Wednesday, July 23, 2014

#hpm Tweetchat 07.23.2014 - The Importance of Language

Language represents symbols and the meaning of those symbols depends on the nature of our interaction. When sitting in a clinic and receiving bad news, patients will cling to every word. Doctors may choose words carefully, avoiding some terms and emphasizing others. Patients and families, listening carefully to each word, walk away from these emotionally charged interactions, often hearing different words, and many times finding different meaning. Vinay Prasad studied the written words used in the Oncology literature, specifically the word “cure”. Defining cure as the chance someone will die of cancer being no greater then that of the age of their peers in general population dying of any cause. However, he found that nearly half the oncology literature uses the word cure to describe diseases that are considered incurable, that do not meet that definition. So, what do is meant by cure?


Another equally confusing term is “fight”. What does it mean to fight cancer? Perhaps even more important, what does it mean to “lose the fight?” Stuart Scott received the Jimmy V award at last weeks ESPYs. Although the language of a battlefield was used throughout the talk, he introduced a new twist when he said, “When you die that does not mean you lose to cancer. You beat cancer by how you live”. Fighting cancer or learning to live with cancer, its a matter of language, its a matter of perspective. Choosing to “fight” or choosing to “live”, we must choose our words carefully.

We will be exploring both of these topics in depth during the #hpm Tweetchat tonight.  We hope you will join in the discussion with us.

-Debra Parker Oliver, MSW, PhD, University of Missouri, Columbia

What: #hpm Tweetchat
When: Wed 7/23/2014 - 9p ET/ 6p PT
Host: Debbie Oliver 
Facebook Event Listing: https://www.facebook.com/events/1443430942595064/
Topics:

T1 What is a "cure?" How does the meaning of the word cure change in different situations? #hpm

T2 @StuartScott gave a moving speech at the @ESPYs this month. Please watch/listen and let's discuss: https://www.youtube.com/watch?v=K9cSX5XPY70 #hpm

If you are new to Tweetchats, you do not need a Twitter account to follow along.  Try using the search function on Twitter.  If you do have a Twitter account, we recommend using nurph.com, for ease of following.

We will be posting the transcript and analytics here after the chat takes place.
Chat Transcript and Chat Analytics courtesy of @Symplur

Wednesday, July 23, 2014 by Christian Sinclair ·

Wednesday, July 16, 2014

Hospice and Palliative Medicine Tweetchat reaches 200th chat

When I first began exploring the health care Twittersphere in late 2008, there were not a lot of people there, and explaining it to others and expand the network was pretty challenging. Six years later, the understanding of Twitter as a space to advocate and influence is well understood in the realms of sports, entertainment, politics and news. Well, we too in hospice and palliative care have made a significant impact on Twitter even if it is in the smaller niche of Health Care.

One of the tent poles for people to gather and find each other has been the weekly Hospice and Palliative Medicine Tweetchat. Having seen the success of the Healthcare Social Media (#HCSM) chat hosted by Dana Lewis (@DanaMLewis), I thought we could do something similar with the HPM community. With the assistance of co-founder Renee Berry (@rfberry), we started the chat on July 14th, 2010. Since then, on every Wednesday (barring significant holidays) there has been a chat on Twitter highlighting hospice and palliative medicine issues for four years and tonight we will have our 200th chat. In a social media world where everything seems ephemeral, this is something you can depend on.
The #hpm hashtag (remember when you didn’t understand what that was?) is quite active through the whole week. For stats on the participation in #hpm, you can check out Symplur’s wonderful Healthcare Hashtag site.

Many of the people who participate have mentioned that the weekly chat serves as self-care because of the camaraderie and support. I know many of the people I have met through these chats have become good friends, regardless if I have met them in person yet, although I always look for the opportunity. Thank you to all of the people who have participated and moderated over the past four years. It truly is a community effort.

We invite everyone to come tonight to join in with the celebration of volunteerism, advocacy, communication, shared goals, and communication. If you used to join often but life’s circumstances changed, please come back tonight and say hello. If you are still a little wary, and not sure about it, use nurph.com to watch the conversation (and maybe join in). If you cannot make it tonight, set a reminder in your calendar until it becomes a good habit! For those of you who will always be Twitter-averse (which is okay!), we will be brainstorming tonight on how to re-purpose the discussions from each weekly chat to reach new audiences.

