Sunday, December 21, 2014

Tramadol-induced hypoglycemia: another reason not to use it

by Eric Widera, MD

In 2013, there were 43.8 million prescriptions for tramadol filled in the U.S. It has a slightly different method of action from many other pain medications, as tramadol is both a mu-opioid receptors agonist and a reuptake inhibitor of serotonin and norepinephrine. It is also thought that the opioid activity is due to both the parent compound and the more active O-desmethylated metabolite (which, like codeine is metabolized by CYP 2D6 and therefore gives the same big inter-individual differences in pharmacokinetics).

The overall efficacy as a pain medicine is comparable to that of other weak opioids. Most people know it is associated with serotonin syndrome as well as seizures especially when used with other medications that lower seizure threshold. A new study that came out in JAMA IM reveals a pretty robust association between tramadol use and hospitalizations for hypoglycemia, even in those without diabetes.

The Study

The authors of this study put together a large population-based cohort of patients from the UK who were either initiating tramadol or codeine therapy for non-cancer pain. They excluded those who were prescribed other opioids, as well as those with cancer and those previously hospitalized for hypoglycemia in the year before entry into the study.

The authors also did a whole bunch of different types of analysis to prove their point (nested case-control, cohort and case-crossover analyses) that would take me five blog posts to write about (if you are interested in the details, here is the article). They also controlled for a boatload (yes that is a technical term that I’m using) of potential confounders.

The Results

The analysis included 334,034 patients (28,110 taking tramadol and 305,924 taking codeine). Tramadol and codeine users were similar on nearly all baseline potential confounders. The authors found in this cohort:

    • Tramadol use increased by more than 8 from 1999 to 2011
    • Patients taking tramadol had a significantly higher risk of hospitalization for hypoglycemia (odds ratio 1.52)
    • The risk of hospitalization for hypoglycemia was highest in the first 30 days of use (OR, 2.61) Patients NOT on a diabetic medication were at increased risk of developing hypoglycemia severe enough to be hospitalized compared to those those taking diabetic medications (adjusted odds ratio of 2.12 vs 1.11)
The Take Home Point

A lot of health care providers have the misconception that tramadol is a safer alternative to more traditional opioids like morphine. This study adds further evidence that this is just not true, and that we should add hypoglycemia as a risk, even in patients who do not have diabetes.

Eric Widera, MD is co-founder of GeriPal and fellowship director at UCSF. We are happy to have him post on Pallimed for the second of 3 posts owed to Pallimed from GeriPal for the World Series of Blogs wager of 2014.
Fournier JP, Azoulay L, Yin H, Montastruc JL, Suissa S (2014). Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Internal Medicine PMID: 25485799 (OPEN ACCESS!)

Sunday, December 21, 2014 by Pallimed Editor ·

Wednesday, December 17, 2014

Is methadone plus haloperidol ready for prime time?

Methadone: A pharmacologically unusual drug, that inspires great passion.

I've prescribed more and more of it over the years, and I guess I'm in the Methadone: It's a Good Thing, But Probably Not Liquid Jesus camp of thought. While I think most of the patients I place on methadone are helped, a significant minority are not, and a few are clearly harmed (increased side effects, etc). I had a oncology PA I work with today, when we were chatting about whether or not to rotate a patient to methadone, note something along the lines of "I've been seeing more and more people on it, and many of them just seem to be zoned out...flattened." A single, anecdotal observation to be sure, but I wasn't shocked to hear her say it as I'd seen it a few times as well.

So I've been paying attention to the rumblings in our literature, which have been around for a while, around using very low-dose methadone as a co-analgesic, as well as the emergence of a discussion in Journal of Palliative Medicine of using scheduled low-dose methadone plus scheduled low-dose haloperidol (+/- use of other short-acting opioids prn if needed).

The proponents of this practice seem to argue that it prevents opioid-induced hyperalgesia (they even put it in the title); that it's a very effective and tolerated analgesic strategy: see here for their publication laying this out. This was a retrospective case series of hospice patients with no comparison group: needless to say it proved nothing and prompted this terse and I think entirely justified letter saying, essentially, Nice idea but you should back off on the over-reaching claims until you have data.

