Wednesday, April 30, 2014
“I’m going to get out of here one of these days… in a box” Jack Hall
“When you find yourself doing a life sentence, the thought of your death comes to mind. So when the prison administration started looking for guys to do volunteer work in the hospice program I said sign me up.” Glove
“When I started hospice I thought it would be about what I could give to the patient or what I could do for the patient to make them feel better. But when you do when you do what you do; the feeling you get back from then you can even describe it. I get the feeling in the inside that for once I’m somebody that nobody thought I could be” inmate hospice volunteer
|Jack Hall and inmate volunteers at bedside|
I suggest you read the prison terminal press kit to learn more about how the documentary was made and more details on the people shown in the movie.
you can learn more recent news by following the social media sites for prison terminal:
Wednesday, April 30, 2014 by Jeanette Ross ·
Monday, April 21, 2014
Empathy plays an important role in all of healthcare communication, but it's especially heightened when clinicians are working with patients with serious illness and their families.
Journal of Palliative Medicine published an article by Vital Talk's Tony Back and Bob Arnold recently about the role empathy can play in the delineation of goals of care for seriously ill patients. Empathy without any specific action is valuable to the suffering person. Merely being understood often times has some ameliorative impact on the suffering person and fosters a therapeutic relationship, even when some problems cannot be solved.
- See affect as a "spotlight"- be curious about the reasons for the emotion. Don't assume sadness is exclusively about dying. The first step is merely recognizing the spotlight, even if it's not patently obvious where it's shining.
- Use the affect to connect with the patient- bring it out in the open to demonstrate for the patient that you are noticing it. They recommend doing this before moving on to figuring out what is being spotlighted.
- Read between the lines to infer what is important- listen for cues that suggest a deeper concern or narrative that isn't being openly talked about. The evidence here will be incomplete, and the clinician needs to hypothesize and test the hypotheses with the patient.
- Develop action plan jointly with patient to address the need. The patient needs to be committed to the plan, and when a patient is committed to action that helps them address the goal, the process is defined as a success.
|Image: FracFX "In the Spotlight"|
Back AL, & Arnold RM (2014). "Yes it's sad, but what should I do?" Moving from empathy to action in discussing goals of care. Journal of Palliative Medicine, 17 (2), 141-4 PMID: 24359216
Monday, April 21, 2014 by Lyle Fettig, MD ·
Wednesday, April 16, 2014
If you are thinking to yourself, “Darn it, I always forget about NHDD every year and have always wanted to help and get involved,” well there are still some simple yet effective things you can do today!
1) Sign up for the monthly NHDD newsletter that comes out on the 16th of each month,
2) Gather your team and start making plans for next year,
3) Find someone in your community who is already doing something for NHDD and partner with them,
4) Follow @NHDD on Twitter, and then Tweet and Retweet about it using the hashtag #NHDD
Today is #NHDD! http://t.co/tv5oz68XjK Please take a moment to learn about the importance of advance care planning. pic.twitter.com/OgryrbdD935) Go like and share the great viral info on the NHDD Facebook page
— NHDD (@NHDD) April 16, 2014
If you are seeing any innovative efforts on NHDD today, please share them in the comments below, on Twitter, or on Facebook. Happy NHDD!
NHDD Speak Up Video from NHDD on Vimeo.
Wednesday, April 16, 2014 by Christian Sinclair ·
Thursday, April 10, 2014
Ms BB is a 57 year old woman with fallopian tube cancer with multiple mesenteric and peritoneal metastases and a history of large and small bowel obstructions. She presented with nausea, vomiting, and abdominal distention. She was found to have another bowel obstruction and had an NG tube placed with improvement in her symptoms. She then went to the OR for an exploratory laparotomy. She was found to have massive carcinomatosis and ascites and it was felt that a debulking was not possible so a venting gastrostomy tube (g-tube) was placed and the operation was aborted.
Palliative care was consulted to assist with postoperative nausea and vomiting. Despite placement of the venting gtube, the patient had persistent nausea and held a basin next to her during the interview to catch her frequent episodes of emesis. She was despondent because the surgeons had told her that the g-tube was working well and draining large amounts of fluid but that it was unable to keep up. Antiemetics were not helpful. The patient thought that there was nothing left to do and that she would have to live the rest of her life with this level of discomfort. A trial of octreotide 0.1mg subcutaneously three times daily was initiated in addition to continued drainage by her venting gtube. She was also given around-the-clock intravenous haloperidol and PRN intravenous ondansetron. By the next day, her g-tube output had decreased and her nausea and vomiting had resolved. Her pain was controlled with a hydromorphone PCA. She was eventually able to be discharged home with plans to follow up with her outpatient oncologist to consider next steps. With her symptoms controlled, she was able to move past her initial distress and talk openly about her hopes for the future and how she wanted to spend the time she had left.
