmouth Atlas Documents Medicare Cancer Care Variations in Last Month of Life


For those of you wondering what to do with all of your free time now that the boards are over, I highly recommend immersing yourself for an hour or two in the maps, graphs, and tables of the Dartmouth Atlas’ first comprehensive report on end of life care for patients with advanced cancer. The premise of the Dartmouth Atlas is that the large local variations in health care services which Dartmouth has documented, are caused by supply (more surgeons=more surgeries; more hospital beds=more hospital days) and by local patterns and customs of care, NOT by evidence-based care delivered to achieve better outcomes. The Dartmouth Institute researchers assert that
Our findings point to important opportunities to improve not only the quality of care (by ensuring that effective care is reliably delivered) but also to reduce the costs of care (by reducing avoidable hospitalizations and unnecessary specialist visits).”[1]

Read more »

by Dale Lupu, PhD ·

Sunday, November 14, 2010

Good luck on boards!!

Just a quick little note of encouragement to all the doctors out there preparing for the 2010 hospice and palliative medicine boards.  Keep studying, you will do great!  If anyone has any stats about number of people taking the test that would be great to post here!

Sunday, November 14, 2010 by Christian Sinclair ·

"Facing Death" on PBS Frontline

PBS Frontline is known for in depth documentaries on important issues of the day, often focusing on specific narratives about individuals to help illustrate the larger dilemmas at hand.  They have covered palliative related topics like geriatrics, Parkinson's, suicide tourism and the gaps in US health care, but next week is one that seems to be right in the palliative care wheelhouse; "Facing Death" focuses on the life and death decisions in the ICU.  And to be more specific the Mount Sinai ICU.

Interestingly PBS Frontline has decided to air the episode during Thanksgiving week, maybe in hopes like the Sesame Street episode on the Death of Mr. Hooper, it will spur family discussions about what one values and what choices your family would make in similar situations.  But lucky for you, the internet has made time and space bend so you can actually watch the full episode right now online.   Or you can wait until next Sunday  the 21st at 9p ET when you can watch it simultaneously with hospice and palliative care advocates online at Twebevent. You do not need to be on Twitter (unless you want to participate) to watch the stream of comments.

The PBS Frontline site also has extra materials, interviews and footage so make sure to explore the main site, leave comments and share with your teams.  If anyone would like to post a review of the show here to Pallimed, please email them to me ctsinclair@gmail.com and I will post them next week.  The deadline is Nov 22nd at noon CT. I will accept reviews that are anonymous if well written. If you don't want to leave a full review please feel free to post comments here.    I would love to hear your comments on the choice of title, how palliative care is portrayed, if this is helpful for education to health care professionals or patients and families.

by Christian Sinclair ·

HPM on Wikipedia


I've grumbled umpteen times that Wikipedia ought get a "Hospice and Palliative Medicine" article written. As it stood when HPM, as a subspecialty, was the intended idea, writers would usually cobble together links to the separate "Hospice" and "Palliative Care" articles. Then I suddenly remembered that we are Wikipedia, and such an article wasn't going to write itself. So I clicked the letters in red of an unwritten article, and wrote one.

Since this is a pretty active Web-2.0 community aligned with the "collaborative, publish first, refine on the go" paradigm, I thought I would turn it over to all y'all to grow it from an initial stub into its full-blossomed elaboration.

So sign in and edit as you see fit, and let's see what we come up with. Also go through the various other, related articles and fine tune the links in the web of Wikipedia knowledge.

Enjoy!

by Brian McMichael, M.D. ·

Wednesday, November 3, 2010

Cartography of EOL Pain


Alex Smith and Eric Widera of GeriPal fame, et al., have just published an article in Annals of Internal Medicine, The Epidemiology of Pain During the Last 2 Years of Life. The L.A. Times article is here. Little is known for certain about the contours of this landscape; so, let's explore.

