Tuesday, February 2, 2010

Best of January 2010 Posts & Comments

Most Viewed Posts from January 2010
1. Palliative Care Grand Rounds Vol. 2.1
2. Catholic Directives on Artificial Hydration and Nutrition
3. Paradoxes in Advanced Care Planning
4. Judy Chamberlin, Hospice Patient & Blogger Died January 16th
5. Overdose in Patients Prescribed Chronic Opioid Therapy

Most Commented on Posts from January 2010
1. What is the Role of Palliative Care in Haiti After the Earthquake? - 11 comments
2. Paradoxes in Advanced Care Planning - 9 comments
3. Palliative Care Grand Rounds Vol. 2.1 - 8 comments
4. Outpatient Rotations to Methadone - 6 comments
Multiple other posts with 2-3 comments

Best Comments from January 2010
Dr. Pam on What is the Role of Palliative Care in Haiti After the Earthquake?

Many developing countries have a severe lack of supplies and meds even BEFORE disaster strikes--destruction of the infrastructure for delivery of services and for basic food/shelter then further compounds the issue. Pain meds are often rare outside developed countries. 

So, if palliative care specialists hit the ground early, I believe we would largely be "empty-handed" in the work. There would still be the possibility of helping triage and of providing some basic human comforts, but symptom management as we know it here in the States is a luxury most of the rest of the world cannot afford. (The places I have been in Africa did not even typically have Tylenol of NSAIDS!) 

Suzana Makowski on What is the Role of Palliative Care in Haiti After the Earthquake?
When I think of suffering - the physical suffering of pain, dyspnea, are certainly paramount and a role to be filled by palliative care docs and often anesthesiologists (the former, a heck of a lot cheaper!). The practical suffering - food, shelter, sanitation - public health officers, etc. will take on the lead. Social and emotional suffering - their churches have always been a core place of refuge - who supports the clergy? How does an international effort tap into these non-national entities to support a people? Bereavement and survivorship issues - who will address these?

Dr. Bryan Byrd on What is the Role of Palliative Care in Haiti After the Earthquake? 
I spent 9 days in Haiti as part of a first-response medical relief team. We were busy treating closed and open fractures, burns, wounds and broken hearts.

Hospice/palliation came up several times. A good example was a wonderful 97-year old woman who suffered a femur fracture. Although she was otherwise in pretty good shape, her age and the limited access to surgery led us to talk about palliation-only treatment.

The Haitians, so wonderful and buoyant in spirit, embraced our recommendation. We counseled them on infection and bed sore prevention, and talked about traction for pain control.

Dale Lupu on  Paradoxes of Advanced Care Planning
This paradox makes sense to me. The paradoxical nature of the finding "I don't want to talk to my oncologist about AD but I prefer my oncologist if it really has to be someone" seems to me to come from the very real paradox that we hold inside ourselves, expressed through "hope for the best, plan for the worst." So in hoping for the best, patients don't really want to talk to anyone about AD - especially the oncologist who they HOPE is going to cure their cancer. But if really pressed to PLAN for the worst case, then they figure their oncologist is the better of the bad choices.

Anonymous on Paradoxes of Advanced Care Planning
I'm glad to hear your skepticism of AD's and about the lack of data they do anything. I find that working in a hospital setting, sometimes too much emphasis is placed on these documents as if they are the gospel truth, as if we must stick to the letter of what these documents say, when they can't possibly predict every possible scenario or health outcome, or precisely define the beliefs and attitude of the person they are supposed to represent under the various multitude of circumstances. The flip side is their absence, I find, often shackles caregivers and clinicians into believing we cant possibly know what the patient wants, when most rational people would not want to be bedbound, with trach & PEG for the rest of their lives, for example.
Some states have recently adopted rules that state healthcare providers cannot act against a person's AD, that this would be considered a felony. I'm not sure this is the best route to go, as I've decribed above, there are nuances to every situation that AD's cannot adequately addressed, usually because they are often generic, vague, and poorly written (certainly not written by health care professionals!)

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