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)

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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




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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.

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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, MD ·

"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:

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by Lyle Fettig, MD ·

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