This was an observational study gleaned from the Health and Retirement Study, a nationally representative survey of community-living adults. The subjects were deceased who, either the subject or proxy, had been interviewed once within the last 24 months of life. The subjects were divided into 24 consecutive cohorts on the basis of the number of months between the interview and death. The prevalence and time-course of clinically significant pain (experienced often and as moderate-to-severe) were described and analyzed with respect to demographic, socioeconomic and clinical factors. These data were modeled and adjusted for the different factors.

Read more »

Wednesday, November 3, 2010 by Brian McMichael, M.D. ·

National Hospice and Palliative Care Month

As many of you know November is Hospice and Palliative Care Month.  You probably saw the announcement from your organization or an email from NHPCO, SWHPN, AAHPM or HPNA and thought 'Well isn't that nice!'

And then you probably moved on with your day.

Well it is time to not be passive about this.  You now have an excuse to talk about hospice and palliative care to everyone you see all month long.  In a long elevator ride with no one talking? Perfect! You can just bust out with:
"Hey did you know November is National Hospice and Palliative Care Month?  I wonder if when they were picking months they chose it because of Thanksgiving and getting together with family or maybe the symbolism of summer changing to winter? What do you think?"

Read more »

by Christian Sinclair ·

Palliative Care Grand Rounds Up at Compassion and Choices

Compassion and Choices has the latest edition of Palliative Care Grand Rounds up Wednesday morning.  Head on over to their very active blog and check out the links to the best of the hospice and palliative care blogopshere in their 'Patient Empowerment' edition.

by Christian Sinclair ·

Sunday, October 31, 2010

Some Halloween Links Related to Palliative Care

Hopefully everyone had a safe Halloween with not too many eyes scalded by the proliferation of Lady Gaga, Justin Bieber or Christine O'Donnell costumes.  While many of you will be reading this technically on November 1st, I wanted to share some Pallimed posts to Halloween and other seasonal content.
Maxx - A Skelanimal
This post from 2007 reflects on the Mexican tradition, Dia De Los Muertos, particularly the symbolism and respect regarding those who have died.  Public displays of remembrance and celebration of the history of one's family, all with a touch of humor and wit make Dia De Los Muertos an event worth considering adopting into mainstream American culture.  The cartoonish skeleton motif has already been adopted in the past few years into numerous clothing lines.  In leafing through the Christmas Toys R Us catalog (for my 4 year olds, not me, honestly)  I saw not one but two brands (Monster High and Skelanimals) featuring 'cute skeleton' themes. (And after looking through the Skelanimals website I think I have an idea for a Pallimed: Arts and Humanities post)

Read more »

Sunday, October 31, 2010 by Christian Sinclair ·

Thursday, October 28, 2010

World Opioid Consumption

Image from www.painpolicy.wisc.edu
The Pain & Policy Studies Group (PPSG) at the University of Wisconsin recently released its figures for 2008 comparing the opioid consumption of all the countries reporting to the INCB (International Narcotics Control Board).  I am always fascinated by these reports.  One because I always find it shocking, and it helps my palliative care advocacy flame burn brighter.  Two, because the information makes a great graphic for talks on why palliative care is necessary world-wide.  Some day, I hope to not find them so interesting, but unfortunately I think that day is still distant.  


Let's face it, almost everyone wants to avoid the experience of severe pain personally and for their loved ones.  The reality, as illustrated by the interactive DCAM (Drug Control and Access to Medicines) Consortium Opioid Consumption Map, is that most of humanity does not have that luxury.

Guess which color is > 10 mg morphine/capita
Image from www.dcamconsortium.net




Read more »

Thursday, October 28, 2010 by Holly Yang, MD ·

HPM Tweetchat party, anyone?

Ok, all you twitterphobes!  Find a person, possibly your local teen or tween to teach you how to use it and join in the fun on November 17th 6 pm PST/8 pm CST.  (We do these weekly, but I'm encouraging hesitant newbies to come to the party together to avoid any sensation of social awkwardness.)


No RSVP necessary, you can watch from outside the party (aka lurking), but if you want to join in the lovely conversations you need to use Twitter.

Cue typical protest: "I'm too busy!"