Looking back at the first post about #HPM Tweetchat, the reasons to participate still resonate:
So why is something like this important?
  • A Tweetchat creates content that might spread
  • A Tweetchat lures other people into the conversation
  • A Tweetchat places you on the map
  • A Tweetchat connects people
  • A Tweetchat increases your sphere of influence
  • A Tweetchat exposes you to new ideas and resources
  • A Tweetchat is a place to get questions answered

(And if you were wondering why we chose #hpm and not the more inclusive #hpc, well Twitter was dominated by tech early adopters and #hpc was primarily used to discuss HP computers. #eol or #eolc were also too restrictive and reinforcing of the common bias that we help only at EOL. #hospice and #palliative are in more common use now as is #hpmglobal.)

Wednesday, July 16, 2014 by Christian Sinclair ·

Wednesday, July 2, 2014

Deadline for Comments on HPM Fellowship Update July 2

Apologies for the late notice, but I only heard yesterday about the deadline today (July 2, 2014) to the ACGME update to the Hospice and Palliative Medicine Fellowship requirements.  These updates do not come around too often and this is the first significant chance for an update since the accreditation became official in the late 2000s.

Here are some of the key files for your reference:
Impact Statement (only 5 pages - summarized below)
Program Requirements (24 fun-filled pages)
Review and Comment Form (you need to complete this and send it to familymedicine@acgme.org)

Whether you agree or disagree it is important to offer feedback either through your official representation from your institution or even as a clinician or advocate for hospice and palliative medicine.  So here is a quick summary of some (not all) of the changes and why I think they may be critical to the future of our specialty.

1) Increasing the hospice experience from 8 weeks to 10 weeks

When I first heard the requirements for hospice experience were placed at only 8 weeks in the first edition of these guidelines I was quite surprised.  My fellowship experience was based out of a community hospice, and the one I helped found in Kansas City was also initially born out of a community hospice.  So a good balance in my eyes, was more around 50/50.  I think this is a step in the right direction.  I wish it was from 8 weeks to 12 weeks, but I'll take what I can get to advance the competencies of HPM clinicians in hospice. Of note a pediatric palliative home care experience can be an adequate substitute for a Medicare or a VA based hospice experience.  I do think all programs should have exposure to pediatric HPM, but not necessarily at the expense of a shortened hospice experience.

2) Changing the fellowship requirement to a total of 12 months instead of a duration of 12 months.
The duration of a fellowship program in hospice and palliative medicine is 12 months. A fellowship program in hospice and palliative medicine must consist of 12 months of education in the subspecialty. 
This change allows the flexibility to include mid-career learners who may not be able to devote an entire 12 months straight to a fellowship program.  And with the current growing HPM workforce shortage, we need flexibility to train HPM specialists.

3) Increasing the protected time for a program director to 20-50%

Original language was vague and left it up to the institution to set the time aside.  If we are to have strong programs across the nation, then we need PDs who are protected to develop great programs, and not just working into the wee hours

4) Faculty to match the program size
In addition to the program director, there must be at least one other hospice and palliative medicine physician faculty member who devotes at least 10 hours per week on average sufficient professional time to the program. For programs with more than two fellows, there must be additional at least three hospice and palliative medicine physician faculty members.
I came from a single faculty program way back in 2003-4.  The teaching was great, but I could see the concern about smaller programs not providing a broader knowledge and skill foundation when you are limited to one faculty member. It would be great to support some of the smaller programs with some of the support found in the PCHETA bill to establish more faculty in HPM.

5) Decrease longitudinal patients across settings from 25 to 10

This is a no-brainer.  This requirement is a good idea in theory, but in reality it is really hard to execute even with the best intentions and frequent reminders.  So 10 seems an achievable number that allows for exposure to the importance of continuity, but it is realistic when factoring in fractured health care delivery systems and a premium on the fellow's time.