One of my passionate, pro-methadone colleagues carries the case-series around and has been gung-ho about trying it. I've told him I think we should wait for more data and that this is practice should be treated as extremely hypothetical. While we're prescribing methadone anyway, in particular I'm worried about committing our patients to scheduled haloperidol, especially as many of our patients are not dying and may live for a long time and I worry about long-term extrapyramidal side effects. I've also remained extremely skeptical neuroleptics have any real analgesic properties, but one has to acknowledge that one can be wrong, and can be convinced otherwise by good data, and I'll note that in pinging this question off Cochrane it seems like there is a smidge of data that neuroleptics are analgesic. A smidge.

Which brings us to today, and the reasons I'm writing this.

The methadone+haloperidol group has published their 2nd foray. This time a hospital-based case series, again uncontrolled. It's from a single hospital, and looks at patients who were started on, or rotated to methadone after receiving a palliative care consultation (n=43). They're not entirely clear but my sense is that this team's practice was to routinely rotate (they don't say under what circumstances they actually do the rotations, if not automatically) all their patients to methadone+haloperidol.

They used low doses, and were not rotating patients off of very high doses of other opioids (median morphine equivalent daily dose was 78mg before rotation): most patients ended up on 5-10mg of methadone a day and 1-2mg of haloperidol a day. Small doses. Key to their strategy as they present it  is that they really try to minimize patients' exposure to other opioids, I believe because they consider the hyperalgesic effects of them to have a significant clinical impact, and stopped them completely in many of them (some of them they didn't and continued a prn short-acting non-methadone opioid).

Basically by week 1 and 2 after rotation, median pain scores went from 5/10 to 0/10 in the groups. Yup. And this:
"There was a significantly greater reduction in severe pain scores by week 1 for full conversion, using haloperidol for breakthrough pain, compared with tapered conversion, using short-acting opiates (Fig. 2; p=0.02 for difference). Similar reductions in scores were seen in patients with cancer and noncancer diagnoses (Table 4; p=0.06 for difference). Significant improvements in pain scores were seen for those with an initial MEDD of ≥250 mg (median, 415 mg) and for those with a MEDD of 30 mg to 80 mg (median, 37.8 mg), but there was a significantly greater improvement associated with highest-dose opiate group (p less than 0.001 for difference). The patient with the highest initial MEDD (1600 mg) had full conversion to methadone 7.5 mg/day, for a conversion ratio of 213."
To be clear, these are  uncontrolled data. We don't know what other interventions were tried, we don't know what would have happened if they left the patients alone (regression to the mean and all that good stuff), we have no organized collection of data on side effects and toxicities, etc etc.

But, I have to say that after reading the most recent study, I am officially intrigued, and no longer willing to discard this idea on the without further consideration. 

So, to the authors of this line of investigation, I implore you - keep it up, but please move onto to higher quality investigational methods. Yes a double-blinded RCT would be great, but even a prospectively planned and implemented observational study of a clearly defined protocol (including patient inclusion criteria) which collects prospective safety data (not just efficacy) would be a big move in the right direction.

Also, if anyone out there is doing this - I think it's been an idea that's been floating around in various forms for years (?decades) - please comment and share your experience.

Salpeter SR, Buckley JS, Buckley NS, Bruera E (2014). The Use of Very-Low-Dose Methadone and Haloperidol for Pain Control in the Hospital Setting: A Preliminary Report. Journal of Palliative Medicine PMID: 25494475

Wednesday, December 17, 2014 by Drew Rosielle MD ·

Tuesday, December 16, 2014

Time For A Robust HPM Public Engagement Campaign - Picking the Right Ingredients and the Brand

As national news and media sources talk about Being Mortal and the IOM report - Dying in America quite literally and figuratively; and Palliative Care is seen as a major solution in the conversations - it is important who is leading the conversation. People are overwhelmed with the complexities of the healthcare system and overload of misinformation.

As Hospice and Palliative Medicine (HPM) professionals, we strive to guide our patients and families through the complexities of the system everyday, it is all the more important for us to engage with the public outside our offices. The benefits of public engagement range from increasing awareness about benefits of hospice and palliative care to being #hpm ambassadors, recruiting volunteers, advocating for policy reform, raising funds for advocacy, education, research and improving access.