I agree, you are busy!  I know it deep in my core that all you hospice and palliative medicine (#hpm) folks are busy doing good work, caring, listening, relieving suffering, teaching, researching, promoting the field, and having a life yourselves.  I am too.  But, let me tell you why I bother with twittering about hospice and palliative medicine.  (By the way, translations are at the end.)

1)  Christian Sinclair does it. (@ctsinclair)

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by Holly Yang, MD ·

Tuesday, October 26, 2010

Shorthand for Palliative Care Professionals

As EMR's move closer to becoming sentient beings that will eventually control the world, which at the current pace of their development I would estimate to take another 643 years, I have noticed a change in how I take down details about my patients as I round each day.  With a paper note I would typically write down information on the actual progress note I expected to put in the chart.  Therefore the information I wrote would have to be in the final (hopefully) legible form.

But with a EMR, I find there are times when the clinical day is so busy that directly entering the note right after the clinical encounter is difficult to do with out jeopardizing or delaying the care of other patients, so like many other clinicians I have talked to or seen we are left charting at the end of the day, transferring information from our brain, and our hasty notes into the EMR in the final (very) legible form. I also use these shorthand techniques when taking notes from nurse in the field calling to collaborate. 
So I thought I would share a few of my shorthand techniques and see what else the palliative care community had to add.  Now we are not just talking about simple abbreviations here like DNAR = Do Not Attempt Resuscitate, but more complex system, although not nearly as complex as Gregg Shorthand.

So here are a few of my shorthand notes:

F25 = Fentanyl 25mcg patch q72h (The 72 is always assumed, but if the patient is on q48h, I usually put a dash modifier after the number, like this F50-)

R5, R10, R510, R1020 = Roxanol (liquid concentrated morphine) with one or two digits equaling a non-ranged dose, and R1020 = Roxanol 10-20mg.  Q1h is assumedas a common dosing interval in hospice.

MS = IV/SQ morphine, never PO/SL since that is R

M = methadone (assumed oral unless written otherwise)

HM = hydromorphone (Dilaudid) IV/SQ.  Chose not to use the  D so not to confuse with 0

hm = hydromorphone PO/SL.  Used lowercase since it is not as strong as IV/SQ per mg dose

Oxy = oxycodone
OxyLA = oxycontin These two are fairly obvious.

H = haloperidol I do not make a distinction in the abbreviation here or for lorazepam for route and usually will add route after.  So H12-4 = Haloperidol 1-2mg q4h prn

L = lorazepam
SC = scopolamine patch q72h
G = glycopyrrolate (not 'R' because that would be roxanol)
A = atropine (since L = lorazepam)
B = benadryl
C = compazine
Z = Zofran
MNTX = Relistor (methylnaltrecone)
S/S = senna - s with the number of tabs am/pm indicated after S/S 2/2 = Senna-s 2 tabs Twice a day.

PCA shorthand
I have tried a couple of different systems but the one I think that works best is

HMPCA 2 / C2-60/ P1-30 = Hydromorphone PCA with 2mg/hr basal, 2mg q60min Clinician bolus PRN, with 1mg q30min Patient bolus.

Other examples MSPCA 3 / C5-60 / PØ  ( If there is no clincian bolus or Patient bolus I use a line through a zero.

Scheduling vs. prn
If a drug is scheduled then I will circle the interval, so Haloperidol 2mg every 8 hours scheduled would look like H2-8 (with a circle around the eight)

Family meeting shorthand
When everyone is doing introductions, I try and write everyone's name down with out looking at the paper, so I can have reference later in the meeting if I need to address someone.  I add the names in the pattern they introduce themsleves so I ahve a little map to refer back to after the meeting.  I never worry about spelling peoples names and usually will just try and spell phonetically as or include a few letters. So William = Wm; Brenda = Brda, Allison = Alsn, etc. Usually that is enough for me to remember them later on when the official note is written.  But it is important to know the relations so for family relations I use the following key after the persons name.  Most of the following are obvious but there are a few tricks.

