Sunday, October 30, 2011

Most Days I Clamor for POLST

Helen Kao at Geripal recently wrote a thoughtful post which highlights some of the flaws in the California POLST form. It's worth a read and I agree with her comments.  (And even though I use "POLST" here, I agree with her thoughts on using "POST" instead.)

For jurisdictions which are considering the establishment of POLST, it is important to consider the experience of other states as new forms are designed and legislation is drafted. I live in one of the many states which is in the process of developing a program. In spite of the weaknesses of forms currently in use in other places, PO(L)ST/MO(L)ST remains a very helpful tool with new research continuing to back its utility.  For instance, consider a recent study published in the Journal of the American Geriatrics Society which demonstrated high consistency between treatments provided to nursing facility residents and orders recorded on POLST forms. The study found that overall, POLST orders were consistent with treatments provided 94% of the time. Consistency rates were especially high for resuscitation orders. Consistency rates were slightly lower for antibiotic use and much more modest for feeding tubes use. 

Reasons for inconsistencies between orders and treatments should be evaluated further.  It's unclear that improving the form itself would reduce these inconsistencies.  Patients' preferences sometimes change and sometimes patients want their surrogate to have the leeway to change orders after the patient loses capacity (perhaps using a "best interest" standard of decision-making at that time rather than a pure "substituted judgment" standard). 

I hope that my state will "get it right the first time" taking into account the experiences of others. However I know that it is impossible to get it completely right the first time. Therefore, I hope that any legislation approved will include a process for modification of the forms which does not require the wheel to be reinvented down the road.

Sunday, October 30, 2011 by Lyle Fettig, MD ·

The Death of Steve Jobs: In Medias Res

The illness and death of the iconic Steve Jobs have stimulated much conversation both online and off. I won't rehash that now.

In case you missed it, NYT published the eulogy delivered by Steve's sister, Mona Simpson, who is a novelist and English professor.

"One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.
I told him: Steve, this is special treatment.
He leaned over to me, and said: “I want it to be a little more special.”
Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit. And every time his wife walked into the room, I watched his smile remake itself on his face.
For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.
By that, he meant that we should disobey the doctors and give him a piece of ice."
A remarkable blending of the mundane with the extraordinary. He put his two pant legs on and wanted his ice chips just like everyone else.

Oh, how I'd love to see those drawings.

The eulogy hints at how Jobs' illness and treatments interacted with his goals of care (which I'm guessing he was able to clearly define) and quality of life. Given the amount of discussion in our society which surrounded his illness and death, how special might it be to know how he went about making various decisions related to his health care? That could be a beautiful contribution to our society. There is no doubt that limitless financial resources played a role in the care which he received, but he wasn't in the ICU or even the hospital when he died.
"We all — in the end — die in medias res. In the middle of a story. Of many stories."

by Lyle Fettig, MD ·

Friday, October 28, 2011

Innovation Advisors Program

Attention! Palliative Care advocacy opportunity!
Do you want to get palliative care on the health care agenda? Are you interested in healthcare innovations? Please consider applying for the Innovation Advisors Program with the Center for Medicare and Medicaid Innovations (CMMI). Deadline for applications November 15, 2011. Check it out!!!

Friday, October 28, 2011 by Holly Yang, MD ·

What caught my eye in Twitter this week (10/28/11)



(From http://www.thedesignwork.com/)

What follows are a few of the things of the interesting things that went by me on Twitter this week (most recent on top). If you don't tweet, no worries, I removed the hashtags (those pesky # signs).  I did leave in the @ signs for those of you who do tweet so you can see who the tweets came from and to give proper credit, but I included who they are in parentheses if it wasn't really obvious. Let me know if you like having the tweets cherry-picked for you. (Disclaimer: I don't read all the tweets in Twitter, so you are getting some of the select few I found interesting enough to retweet/repeat.)
Congrats to Dr. Anthony Back of Seattle Cancer Care Alliance for Sojourns Award! http://bit.ly/tAnzWU

*Well-deserved!!! Check out the ONCOTalk website at http://www.oncotalk.info. A great resource for improving communication skills and teaching communication. In my opinion, if you haven’t looked at it, you should. Thanks for the link @rabob (Bob Arnold), @jfclearywisc (Jim Cleary), @renee_berry (Renee Berry), and @RegenceWA (Regence Blue Shield - Washington)!

New@lifebeforedeath (LIFE Before Death) Short Film 'Together We Are Stronger' online: http://bit.ly/sveCLp
@lifebeforedeath (LlFE Before Death) awarded Best of Show in the Best Shorts Competition - film for social change. http://on.fb.me/pcvWEJ 
*Two this week about this great series about the global pain crisis. One is the latest released short, the other is ANOTHER award for the project. See previous Pallimed posts about this work here and here. Thanks for the links @lifebeforedeath!

Mindfulness training for doctors: http://nyti.ms/sUgO13

*NY Times article on mindfulness for physicians. See previous Pallimed post about mindfulness here. Thanks for the link @Robert_Fried (Bob Fried)!