T1: Examples of public engagement campaigns via HPM and non-HPM professional organizations and non-profits. What have we learnt?

(A quick search led to these, and by no means is comprehensive - feel free to suggest additions)

What have we learnt? What should be the strategic call to action for the public from the HPM professional organizations perspective?

T2: What would be the ideal ingredients of a viral Social Media campaign, that raises the bar for HPM public engagement?

We have all witnessed how the ALS Bucket Challenge and Stand Up To Cancer recently swept away the fundraising industry. A little while ago, it was the Livestrong Foundation campaign, the Alzheimer's Association and so on. We have seen how crowdfunding has proven valuable to HPM awareness and care delivery - recent Pallimed blog. Do we think, a HPM campaign can garner enough celebrity endorsement, public support, and much needed impetus via social and new media to establish the right brand for Palliative care amongst masses?

T3: Value of the Brand - How can we make it stick and pull people in?

What are we talking about? Serious illness, advanced illness, living well with serious illness, dying well, quality of life, healthcare system navigators, alleviating suffering, assisting caregivers and more. Our definition isn't as simple as professionals treating cancer, alzheimer's, heart disease, ALS etc. How can we balance our diversity and focus to connect with the public?

This is our last Tweetchat of 2014 as we will be on break for the last two weeks of the year.  We hope you will join us!

What: #hpm chat on Twitter
When: Wed 12/17/2014 - 9p ET/ 6p PT
Host: Ankur Bharija, MD 
Facebook Event Listing:

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, 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

Ankur Bharija, MD is a clinician educator in Geriatrics and Palliative Care, works at the PACE of East Boston Neighborhood Health Center and Faculty at Boston University School of Medicine. He is "wannabe" culinary Indian cook, a runner and enjoys traveling and photography.

Tuesday, December 16, 2014 by Pallimed Editor ·

Tuesday, December 9, 2014

Crowdfunding a Palliative Care Service: Can it really work?

In my experience, people in hospice and palliative care work have undercurrents of being early adopters and innovative. Of course there is the caring, empathetic side many of you have developed, but until recently, to succeed in hospice and palliative care meant going against the current.

Seeing people break out of the box in their thinking is one of the things I enjoy about palliative care and hospice. Dr. Michael Fratkin and his Resolution Care team are staking a claim on innovative funding when it comes to palliative care with their crowdfunding initiative on the Indiegogo platform. The campaign is nearing the end (December 11, 11:59pm) and frankly I am impressed at the level of funding he has been able to get from over 300 funders. The goal is $100,000 for this campaign, and as of the writing of this post they are almost past $60,000. And if they raise just $10k more to get to $70k, apparently a donor is willing to make up the rest to get to $100k.
Before we talk about Resolution Care more, I hope I didn’t lose you with the words crowdfunding or Indiegogo, so let me explain briefly. Many people may have heard of crowdfunding via KickStarter, the platform that has probably been the most well known. Basically, you tell the world about the project you want to accomplish, and set up rewards at different levels for funding The range of rewards in crowdfunding campaigns are pretty wide from a thank you on social media to exclusive hard to get items. Sometimes the rewards are ancillary to the project itself (similar to getting a tote bag from NPR, or a coffee mug from your local symphony.) Other times the rewards are the actual product/service. you are supporting One end of life related crowdfunding success story you may be familiar with is the First Death Cafe in the USA by Lizzy Miles in 2012, who is now a Pallimed contributor. I’m sure many of you who have heard of Death Cafe’s may not have realized that this big movement start via crowdfunding.

In crowdfunding, there are a few big winners who may get a1000x the initial ask, but there are many more who barely get off the ground for several reasons. By using Indiegogo, the Resolution Care team doesn’t have to reach $100k to get the crowdfunded money, like you have to do on KickStarter.

The approach for Resolution Care to deliver palliative care is pretty straight forward for any readers of this blog with a few twists thrown in. You can read more about the delivery model for Resolution Care on their website. It is important to note the initial delivery site will be aimed at a rural population, but they have talked about expanding to more areas depending on the success of the program.

I have watched the crowdfunding sites for sometime for hospice and palliative care related projects. This is the first one I have seen looking at palliative care program delivery and development. Will this idea spring up in more areas? Are you planning to support this project? Why or why not? Is your hospice or palliative care program thinking of doing a crowdfunded project? Have you already completed one? These are not rhetorical questions, I really am interested to see what the wider HPC community thinks.

