Wednesday, September 15, 2010
Feeling Millennial - Our 1000th Post
I've been toying around with an idea for a lighter post the last few months, particularly with the new fresh fellow season which is upon us, and thought our 1000th post was a good opportunity to do this. I've been thinking about this lately with the new fellows, because I've been finding myself saying these things over and over, as I do every year, as I talk with trainees about this wonderful thing we do called palliative care.
So here they are - pearls for successful palliative care consultation (in no particular order). I make no claims that any of these are original to me even if I've lost track of where they came from. Feel free to claim them for yourself in the comments. Few of these, particularly the ones I came up with, are aphoristic - if any of you can aphorize them please do so, in the comments. If we get some good additions we may try to find a more permanent home to our collected wisdom.
- Assume nothing, ever.
- Always talk to the team first.
- Respond to emotion with emotion.
- 75% of what we do is showing up and shutting up.
- Tame the beast inside who just wants to talk, talk, talk.
- Don't just do something, stand there.
- Acute symptoms = acute meds. (That is - don't jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.) This is a variation of the idea behind:
- NO DRIPS 'TITRATED FOR COMFORT.'
- 'Good work' describes a process, not an outcome.
- Palliative care is just good medicine.
- And what is their bowel regimen?
- What is their narrative?
- Just because someone has less than 6 months to live doesn't mean hospice is right for them.
- You should worry more about your patients who want to die, and less about those who are desperate to live.
- It's not about you. (This is in reference to patients' and families' emotions.)
16. You can't shine shit.
Please add your own.
Thanks for reading, thanks for sharing Pallimed with your friends and colleagues, and thanks for commenting.
(Image from here, via Google image search. Could not identify any copyright information.)
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13 Responses to “Feeling Millennial - Our 1000th Post”
September 15, 2010
Drew Rosielle! See what you started!
Congratulations and thanks for these 1000. I'm looking forward to the next grand.
As for pearls, I'm not sure I can top the Weissman one, in fact I'm sure I can't. Andy Probolus has a lovely list of pearls too, so hopefully he'll share a few.
Here's a few I've been taught:
Remember who the customer is.
Don't forget to care for the primary team too.
Be visible. Curbsides become consults.
Realize it or not, you are always teaching.
September 16, 2010
Great post Drew! I have been thinking about doing a post similar for all those little pearls I have collected too. Funny coincidence!
A big thanks to all the Pallimed contributors past, present and future and to the readers and commenters who have made this worthwhile!
-Anything you do either builds trust or loses trust with a patient or family. Figure out which one you are doing.
-'Have a good night' means little compared to 'Have a quiet/peaceful/calm night'
-Drawing is a form of communication too.
-Always clarify the goals and code status in the note, even if only to say they have not changed. (Helps avoid the 'oh! they're palliative care now? concern)
-Give an estimated prognosis with appropriate supportive information
-Allow for overtime in family meetings
-Keep later scheduled consults appraised if you are running late
-Don't always tell people what they need to know. Let them find what they need in their own answers to your questions.
Not all very lyrical or aphoristic (thanks for the SAT vocabulary word Drew!) but ones that help me.
September 16, 2010
"Efficiency is comforting" Cicely Saunders
"Beware the coercive orthodoxy of dying and mourning" Edmund Pellegrino
Paul McIntyre, Halifax, Canada
September 16, 2010
Congratulations to the Pallimed team! But I'm sorry I'll have to burst your bubble. According to the Mythbusters, you CAN shine a turd:
http://videosift.com/video/You-can-t-polish-a-turd-actually-you-can
How this applies to palliative medicine, I am not sure.
September 16, 2010
Great idea for 1000th post.
--Have faith that time spent on a family meeting tomorrow will be repaid in-kind two-fold next week.
--Communication IS medicine.
--Requests for futile interventions aren't synonymous with a diagnosis of crazy. Be curious and broaden the differential.
#11 and #12 are daily gospel...their juxtaposition on the list made me chuckle a little.
Steve- that's disturbing. I view the world just a little differently now.
September 16, 2010
Wonderful post!
How about....The Palliative Medicine 'cone of silence' - what is said in team debriefings stays in team debriefings.
September 16, 2010
Thanks all, keep them coming.
Steve - I don't even know what to say. Only you would know that.