Malignant bowel obstruction can occur with any cancer but is most commonly associated with advanced ovarian cancer, where it occurs in up to 50% of patients. It generally indicates a poor prognosis and carries a heavy symptom burden predominated by nausea, vomiting and abdominal pain. Patients with carcinomatosis, like Ms BB, are generally not candidates for surgical correction of the obstruction or endoscopic stenting. Fortunately, medical management can be very effective. Abdominal pain is treated with opioids and nausea is treated with metoclopramide in partial obstructions and haloperidol in complete obstructions. Corticosteroids are also often used for help in symptom control and because there is some indication that they may promote resolution of the obstruction presumably by decreasing inflammation and promoting salt and water absorption. Gastrointestinal secretions can be controlled with anticholinergics (such as scopolamine) and/or somatostatin analogues (such as octreotide).
Two prospective, randomized controlled trials suggest octreotide is superior to scopolamine. Octreotide works by inhibiting the release of several gastrointestinal hormones thereby reducing secretions, slowing motility, increasing water and electrolyte absorption, and reducing bile and splanchnic blood flow. It is generally dosed 0.1-0.3mg subcutaneously TID. Some palliative care units will use continuous infusions at higher doses with anecdotal success.
Current guidelines suggest placing a venting g-tube if medical management is unsuccessful. A venting g-tube is similar to a traditional g-tube but is used solely for drainage of the gastrointestinal secretions and the liquids taken by mouth that are unable to bypass the obstruction. This drainage prevents the backup of these fluids that would normally stretch the viscus and stimulate vomiting. As experience with this intervention increases, many clinicians advocate g-tube placement early in the treatment algorithm because it can provide more complete relief of vomiting and allow more extensive pleasure feeding. Venting g-tubes can, however, place the patient at greater risk for electrolyte imbalances.
Most guidelines and many clinicians consider venting g-tube placement and medical management with octreotide/ anticholinergics as two separate treatment pathways. This case highlights the fact that, occasionally, both may be needed simultaneously. Although Ms BB’s venting g-tube was draining effectively, she still experienced severe nausea and vomiting, and it was not until octreotide was added to the regimen that her symptoms became controlled. This scenario is borne out in some of the data regarding venting g-tubes.
In one series of patients with gynecological malignancy and upper intestinal obstruction, 4 in 31 had incomplete resolution of their symptoms with placement of a venting g-tube alone. All 4 had complete symptom relief when octreotide was added to the regimen. Clinicians need to be aware that venting gastrostomy tubes and medical management with octreotide/anticholinergics are not mutually exclusive treatment algorithms and a small percentage of patients will require both for adequate symptom control. Fortunately, as was the case with Ms BB, this approach can allow almost all patients with malignant bowel obstruction to regain some measure of comfort.
1. Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer (2008). doi:10.1016/j.ejca.2008.02.028
2. Campagnutta E et al. Palliative treatment of upper intestinal obstruction by gynecological malignancy: the usefulness of percutaneous endoscopic gastrostomy. Gynecologic Oncology. 1996;62:103-105. doi:10.1006/gyno.1996.0197
3. Ripamonti CI et al. Clinical-practice recommendations for the management of bowel obstruction in patients with endstage cancer. Support Care Cancer. 2001; 9:223-233. doi:10.1007/s005200000198
Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. It is published as a means to illustrate important teaching points in health care.
Thursday, April 10, 2014 by Christian Sinclair ·
Tuesday, April 1, 2014
April 1, 2014
by Abe R Feaulx, Special Reporter
Dr. Arya Kiddenme, a palliative care fellow at University of State College Medical School is preparing for a potentially very tense family meeting. The patient is unresponsive in the ICU and the family is having a difficult time coping with a sudden decline in their condition. When it is time to get ready to enter the room, Dr. Kiddenme quickly remembers to grab her iPhone 5s. “Can’t forget the most important tool!” She sits down to begin the family meeting, opens up the Snapchat app, and sends off a short introductory video clip. In a few seconds the family responds, with their first question, “Will dad make it out of the ICU?”
Dr. Hurley Hadopter is the program director at USCMS and believes strongly in capitalizing on the words and tools families use to communicate. “We were seeing more and more families not participating in family meetings and only paying attention to their smartphones. It was clear we had to reach them where they were, so we took a survey and found that many families would be very comfortable with using Snapchat, Twitter, Facebook, LinkedIN, Vine, iMessage, FaceTime and others, although no one choose Google Plus. We settled on using Snapchat because my teenage son said it really was useful to talk to girls, his bros and stuff like that.”
In the first month using Snapchat for family meetings, the palliative care team has already been seeing some impressive results. New consults have dropped off considerably. When asked for comment on why they no longer consulted the palliative care team, the chief oncologist at USCMS state, “I know palliative care clinicians really pride themselves on being great communicators but this is taking the whole ‘communication and listening stuff’ a little too far.”
Tuesday, April 1, 2014 by Abe R Feaulx ·
April 1, 2014 by Abe R Feaulx, Special Reporter
by Abe R Feaulx ·