As we see more of these projects we hope we can bring them to you in an organized fashion. I know Lizzy and I have been batting around ideas, and if anyone else is interested to help cover this new trend, we would love to have you help out.

Go check out the closing days of the Resolution Care Indiegogo campaign and see if it inspires you to support them.

Image credit: Resolution Care - all copyrights reserved

Tuesday, December 9, 2014 by Christian Sinclair ·

Articulating the Benefits and Value of Hospice Care

by Turner West, MPH, MTS

Topic 1- Articulating the benefits and value of hospice care

The language we use when describing hospice services and articulating the value of hospice care for patients and families can affect both perceptions of hospice care and utilization of hospice services. During this tweetchat, I want to know how you describe hospice care and how your message shifts based on your audience. Give me your best description on the benefit and value of hospice care. What do you emphasize when talking about hospice services to community members, to referral sources, to colleagues, to administrators and to policy makers?

Topic 2- Maximizing the hospice experience for patients and families with a short length of stay

NHPCO’s Facts and Figures on hospice care in America calculated that the median length of stay for a hospice patient in 2013 was 18.5 days which is a decline from 2012. What practices, processes, approaches have you or your organization adopted to improve the quality of care for the short length of stay patient. Are there specific discipline specific practices you can share with the group?

What: #hpm chat on Twitter
When: Wed 12/10/2014 - 9p ET/ 6p PT
Host: Turner West
Facebook Event Listing:

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, 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

If you liked this, then check out Turner West's review of the CAPC 2014 conference.
Turner West, MPH, MTS is an educator and administrator at Hospice of the Bluegrass in Lexington, KY. He is married has a 16 month old with a “ask me about palliative care” bib and an 8 year-old St. Bernard.

by Pallimed Editor ·

Sunday, December 7, 2014

Cambia Awards $10 Million to University of Washington Palliative Care

The Cambia Health Foundation made a huge impact in palliative care this week when they awarded the University of Washington Palliative Care Center of Excellence a $10 million naming gift. For many teams working in palliative care, philanthropic support of this kind is something you dream about when your team is trying to plan for the future. This multi-million dollar level of direct charitable support for palliative care projects brings to mind the late 90's and early 2000's when Robert Wood Johnson, Milbank and Soros/Open Society Foundation funded many early projects we still look to today (SUPPORT study, CAPC, EPEC, 1997 IOM report and more).

Cambia Health Foundation was founded in 2007 to make an impact on Palliative Care, Transforming Health Care and Children's Health. They are the corporate foundation of Cambia Health Solutions, a health insurance company that focuses on the Pacific Northwest and previously known as The Regence Group. Some of you may be familiar with what Cambia has done with the Sojourns Awards ($180,000 innovation grants), which have recently moved to a national focus and we discuss in more detail below.

Earlier this week, I interviewed Randy Curtis, MD, the director of the newly named Cambia Palliative Care Center of Excellence (Cambia PCCE) at the University of Washington (UW) and Peggy Maguire, president and board chair for the Cambia Health Foundation about this fantastic partnership.

Sinclair: Congratulations on receiving this grant! Randy, tell me what this award means to you.

Curtis: This is a huge opportunity for the Cambia Palliative Care Center of Excellence. We've been existence for two years as a center for excellence, starting in October of 2012. We have been busy building a program which encompasses both clinical care and education, as well as research, centered at the University of Washington. What Cambia has provided us is an opportunity to dramatically extend and grow our program and to be much more of a resource regionally and nationally as well.

Sinclair: Could you share the clinical history of your programs?

Curtis: The University of Washington Medicine includes the UW Medical Center, Harborview, and our two community hospitals Northwest and Valley for clinical service. We also have outstanding partners in education, research and collaboration at Children's and VA. Palliative care consultation services are present at each of those campuses, and they are all at different periods in their development. UW and Harborview have pretty mature programs.

Sinclair: Peggy, how did you start to connect with UW and Dr. Curtis?