If you like all those things then here is something basic you can add to the 'General Comments' section (feel free to personalize/edit:
As a hospice and palliative medicine/care clinician, I reviewed the impact statement to the hospice and palliative medicine fellowship program requirements.  I agree with the changes being proposed, especially the following:
Requirement Int.C. - Flexible scheduling of fellowships for a total of 12 months
Requirement II.A.1.b - Increased protected time for program directors
Requirement II.B.1.a)-b) - Adequate number and dedicated time for faculty
Requirement IV.A.3.e)e).(1) - Increasing the hospice experience from 8 weeks to 10 weeks
Requirement IV.A.3.k) - Decreasing the longitudinal requirement from 25 to 10 patients

Wednesday, July 2, 2014 by Christian Sinclair ·

Friday, May 30, 2014

Cases: Legacy Projects at the End of Life


Case:

F.B is an 90-year-old woman who initially presented with chest pain and shortness of breath and was found to have a large descending aortic aneurysm. Her aneurysm was not amenable to surgical correction, so F.B. was discharged home with hospice for medical management.  She was interested in sharing her life’s experiences, so a legacy project was initiated.  During the course of the legacy project, F.B. became withdrawn from her friends and family and often felt anxious and depressed.  A long conversation was held with her, and she admitted the legacy project brought back memories of her husband whom she missed dearly.  She also admitted that through the project she was reminded of asset allocation and felt sad by her daughter’s anger regarding distribution of the items.  F.B. eventually completed her legacy project but had difficulty with a segment that involved recording a message to her daughter.  She often expressed worry about the legacy she was leaving behind and how materialistic her life’s memory had become.

Discussion:

Suffering, both physical, psychological and existential, is an important topic for seriously ill patients (1). The 2005 National Consensus Project on Quality Palliative Care highlighted the importance of understanding and addressing patients’ emotional and spiritual needs (2). Emotional and spiritual suffering are important factors that can contribute to the development of patients’ and caregivers’ depression and anxiety (3,6).  Various interventions are available to address emotional and spiritual distress.  One example is legacy project. These projects provide meaning-based coping through the creation of a lasting memento summarizing one's life.

Everyone has a story to tell.  This is a basic summary of legacy project’s purpose.



Legacy projects are individually tailored to help patients discuss life review, accomplishments, and heritage at the end of their life.


Hospices offer legacy projects to all patients well enough to communicate.  Examples of legacy projects include videotaping or writing stories or letters, creating handprints, recording music, or collating artwork, pictures, recipes, favorite prayers, or poems.  Some legacy projects are larger than others but all leave a mark on the patient completing the memory, the family and friends who receive the memory, and the staff and volunteers who help complete the work.


Most organizations depend on trained social workers and volunteers to create and maintain legacy projects.  There is no cost to the patient or caregiver for the project.  Hospices often receive money from donors and grants to fund legacy projects.


StoryCorps, an independent nonprofit organization that partners with National Public Radio (NPR), helps collect stories nationwide to archive in the Library of Congress.  They offer grants to smaller nonprofits and provide a mobile unit with equipment and transcription training to collect stories of patients and families.  Recently StoryCorps completed a project with Forbes Hospice in which several patients and families told their stories.


There is little data on the impact of legacy projects on patient and caregiver rates of depression and anxiety.  Two small studies demonstrated decreased rates of depression and anxiety in patients at the end of life who were involved in legacy projects (4, 9).  However, as demonstrated in our case, legacy projects can bring up questions that are uncomfortable and distressing to patients, affecting their quality of life.


References:
1.      Spirituality, religion, and healing in palliative care; Puchalski CM, Dorff RE, Hendi IY; Clin Geriatr Med. 2004 Nov;20(4):689-714.
2.      Clinical Practice Guidelines for Quality Palliative Care. 2005. (Accessed at http://www.nationalconsensusproject.org.)
3.   Irwin S, Block S. What Treatments are Effective for Depression in the Palliative Care Setting? In: Goldstein N, Morrison RS, ed. Evidence Based Practice of Palliative Care. Philadelphia: Elsevier; 2013:181-9.
4.      Seriously ill patients’ discussions of preparation and life completion: An intervention to assist with transition at the end of life; Steinhauser K, Alexander A, Byock I, George L, Tulsky J; Palliative and Supportive Care (2009), 7, 393–404.
5.      Story Corps: About Us and Programs-Initiatives. 2014. (Accessed at http://www.storycorps.org)
6.      Bryant RA. Prolonged grief: where to after Diagnostic and Statistical Manual of Mental Disorders, 5th Edition? Current opinion in psychiatry 2014;27:21-6
9.      Allen, R., et al. (2008). Legacy activities as interventions approaching the end of life;  Allen, R., et al.; Journal of Palliative Medicine. 2008; 11(7): 1029-1037. (Open Access PDF)
Original Case by Sonia Malhotra, MD, Edited by Christian Sinclair, MD

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 healthcare. Patient details have been changed by Pallimed editors to help with anonymity.