H = husband
W = wife
SO = significant other
SIL = sister in law or son in law.  Check the name to tell the gender
DIL = daughter in law
BIL = brother in law
S = son
D = daughter
M = mother
F= father
G = grandparent
F = friend
N = neighbor
A circled name = DPOA
P = anyone on a speakerphone during the conference
I add the state two letter abbreviation for any out of town relative present
OOH = out of hospital DNR form

Do you have any that you use regularly? I will add more as I recall them day to day.

Tuesday, October 26, 2010 by Christian Sinclair ·

AAHPM Board Meeting - Input wanted!

Just a note that I will be in Chicago Thursday and Friday for the AAHPM Board of Directors meeting.  If there is anything you think I should bring up, please feel free to email me at ctsinclair@gmail.com.  If you just want to talk instead of writing down your concerns/interests to bring to the board, email me and I will send you my cell number. 

Just wanting to encourage transparency and accountability in your elected officials during such a fun political time!

Hopefully I will post a report on the AAHPM blog.

by Christian Sinclair ·

Wednesday, October 20, 2010

Hospice Facts and Figures 2010 Released by NHPCO

The National Hospice and Palliative Care Organization has released the annual report on hospice statistics that we all love to quote.  The free publication, Hospice Care in America is a good review of the basic statistics we all need to know like:
  • Average Length of Stay
  • Median Length of Stay
  • % of US deaths while receiving hospice services 
  • Patients served by Hospice
  • Location of Death (Home, NH/ALF, Inpatient Hospice, Hospital)
  • % Cancer diagnosis
  • % under age 64 (including pediatrics)
If you want to test your knowledge take the short little quiz on the above questions, or just scroll to the end of the post for the answers. (I will post the results of the survey in an upcoming post)

Are there any other stats you find interesting from this report?

Basically there were no major surprises with the 2010 report.  Most of the stats were unchanged from previous years.  The one I found odd to have such a major change was the increase in male patients from 43% to 46%.  No explanation was given in the report.  I can't think of anything that would cause such a profound shift given the numbers.The deaths from kidney disease also increased from 2.8% to 3.8% which is an interesting trend to watch too given the difficulties in getting good early hospice care to ESRD patients because of potentially conflicting Medicare Benefits.  General satisfaction rates were also high as usual.  So did you take the quiz yet? Here are the answers, don't cheat!
  • Average Length of Stay - 69 days
  • Median Length of Stay - 21 days
  • % of US deaths while receiving hospice services - 42%
  • Patients served by Hospice - 1.56 million
  • Location of Death (easy to remember 40-30-20-10)
    • Home - 40%
    • NH/ALF - 29%
    • Inpatient Hospice - 21%
    • Hospital - 10%
  • % Cancer diagnosis - 40%
  • % under age 64 (including pediatrics) - 17%

Wednesday, October 20, 2010 by Christian Sinclair ·

CAPC National Seminar 2010

This Thursday through Saturday the Center to Advance Palliative Care is hosting their National Seminar in Phoenix, AZ. Apparently this conference is sold out. I looked into possibly going and actually heard they expanded the registration because of demand. Guess the economy is not that sour after all! I have never been to a CAPC event but the topics look pretty fantastic for any hospital based palliative care program.

What is really nice to see is the offerings directed towards pediatric palliative care. While we do not blog about it often here, pediatric palliative care is an underserved population both in specialist level care and generalist expertise in good palliative care practice for children. Besides pediatrics other major areas of focus are the new IPAL-ICU* project focusing on the Intensive Care Unit, and the Emergency Department.

If you are like me, bummed you can't make it to the conference you can always check out the Twitter feed since I know a few people going who will be tweeting from the conference, so you might pick up a few tips here and there.  If you are on Twitter just search for #CAPC2010.  Make sure to ReTweet good posts and reply back to the people who are there.

If you are not using Twitter (yet) you can check out the embedded stream below over the next few days or after the conference. (Email subscribers may have to click to the original Pallimed post)



If anyone who is a Pallimed reader happens to be there, please feel free to write up a summary of what you learn on each day and we can post the summaries here. If you are interested in doing this please email me at ctsinclair@gmail.com.  If anyone is interested in blogging from other upcoming medical conferences maybe we could work on getting some blogging/media credentials and reduced registration.