Maguire: Randy is a preivous Sojourns Awards winner (2013) as is one of his colleagues Dr. Tony Back (2011). We first became familiar with their program as we were looking for palliative care leaders and innovators. That was our first connection. When the PCCE was founded at UW in 2012, Cambia Health Foundation made an initial grant to support them. Since then we have had touch points through our Sojourns grant making and awards program. As we got to learn more about the program and the leadership of the Center, we felt there was a really strong opportunity to spread the word about palliative care, both in creating awareness on the consumer side as well as the provider side.

Sinclair: Peggy, can you talk about Cambia Health Foundation's pivot from being a regional supporter to a national leader in supporting palliative care?

Maguire: Yes, I think one of the shifts is in the way we changed our Sojourns Awards, which initially was to recognize leaders in our geographic footprint. In 2014, we focused on emerging leaders from across the country who are doing really interesting projects in palliative medicine. We thought supporting them could develop the field and build a stronger workforce. In our 2014 Sojourns scholars program, we awarded 10 scholars $180,000 each over two years. We also paired those scholars with mentors and established leaders in the field. This allows each scholar to work on their innovations and projects. We're excited about what this group will learn from each other and the dissemination of their work. We hope it will have a big impact.

Also with the UW Cambia PCCE, we hope their outreach will help the Pacific NW be seen as a hub of innovation and leadership. What they develop here will have application not only in Seattle and the Pacific NW but the rest of the country. We think it will become a beacon for other PC programs and we are excited about that.

Sinclair: Randy, coming out of the gate what will be your focus in 2015 that we can get really excited about?

Curtis: We're focusing on both primary and secondary palliative care. One of our initiatives is to improve palliative care delivered by clinicians who are not palliative care specialists. We are developing palliative care training centers, where we offer training for interdisciplinary teams (social worker, nurse, doctor, and spiritual care). This program spans over a nine-month period, including three one-day intensive courses in Seattle, but also distance learning and video feedback. That is one of the programs we are launching right away. In addition, we are working with our faculty member Tony Back and his VITALtalk program to further training in primary palliative and specialty palliative medicine clinicians.

Sinclair: Burnout is a hot topic right now and with you getting a fantastic resource from Cambia like this - how do you see your balance between being really innovative and trying to figure out if you have the right amount of faculty and staff to accomplish day to day clinical duties? I know some who see this award may think, "I could do some of these things, but I don't have the faculty or the staff." How are you and the PCCE looking at this issue?

Curtis: This is a really key issue, and a focus of the center: looking at the ways to reduce the development of burnout and also address burnout when it does develop. We want to focus on the burnout of palliative care specialists, but also the burnout of people caring for serious illness for those doing primary palliative care. The other approach which will be key, which you alluded to is to build the workforce. A key reason for high burnout among palliative care specialists is the inability to fill positions that are funded because they are difficult to fill,. That workload stresses those who are trying to cover all the work. That is another area we will focus on as well.

Sinclair: Peggy, Many people across the country who pay attention to philanthropy and palliative care issues will be reading and talking about this grant within their teams and departments. Besides knocking on your door and calling you to say "Hey, we don't suppose you have any more amazing palliative care grants laying around?", how can something like this jump start the local philanthropic effort in other cities and regions? It obviously shouldn't have to be all Cambia, but don't we need to find other Cambia-like organizations to try and start doing something like this?

Maguire: I love that question. Our cause as a company is to transform health care and to create a more person-focused system. The Cambia Health Foundation is the philanthropic arm of Cambia and we take our role as a catalyst very seriously. If other organizations want to collaborate with us to help support great work, we welcome that. It would be wonderful if another funder called us up to collaborate or another funder was inspired to give a gift like this. We would be happy to work with like-minded partners. That is a fundamental tenet of who we are. We don't want to do it all by ourselves, We can be a catalyst to inspire others and make an impact on the field.

Sinclair: Any other points we did not touch on, which are important to the future of this program?

Curtis: A big part of naming the Cambia Palliative Care Center of Excellence is a responsibility on our part to serve as a resource to our region and the nation for programs that want to help identify donors and grow. We will be focused on outreach to provide that resource.