Nurse and Doctor describe their own experiences with cancer http://t.co/koRQdPMc
*Two stories about how personal experience with breast cancer has changed how a nurse and a physician approach patient care. Makes me think of a quote, “We are all healers who can reach out and offer health, and we are all patients in constant need of help.”- Henri Nouwen. Thanks for the link to the article @hastingscenter and @CNN!

The promise and pitfalls of palliative care http://lat.ms/mUeprR
The costs of palliative care teams  http://lat.ms/ojEoNH
*Two stories in the LA Times featuring palliative care. Important to see what the public sees about our field. Thanks to @suzanakm (Suzana Makowski) and @AAHPM for the links!

Dr. James Tulsky, innovative researcher in Palliative Medicine, named to NINR Advisory Council. http://1.usa.gov/qjxtXL
*Another well-deserved honor! Congrats!!! Thanks @geri_doc (Ken Covinsky) for the link!

What does Siri know about hospice and palliative care? http://bit.ly/n9jVHW

*Hilarious post from @EWidera (Eric Widera) at @Geripal. Thanks @donaldhtaylorjr (Don Taylor) for the link!




by Holly Yang, MD ·

Wednesday, October 19, 2011

Oncology Patients in the Emergency Department

Dusting off the Blogger account and checking in......

JCO published a population-based snapshot that looks at the characteristics of patients with cancer who visited emergency departments in North Carolina during 2008. Lung cancer was the most common cancer identified in visits by a significant margin while breast, prostate, and colorectal cancer were each identifed in a smaller number of visits. Patients with lung cancer were more likely to be admitted to the hospital with a total of 63% of all ED visits for patients with cancer resulting in an admission. The top three complaints included pain, dyspnea, and gastrointestinal complaints. More ED visits occurred during night and weekend hours than regular office hours.

Few brief thoughts/questions to ponder:
  • What percentage of the ED visits were preventable? What systems could be introduced to prevent the visits? (Urgent clinic availability, telemedicine, enhanced home health, etc)
  • Would these system changes result in a more timely manner and would that result in reduced need for hospital admissions?
  • As a palliative care clinician, it's not a surprise to see lung cancer disproportionately represented. One of the results of the Temel et al study regarding palliative care involvement from the time of metastatic NSCLC diagnosis was reduced hospital admissions/ED visits. It's not clear what the "mechanism of action" is, but improved access to a team that can help with the top symptoms certainly is one plausible hypothesis.
  • What is the "right number" of appropriate ED visits/hospital admissions? Hard to say, but palliative care as a field should actively work to help our oncology colleagues to push the numbers as low as possible. As much as I like my ED colleagues, the ED is not a fun place to be.

Wednesday, October 19, 2011 by Lyle Fettig, MD ·

The New Language of Medicine

NEJM published a perspective piece where the author briefly describes recent evolution of certain terms within medicine which may resonate with you.

"Patients are no longer patients, but rather “customers” or “consumers.” Doctors and nurses have been transmuted into “providers.” These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries."

"The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain."
The terms "providers" and "consumers" do strike me as "health care industry"-centered terms which have served to frame the discussion in a way that is favorable to said industry.  Hopefully, the terms (especially "consumers") don't advance any further in the lexicon and maybe more feedback needs to be given to media sources regarding better terms to use.

by Lyle Fettig, MD ·

Oligometastatic Lung Cancer

NEJM presents a case of a man found to have a primary lung cancer and a solitary brain metastasis.  The discussion regarding management of the patient is noteworthy, especially the possible role of surgery and a brief discussion regarding the use of tyrosine kinase inhibitors.

The palliative care consultant should be aware of the available case series which suggest that a minority of patients might have a longer survival than what is usually expected in patients with brain mets.  (See Table 1 in the article.)  In the case series, patients received aggressive surgical intervention for the brain met and aggressive attempt at locoregional control of the primary cancer.

The article provides some guidance for selection of appropriate patients for aggressive disease-based management.  No particular quality of life outcomes are mentioned related to aggressive surgical management.

The bottom line dilemma: This is a scenario where multidisciplinary/multimodality management may give a small number of patients a chance at longer term survival.  The approach may be worthwhile to some, but talking about prognosis on multiple levels (survival, anticipated quality of life/burden of procedures) is essential.  I cannot remember encountering this scenario recently, but a palliative care consult would be appropriate in any patient with Stage IV lung cancer.  It's possible that the complexities of therapy and communication surrounding prognosis may only increase the usefulness of palliative care in this scenario.

by Lyle Fettig, MD ·

NPR Series on Aging and End of Life: Hospice and Palliative Care in Prison Population

The NPR show Tell Me More has a week long series on issues surrounding aging and end of life.

Today, the show highlighted the documentary Serving Life about care provided to inmates at Angola Penitentiary in Louisiana.  The documentary aired this summer on the Oprah Winfrey Network. 

Also, see this recent perspective piece from Annals of Internal Medicine which addresses the issue of compassionate release of prisoners near the end of life.

Pallimed has featured stories on palliative care in prisons previously (see search results for "prison" here).

by Lyle Fettig, MD ·