*Is it just me or does it seem to be a natural to use the PAL part of palliative? PALlimed, GeriPal, Pal-Med Connect, IPAL-ICU. Does a marketing tagline exist here? "Palliative Care - When you need a PAL."

by Christian Sinclair ·

Palliative Care Grand Rounds - Palliative-SW Blog

Palliative Care Grand Rounds was published earlier this month at the new 2010 blog for SWHPN, called Palliative-SW.  If our lack of blogging in October has left you pining for good hospice and palliative care blogging check out the 10th edition of 2010 Palliative Care Grand Rounds!

by Christian Sinclair ·

Monday, October 4, 2010

National Quality Strategy Intiative and National Quality Forum - Call to Action

(Cross-posted to Geripal by Alex Smith also - it is that important!)
{Diane Meier asked us to please post this important message about the opportunity to actually voice your opinion to policy makers about the important role of palliative care in all aspects of health care. Please see Lyle's follow up post to see what he decided to write to the HHS. - C. Sinclair}
Dear colleagues-
We have an important opportunity to influence the degree to which palliative care and hospice are integrated into our future health care system. There are currently 2 places requesting input from the public:

1) Department of Health and Human Services (HHS) National Quality Strategy initiative
and the
2) National Quality Forum calls for public comment on quality of care.
Palliative care is the linchpin for quality among the highest risk highest cost patient populations in the United States and this is an opportunity for us to focus attention to the impact and priority of our work (or, as they say, "be at the table or be on the menu").
Deadline for HHS is October 14, 2010 and deadline for the NQF is October 19, 2010.

Read more »

Monday, October 4, 2010 by Christian Sinclair ·

Sample Feedback to the National Healthcare Quality Strategy and Plan

Below, you will find my humble attempt to provide feedback to the HHS regarding the National Healthcare Quality Strategy and Plan (see red text for responses).  My hope is that the comments below will serve as a starting point as you think about your response.  Please comment to this post with suggestions.  How would you respond differently?  I did not answer the state-specific questions because I ran out of gas completing the first part and wasn't sure how to respond, so if you have ideas, let us know.


Don't worry about perfection of responses or whether you agree with what I've said.  It's the passion for the work that counts. While I'm certain that higher quality responses garner attention, let's aim for a high volume of responses that succinctly mention areas of concern to our field.   


Once you have decided on your answers, go to the HHS website to send feedback.

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by Lyle Fettig ·

"We're All Going to Die. Deal With It"

So says the editorial  associated with a recent BMJ "Spotlight" series of review articles on palliative care in patients with diagnoses other than cancer.  The series was financially supported by the British Heart Foundation.

The reviews are rather cursory but give a sense of the perspective on the other side of the pond.  The major highlight is the announcement from the BMJ Group that they will begin publication of a new journal next April entitled BMJ Supportive and Palliative Care.   Great to see!  (Any comments on the journal name?)

Articles include:

Read more »

by Lyle Fettig ·

Sunday, September 26, 2010

What is health policy? Part 1: The view from the mountaintop



A Perfect Morning at Glacier National Park
Photo by Flickr user: Trey Ratcliff
**Editor's Note: We would like to welcome Dale Lupu to the growing number of Pallimed bloggers.  Dale has considerable experience in working with palliative medicine professionals.  Dale will be working on an occasional series of posts to help all of us learn why health policy matters to all of us. Please welcome Dale warmly!**

This inaugural post in a new Pallimed series on health policy for palliative care groupies has taken longer to write than I expected. Why? I expected to start in the clichéd manner: by defining the term “health policy.” But I was stopped short when I could not find a definition for health policy. The websites, textbooks and articles that I consulted all take for granted that we know health policy when we see it. Many sources discuss topics covered under health policy (such as access, quality, financing, delivery systems, workforce), but none that I could find offered what I considered a useful, concise definition that set clear boundaries for the field.