The second point is we have gotten to know the Cambia Health Foundation through the last three years through the Sojourns award program and it is a real honor to be associated with the name Cambia . Their values are in the right place; for them this about making health care more person-centered, incorporating patients and their families. That is a relationship I am very proud to be a part of. This is an opportunity because palliative care is at a tipping point. I think what Cambia is doing with the naming grant and other programs is contributing to that tipping point. With that, I believe there will be more opportunities for all of us to identify additional resources to find philanthropy and funding.

Maguire: Absolutely our dedication to palliative care runs very deep in our organization, and it is very personal to us, to the members of our foundation board. Palliative care is critical to the health care system in our country. I can't think of a better approach to patient care and having a workforce that is trained and skilled in palliative care will only help patients and families in health care.

Image Credit: Cambia Health Foundation
Photo Credit: University of Washington
Photo Credit: Cambia Health Foundation
Photo Credit: howardignatius via Compfight cc

Sunday, December 7, 2014 by Christian Sinclair ·

Saturday, December 6, 2014

How Hard Is It To Get Dental Care at Home?

(Originally posted on Geripal as part of the World Series of Blogs Payback-Ed.)

Have you ever had a patient at home who was in need of dental care? Perhaps they were receiving hospice services or maybe they were just discharged from the hospital not on hospice, but still too frail to get to the dentist. Of course the focus is often on the medical issues, yet the most significant issue was broken rotted teeth, which made oral intake nearly impossible without pain. Clearly, the answer here is not opioids for pain control, but rather to take care of the root problem: access to dental care.

Clearly dentists and their staff are not part of a hospice or palliative care IDT, but when you need them, boy do you need them. If the short case I outlined is not clear enough for you, I would really encourage you to read “Love” by Jean-Noel Vergnes, DDS, PhD recently published in the Annals of Internal Medicine (paywall). Written by a dentist in France caring for his wife who had a stroke and was desperately in need of dental care he himself could not provide, it illustrates the anguish of not being able to provide care you know someone needs.
“And little by little, it got difficult to clean her teeth with a toothbrush, too; she made little animal noises all the time, as if we were hurting her. So, it’s true that I didn’t take that much care of her mouth.”
Yet in the end there is a deep satisfaction when a dentist is found who will come to the home and provide the much needed care for his wife.
“Knowing that such a possibility existed made me change my mind. Actually, I’d always had this little voice in my head telling me that I wasn’t doing what was best for her, that I might be convincing myself that it was useless just because I didn’t have the strength to get on with it.”
Reading this story makes me reflect on the access to home visit dentists in my metro service area. When we need a dentist, the team works frantically to find someone willing to come out. So what are the barriers for a dentist? Is it malpractice insurance out of the office? Lack of access to the ever more complicated tools while in someone’s home? Lack of adequate reimbursement? Lack of time? I know many dentists do charitable activities in urban and foreign locations (usually for children), so I know the barrier is not likely to be a cold, uncaring heart. How can we as palliative care providers strengthen this relationship with dentists so the care is not needlessly delayed? The answers are likely complex and different in every community, and I know the answer is not the DentiDrill Home Dentistry Kit. Yet, I’m hopeful by asking this question of our great communities we might find a better answer together. Then maybe more people can have memories like this:
“She gave me a wonderful, broad smile. She was beautiful, so very beautiful. Ah, how can I put it? I knew that smile would be her last. I smiled back at her, savoring the moment . . . a moment that I couldn’t even try to describe. And that smile was, indeed, her last. I’ll remember it every day that I have left to live.”
Vergnes, J. (2014). "Love", Annals of Internal Medicine, 161 (10) DOI: 10.7326/M14-1076

Saturday, December 6, 2014 by Christian Sinclair ·

Thursday, December 4, 2014

Medicare (CMS) Reimbursement for Advance Care Planning - Speak Up!

by Phil Rodgers, MD, FAAHPM, Co-Chair, AAHPM Public Policy Committee

(The following is part of a three-post progressive blog about advance care planning, prompted by the Centers for Medicare and Medicaid (CMS) decision not to pay for the new “complex advance care planning” codes in this year's Medicare Physician Fee Schedule. Now is the time to tell CMS why you support reimbursement for these important services! The agency is accepting public comments through Dec. 30 —it’s easy to submit comments online!