Friday, May 30, 2014 by Christian Sinclair ·

Wednesday, April 30, 2014

Prison Terminal: The Last Days of Private Jack Hall

Until I watched the documentary prison terminal I had not given much thought to what the end of life is like for a prisoner serving a life time sentence.  The Prison Terminal film was nominated for a 2014 Academy Award in the category of Documentary Short Subject and it is currently being shown in the channel HBO. 

Filmmaker Edgar Barens transports us to the inside the Iowa state maximum security prison recording how the terminally prisoner Jack hall lives his final 6 months (even his last breath). As the film evolves we meet 82 year old Jack Hall who was once a decorated World War II veteran who fought in battle and was a prisoner of war. He spent 21 years in prison of which the last 12 where in the infirmary wing.  Jack Hall’s youngest son had problems with drug use and committed suicide.  Hall was serving a life sentence after being convicted for killing his late son’s drug dealer.  When we meet him he is a debilitated man who has struggled with PTSD, tobacco and alcohol problems and who is struggling with COPD. He is aware of the short time he has to live and is resigned to die in prison:
 “I’m going to get out of here one of these days… in a box” Jack Hall

Jack Hall has the fortune of being in one of the few prisons with hospice services.  They have two hospice rooms that look similar to a standard inpatient hospice unit room. The rooms have been fully decorated with donations and furniture built by prisoners.  Hall has an interdisciplinary team with a nurse, doctor, social worker, chaplain who meet and develop care plans like any outside prison hospice patient would.  Prison hospice is different in that security is an integral part of part of his team. 

There are three inmate volunteers (Herky, Glove, and Love) who are taking care of Jack Hall.  These inmates are murderers serving life sentences in prison.  They keep Hall company, they bathe him, put lotion on him and they become their friends and caregivers. Serving as hospice volunteers for these inmates is rewarding and gives them a sense of purpose:
“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
 
Like many hospice patients Jack Hall has some unfinished business. Hall says goodbye to his friends, and establishes a relationship with his older son (who turned him in for the crime), and even manages to quip a goodbye to his doctor “see you in hell”.

When Jack gets very weak he goes in to the hospice room, his symptoms are managed and the volunteers are always by his side.   He dies and he is taken out of prison in a bag.  Due to his murder conviction he is no longer deserving of military honors, a military funeral or burial in a national cemetery.

What would have happened to Jack hall if he had been in a prison without hospice?  

He probably would have died alone shackled to his bed and struggling to breathe in his cell.

There are 1,800 prisons in the U.S. and only 75 have a hospice program and 20 of those run by inmates.   In the year 2025 it is estimated that 20% of the prison population will be elderly. These inmates have committed terrible crimes for which they are paying by serving time in prison. They are dying with many chronic conditions and should be treated humanely at the end of their lives.
Prison terminal is being shown in prisons; I hope it leads to more prison hospices being established.

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:
If you are interested in watching a previous documentary that Edgar Barens  did over a period of two weeks in the Angola prison hospice you can watch it on Youtube:




References:
1.HBO documentary Prison terminal the last days of private Jack Hall accessed on 4/16/2014 at http://www.hbo.com/documentaries/prison-terminal-the-last-days-of-private-jack-hall#/
2.Press kit and press contacts for the film Prison Terminal: The Last Days of Private Jack Hall. Accessed 4/16/14 at www.prisonterminal.com/prison-terminal-press-kit.html
3. John Walters. HBO Documentary 'Prison Terminal' Shows the Human Side of Dying in Prison. Published by Newsweek 3/31/14 Accessed on 4/16/14 at http://www.newsweek.com/hbo-documentary-prison-terminal-shows-human-side-dying-prison-238972
4. Bruce Reilly.  Terminal Illness in Prison.  Published by the LA Progressive on 03/27/2014 Accessed on 4/16/14 at http://www.laprogressive.com/terminal-illness-in-prison/
5. Human Rights Watch  US: Number of Aging Prisoners Soaring published 01/26/2012  accessed 4/16/14 at http://www.hrw.org/news/2012/01/26/us-number-aging-prisoners-soaring
6. S. 923 AND H.R. 2040, TO DENY BURIAL IN A FEDERALLY FUNDED CEMETERY AND OTHER BENEFITS TO VETERANS CONVICTED OF CERTAIN CAPITAL CRIMES accessed on 4/16/2014 at http://commdocs.house.gov/committees/vets/hvr070997.000/hvr070997_0.htm
 
Follow Dr. Jeanette Ross on twitter @rossjeanette


Wednesday, April 30, 2014 by Jeanette Ross ·

Monday, April 21, 2014

Empathy, Goals of Care & Training Opportunities to Improve Your Communication Skills and Teaching

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.