Since it is impossible to prove the negative, and feeling very uncertain about the thoroughness of my research (maybe I had just missed some great definition out there that EVERYBODY but me knows about), I consulted with Dr. Gerard Anderson, my professor from doctoral student days in health policy and management at Johns Hopkins School of Public Health. Gerry confirmed in an email, “there is no uniformly agreed upon definition.” There you have it. So I am left to my own devices in trying to paint for you readers the major concerns, techniques, and boundaries of the field of health policy.

So what is health policy?  For me, a key defining aspect of health policy is that it takes a 30,000 foot view of the health of a population and of the systemic factors (political systems, health financing, cultural norms) that contribute or detract from a population’s health. Contrast this to the clinical view, which put the needs and concerns of a particular individual (and possibly that individual’s family) first and foremost.

Rosa Passione
Photo by Flick user Bruno C
To compare the clinician’s usual view with the health policy view, consider looking at a garden. One can look up close at a single rose bush in the garden and work on pruning it, fertilizing it, removing pests, watering it. This is the clinical view.  In contrast, the health policy view is like an aerial view of the garden that reveals the overall plan for the whole. Taking this big view, one can see if there is an irrigation system for the entire garden, if the rose bed is in a sunny enough site, or if retaining walls are sited appropriately to stop soil erosion. In this “policy level” view, the health of one particular rose bush is not the focus of concern, and may even be obscured.

A second defining aspect of health policy is the “policy” part – the general rules (often expressed in laws and regulations at the governmental level) that are used to guide organizational and system behavior, particularly allocation of resources. Although we may be able to read the words of the laws and regulations, it can often be difficult to understand the policy goal and the policy assumptions that motivated them. In the words of Eugene Bardach (more on his policy analysis guide in the next post):

In real life, policy problems appear as a confusing welter of details: personalities, interest groups, rhetorical demands, budget figures, legal rules and interpretations, bureaucratic routines, citizen attitudes, and so on. ..You therefore need to learn to “see” the analytic concepts in the concrete manifestations of everyday life.[1]

To get a feel for the types of questions and the approaches to analysis that are typical of the health policy world, I suggest you explore these notable sites that track and digest health policy issues:

§  The Henry J. Kaiser Family Foundation (not associated with Kaiser Foundation of managed health care fame) is widely respected for its analysis and reporting on health policy issues. In particular, they are a source for cogent and succinct summaries explaining Medicare issues. Although they have a big focus on chronic care and on disparities between different subpopulations, Kaiser has yet to do much work on palliative care or hospice issues.

§  The Englelberg Center For Health Care Reform at the Brookings Institute does its own research as well as presenting analysis of others’  research.

§  While there are several journals that cover health policy in the US and internationally, Health Affairs is the preeminent source. They have covered palliative care and hospice sporadically in the past, but seem to be paying closer attention recently.  The January 2010 issue carried several coordinated articles addressing policy issues about delivery, quality and financing of palliative care in the nursing home setting.

§  Finally, a personal favorite of mine is a website that serves as a portal to a host of information sources, US Health Policy Gateway.  This is a good starting point when you are looking for information. It’s thin on the palliative care info, and hit or miss in some other areas, but its simple, straight-forward presentation makes it an excellent starting point.

My goal in this column and those to come is to give my palliative care clinical colleagues an introduction to health policy as it impacts palliative and hospice care. In the coming months I will cover analysis methods, data sources, issues, governmental and non-governmental players, all with a focus on their relevance to palliative and hospice care.  I am planning to write about the standard format for a health policy analysis, large scale data sources that are used to understand palliative care, options for financing and promoting palliative care in the long-term care setting, and the mysterious “U-shaped curve” that Medpac proposes for hospice reimbursement reform. If you have other topics you would like me to cover,  please leave a suggestion!


[1] A practical guide for policy analysis : the eightfold path to more effective problem solving.  3rd edition. Eugene Bardach. Washington, D.C. : CQ Press, c2009.