Please also see AAHPM Public Policy Committee Co-chair Gregg VandeKieft's update on how key organizations are collaborating beyond AAHPM to make Advance Care Planning efforts succeed. And don't miss out on AAHPM State Policy Issues Working Group Chair Paul Tatum’s GeriPal post where he makes the case that it’s time for advance care planning to become routine for patients with serious illness. - Ed.)

Late on October 31st, the Center for Medicare and Medicaid Services (CMS) published the 1185-page 2015 Medicare Physician Fee Schedule (MPFS). What is the MPFS? If you don’t know, don’t worry—the majority of Americans (including many health care professionals) have no idea this document exists, and until recently I was among them.

In short, the MPFS lays out how Medicare intends to reimburse ‘practitioner’ services for the coming year. ‘Practitioners’ include physicians, nurse practitioners, physician assistants and other professionals who provide ‘qualifying’ services to Medicare beneficiaries. These services are most often described by Current Procedural Terminology (CPT) codes, and valued through Resource-Based Relative Value Units (known as RBRVUs or just RVUs).

I have been fortunate enough to be supported over the past year by the American Academy of Hospice and Palliative Medicine (AAHPM) to serve as their advisor to the AMA’s Relative Value Scale Update Committee or ‘RUC’, which recommends RVU values to CMS for each and every CPT code. In this role, I’ve been able to advocate for the work that HPM professionals do every day, in the process by which those services are described for CMS to determine how much they will pay for them. In other words, HPM has a voice in the process (or ‘seat at the table’, choose your favorite metaphor), in helping CMS understand what it takes to deliver high-quality care for patients with serious illness.

Why should we care? Medicare fee-for-service covers 33 million older and disabled Americans, and in most markets is THE largest payer of hospice and palliative medicine practitioner services. It also often sets payment benchmarks for commercial payers (including Medicare Advantage plans, which cover an additional 14+ million beneficiaries). As a result, the MPFS tells us how and how much HPM practitioners will be paid for a large part of the work they do. So, dense and obtuse as this all may seem, it matters.

The 2015 MPFS matters even more to HPM providers, as it (for the first time) includes Advance Care Planning (ACP) services. These services are described as “…the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; face-to-face with the patient, family member(s), and/or surrogate.” While the descriptor mentions ‘form completion’, these codes really cover more substantive discussions about goals of care, treatment options, values and preferences.

The CPT and RUC processes have developed and valued two codes for these ACP services: 99497 (first 30 minutes, valued at 1.50 RVUs) and 99498 (each additional 30 minutes, valued at 1.40 RVUs). They can be billed in addition to Evaluation and Management (E/M) codes, reflecting the ‘separate and identifiable’ (in CPT lingo) nature of more complex ACP discussions.

The ACP codes have a backstory (see Pam Belluck’s excellent piece in the Aug 30 New York Times) that brushes up against everything from ‘death panels’ to a growing number of commercial insurers and Medicaid programs who have already begun to pay for ACP services. In the 2015 MPFS, CMS acknowledged both codes, but stopped short of authorizing Medicare payment for them for 2015 (more on that below).

I want to pause here to acknowledge two things about these codes. First, it is a major step forward even to describe and value advance care planning services, the enormous impact of which is demonstrated by a growing body of research and the daily work of health care professionals who perform them (including many Pallimed readers). Yes, it’s many years too late and still part of a system of many misaligned financial incentives, but it’s an important start. Second, and more importantly, is that support for ACP services is broad and deep within the physician community. The most striking part of my experience working on these codes has been the coalition that formed to advocate for them.

The American Geriatrics Society − which only received a permanent seat on the RUC in early 2012 ­– has taken the lead to organize this coalition, providing staff support for stakeholder societies (including AAHPM) to join forces and advocate for the ACP codes through the RUC process, and in joint communications and face-to-face meetings with CMS. There are big players involved – like the American College of Physicians and the American Academy of Family Physicians which together represent over 250,000 physicians – along with specialty societies like AMDA – The Society for Post-Acute and Long-Term Care Medicine, the American Academy of Home Care Medicine, the American Academy of Neurology , and the American Thoracic Society. The physician leaders from these groups continue to speak eloquently and passionately about caring for patients with serious illness, and specifically about the necessity of high-quality advance care planning.