However, in the face of insoluble problems (e.g. cancer not responding to chemotherapy), patients understandably want helpful action, and clinicians still want to act.  Do something that will help me!  What can I do to help myself?  The question is, how do we figure out how to direct both our energy and the patient's? 

Back, Arnold, and others have written extensively on this topic, and the current article adds even more nuance to goals of care exploration.  They write about how patient emotion can be translated into meaningful action that moves patients towards achievable goals of care.  They recommend the following steps:

  1. 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.  
  2. 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.
  3. 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.
  4. 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"
The "goals of care" concept is already patient-centered and the described process adds to the patient centered-ness of it.  You don't automatically know what the patient's affect is about.  There's some guesswork.  But you're not going to move to an action plan until the patient confirms you've got it right AND that they are committed to the plan.  Step 4 suggests a role for patient behavior change in the goals of care process:  What can patients do to help themselves achieve important goals? In the face of serious illness, patients frequently feel like they lose control over activities in their life. Exploring emotions that might arise from this loss can help us figure out how to help patients restore some semblance of control. 

This newly described process shares elements similar to other communication skills and processes taught by Vital Talk. It's not meant to be a dogmatic process, but rather a distillation of small ingredients essential to meaningful conversations about serious illness.  

Vital Talk has some upcoming training opportunities for both clinicians wishing to improve their own communication skills and also for educators wishing to improve their teaching of communication skills. Having been through both types of training before, I would use the following descriptors: high yield, dynamic, supportive, fun, and life-long.  In addition to coming home with improved communication and teaching skills, you also come home with a process for how to continue your improvement.  

See here for more on my experience with a Vital Talk faculty development program for teaching communication.  


ResearchBlogging.org 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

National Healthcare Decisions Day April 16th, 2014

What a great thrill it is to see something start from a small local idea and take on a full national impact. National Healthcare Decisions Day (NHDD) is today, Wednesday, April 16th, 2014 and so many more organizations are getting involved, beyond those who might naturally be inclined to assist their community with advance care planning. Many healthcare organizations, employers and communities are mobilizing today and this week to make sure that patient’s preferences wishes are being documented and recognized by the medical community. I even saw it on my health insurance employee wellness homepage!

Since the manufactured outrage over non-existent ‘death panels’ has appropriately faded, I think many people feel much more confident in addressing these issues. And interestingly it seems as if advance care planning is becoming a growth niche with so many different local, regional, and national options supporting this effort. So with all these options it is even more critical for health care providers and health advocates to be informed and involved with the people making these decisions.

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
5) Go like and share the great viral info on the NHDD Facebook page


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

Cases: "Am I really going to have to live like this?": The Role of Octreotide in Patients with Persistent Nausea and Vomiting after Venting Gastrostomy

Case: 

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.



Discussion:

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.

References:

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


Original Case by Gordon J Wood, MD, Edited by Christian Sinclair, MD

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

Innovative Palliative Fellowship Using Snapchat for Family Meetings

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 ·

Pediatric Hospice is First in the Country with Emoji-Based Pain Map

April 1, 2014 by Abe R Feaulx, Special Reporter 


Pediatric Hospice of the Silicon Valley watches emerging trends in technology very closely. Seeing patients who had already staked a preference for Apple products, they wanted to make sure they could understand and relate to them differently then they would to children who grew up on Android based platforms, and the small minority that have Windows, Blackberry or Palm Pilot smartphone experience.  

Social Worker Jo King emphasized, "We noticed that the iOS children in our program would communicate using almost exclusively using Emoji. And we thought, how can we better understand what they are feeling, fearing, and thinking about.  They don't type words, even though they may be 11 or 12.  They just kept going back to these icons."  The team is eventually hoping to publish research about this strange new way of communicating.  Also understanding that a scale was too constricting, the pediatric team took a Ouija board approach and just placed Emoji all over a page and let the children pick without subjecting them to a constricting scale from 0-10.

When asked for clarification on how this was different than just giving the child an iPad, Ms. King replied, "Yeah, basically we just let them play on an iPad."

by Abe R Feaulx ·