Sunday, September 26, 2010 by Dale Lupu, PhD ·

What is health policy? Part 2: the art and the science


To make an impact on health policy (and I assume that the reason you are reading this post is that you – eventually- want to influence the policies that affect you and your patients), one must deal with two different but related spheres that I will call the art and the science of policy-making. The art aspect is the political and organizational process for making, changing and implementing policy. It’s a messy process where emotions and alliances usually have more influence than information. The science portion is the rational, analytic approach practiced by the armies of policy analysts that populate think tanks and government policy offices. The science of health policy analysis – with its tools like adjusted quality of life scores and mortality risk adjustment – attempts to professionalize the otherwise very messy political process.

 Of course, the two categories are not mutually exclusive.  There is art to the science of policy analysis: how to organize information and arguments, what options to analyze. And there is science to the art:  the entire field of “Political Science.” My own practice of the art has been instinctual and uninformed by formal study of political science. Therefore, I’m going to leave an explanation of the political process to others. In this post, I’m going to try to give you a feel for the science side: rational policy analysis methods.

One guide to policy analysis that I like very much is A Practical Guide for Policy Analysis: The Eightfold Path to More Effective Problem Solving by Eugene Bardach.[1] (Nowhere in the book did I see an explanation of the title’s allusion to Buddhism’s eightfold path, but I would be surprised if it were merely a coincidental reference.) Although this guide is not specific to health policy, its common sense approach and readable style makes it a quick and useful read. 

Bardach’s 8 step method is:
§  Define the problem
§  Assemble some evidence
§  Construct the alternatives
§  Select the criteria
§  Project the outcomes
§  Confront the trade-offs
§  Decide!
§  Tell your story

These steps are common sense, but Bardach’s explanations of how to work with them is sophisticated, practical, and at least for me as a policy wonk, fun to read. He gives an array of pointers about how to conduct each of these steps in the most artful way. For instance, regarding defining the problem, he warns about the common mistake of defining a solution right into the problem statement:
Don’t say: “New schools are being built too slowly.” Simply assuming that “more schools” is the solution may inhibit you from thinking about ways to use existing facilities more efficiently.  Try instead: “There are too many schoolchildren relative to the currently available classroom space.”

Some people despair that the rational, analytic, and evidence-based realm doesn’t exert much influence on the political process. In our own field, the classic example is the Medicare Hospice Benefit. Congress passed the enabling legislation in 1982 without bothering to wait for the results of the hospice demonstration project, which had been expressly designed to determine whether a hospice benefit was useful and how best to shape it. After the law was passed, Vince Mor and the other social scientists working on the evaluation of the hospice demonstration were able to feed preliminary information from the demonstration to the regulators as they shaped the details of the Medicare hospice regulations. [2] Should congress have waited? Would we have the hospice benefit (with its strengths and its flaws) that we have today if they had?

I am a realist about this. The political aspect of policy-making proceeds at its own pace, usually without slowing to wait for the results from years-long and careful demonstrations.  (Does anyone REALLY know at this point whether medical homes or accountable care organizations work? They are in the health reform legislation anyway.)

Even though rational analysis does not usually have the upper hand in how health policy is determined, I think it nevertheless plays an essential role. It is like the rudder of a sailboat. In calm seas with favorable winds, the rudder sets the course. However, in stormy seas, strong winds and waves may work against the course set by the rudder. Even so, it is far better to have the rudder’s steadying effect than to sail without it.

I conclude with Dr. Bardach’s sage words about the relevant contribution to be made through rational, insightful policy analysis:

Finally, just as policy analysis originates in politics, so it concludes in politics.  Political life has two sides: channeling conflict and building community.  Policy analysis serves both sides.  It channels conflict by showing that some arguments, and their proponents, are in some sense superior to others and deserve to win out. But it helps to build community by marking off potential common ground as well. This common ground Is defined by the rules and conventions of rational discourse- - where opponents may employ analytical procedures to resolve disagreements, or where they may discover that at least some seemingly irreducible values conflicts can be recast as dry-as-dust technical disagreements over how much higher a probability Policy A has than Policy B for mitigating Problem P.


[1]Eugene Bardach.  A practical guide for policy analysis: the eightfold path to more effective problem solving. 3rd ed. Washington, D.C. : CQ Press, 2009.

[2] A Short History of the Medicare Hospice Cap on Total Expenditures

by Dale Lupu, PhD ·

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