Paul - 'coercive orthodoxy' - I think you mentioned that in a comment on our blog years ago, maybe in reference to whether 'palliative' patients should be anticoagulated - and I always remembered it. Thank you for sharing it again. I think particuarly in the nascent stages of my life as a palliative doc that really helped me think more clearly about our patients and their needs.
Maggie: perhaps we should call that standard the palliative care Vegas rules.
A couple more I've come up with: the first is from this month's J Palliat Med go figure, the second is mine:
*Using Coping Strategies Is Not Denial
*Value your patients' will to live.
September 16, 2010
Since Holly set me up so nicely,
I will include my list of pearls. I have been handing them out to the fellows and residents lately. remarkable how they mirror some that have already been submitted.
•To alleviate suffering you must first identify it.
•To identify suffering you must know the story, as told by the sufferer.
•When you do not know what to say, stay silent and bear witness.
•Most people are reasonable people put in difficult circumstances.
•Meet people where they are and then walk with them.
•When in doubt, get everyone together and talk about it.
•This is not about you, if it starts to be, ask for help and take a step back.
•Time spent building rapport is rarely wasted.
•Not everything can be or even should be accomplished on an initial visit.
•Discuss prognosis, by invitation.
•When you do not know what to do, ask more questions.
•Form and communicate a coherent opinion with recommendations driven by prognosis and goals.
•Be the change you want to see in institutional culture.
•Thou shall not pile drive the plan of care.
•Thou shall not throw the referring clinician under the bus.
September 17, 2010
Thanks for the 1000 informative, thoughtful and sometimes funny posts.
My pearl is:
People have the right to make bad choices.
Palliate On!!
September 18, 2010
Andy I'm glad Holly called you out and thanks for sharing. Agree there's a lot of affinity between many.
Here's another I just remembered. I learned this from David Weissman too, who attributed it to his wife I think:
You can't argue with crazy people.
I recognize there are probably more politically correct ways of putting that but that's how I learned it. I'll note that this isn't about people with psychiatric diseases but about identifying situations in which the 'issue' at the root of the conflict is not due to a lack of adequate information sharing between parties - it's not because you haven't said the right thing and it's not going to get better with more attempts at education, re-framing, etc. (Usually in these situations the 'root' is due to emotions - love, attachment, fear, guilt - or fixed beliefs.)
September 21, 2010
Oh! I'm going to have to save these and review regularly. So pleased to see "bowel regimen" addressed in your list.
Laura Hertz, NP
March 27, 2011
Since Holly set me up so nicely,
I will include my list of pearls. I have been handing them out to the fellows and residents lately. remarkable how they mirror some that have already been submitted.
•To alleviate suffering you must first identify it.
•To identify suffering you must know the story, as told by the sufferer.
•When you do not know what to say, stay silent and bear witness.
•Most people are reasonable people put in difficult circumstances.
•Meet people where they are and then walk with them.
•When in doubt, get everyone together and talk about it.
•This is not about you, if it starts to be, ask for help and take a step back.
•Time spent building rapport is rarely wasted.
•Not everything can be or even should be accomplished on an initial visit.
•Discuss prognosis, by invitation.
•When you do not know what to do, ask more questions.
•Form and communicate a coherent opinion with recommendations driven by prognosis and goals.
•Be the change you want to see in institutional culture.
•Thou shall not pile drive the plan of care.
•Thou shall not throw the referring clinician under the bus.
March 27, 2011
Great post Drew! I have been thinking about doing a post similar for all those little pearls I have collected too. Funny coincidence!
A big thanks to all the Pallimed contributors past, present and future and to the readers and commenters who have made this worthwhile!
-Anything you do either builds trust or loses trust with a patient or family. Figure out which one you are doing.
-'Have a good night' means little compared to 'Have a quiet/peaceful/calm night'
-Drawing is a form of communication too.
-Always clarify the goals and code status in the note, even if only to say they have not changed. (Helps avoid the 'oh! they're palliative care now? concern)
-Give an estimated prognosis with appropriate supportive information
-Allow for overtime in family meetings
-Keep later scheduled consults appraised if you are running late
-Don't always tell people what they need to know. Let them find what they need in their own answers to your questions.
Not all very lyrical or aphoristic (thanks for the SAT vocabulary word Drew!) but ones that help me.
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