Now it’s your turn. While Medicare did not agree to start reimbursing the advance care planning codes for 2015, they did signal openness to reimburse them in the future, and invited comments until December 30. Individual comments really do matter to CMS: staffers read every submission, and individual comments are actually cited throughout the MPFS as rationale for payment decisions.

So, it’s time to tell CMS why you support reimbursement for advance care planning services. You do not need to be a physician or even a clinician to comment . A couple of things to consider when writing your comments:
  • Tell why you think it’s important to pay for ACP services through a specific mechanism. CMS has suggested that it believes Medicare already pays for ACP services through the Evaluation and Management (E/M) and extended service codes.
  • Tell them about the unique value of advance care planning, and how it is ‘separately and identifiably’ necessary in addition to all other services (medical therapy, symptom management, etc.).
  • Be specific, be yourself, and write about what you know. It’s OK to reference the literature about ACP services and palliative care, the IOM report, the importance of tracking the frequency ACP is performed, the needs of an older and sicker society etc., but it’s more powerful to speak from personal experience. 
  • Tell patient stories that illuminate a connection between high quality advance care planning and better care for your patients. Every HPM professional I know has dozens if not hundreds such stories.  

Now is the time to tell them.

Comments are open until December 30 and can be submitted online.

Don't forget to check out the other two blog posts in our progressive blog party! Click the images below.

Thursday, December 4, 2014 by Pallimed Editor ·

Wednesday, December 3, 2014

Cases: Are Goals of Care Conversations About Emotion or Fact?

by Bob Arnold, MD

It had been a tough day rounding. We had four family meetings one after another. In one, the daughter walked out in the middle because she just could not hear any more. In another, the daughter made it clear that she just was not ready to think about the therapy not working. As we walked to our next meeting, the resident said to me, “Sometimes, I feel that you are too easy on them. Why do you not just tell them that it will not work? They need to understand that the therapy will not work.”

There is a common misperception that conversations about goals of care are always factual conversations. The doctor has to tell the family about the medical condition, the fact that current treatments are not working, and what, if any, options there are. The object of the conversation is to tell the information in a way so that family members “get it” and make “appropriate decisions." Doctors often think that families who do not understand this information are in “denial” or worse, have a financial motive for not understanding what is happening.

In my experience, this is rarely the case. Families often understand the information that the healthcare providers give—they just do not agree with it. (Given that we are giving prognostic information about what is likely to happen in the future, we cannot claim to hold the truth. We are probabilistically more likely to be more accurate, but what the future will bring is, until it occurs, unknown.)

Instead these conversations are about loss, sadness and anxiety. Loss about the current treatment not working. Sadness that the patient will not be able to achieve the goals they were hoping for. Anxiety about what the future might bring. Until these emotions are heard, acknowledged and processed, it may be hard for family members to move onto the next step—thinking about what their loved one would say given the new medical situation.

What data do I have for this belief? The family says things like “I know, but we cannot stop hoping,” or they just keep wondering if there is not something else that might work, or they hope for a miracle (which by definition means they know that what we are doing is not working). In these cases, the family does understand what clinicians are saying—they just do not agree with it, do not want it to be true or cannot imagine the consequences if our view of the future proves true. Trying to convince the family that our view of the future is the correct one often leads to conflicts where we are repeatedly giving bad news, the family keeps wondering or demanding something else, and we all leave unsatisfied. The family feels like we are giving up, and we feel like they “do not get it.”

There is another way to think about how to have these conversations. Think about them occurring on two planes—a factual plane and an affective (or emotional) plane. Typically we operate on the factual plane where we try to convince the family that our view of the future is the correct one. The problem is that what is happening on the emotional level precludes family members from cognitively processing and using this information. Psychologists know that we do not process cognitive information when we are emotionally flooded. In addition, when the information is too painful, one may actively resist acknowledging it because it is too painful (“denial”).

In addition, family members’ emotional reactions tell us about what is most important for them at this time. It gives the clinician a window into the things that the family is most concerned about, cares about and is worried about.

Finally, these emotions are normal when someone is being asked to confront or see something that they do not like. The fact that the family is having these emotions is, in fact, pretty good evidence that they do understand what you are saying, and they do not like it. Rather than trying to convince them on the factual plane that you are right, it will lead to a healthier relationship and better conversations if you meet them on the affective plane.

What does this mean for the clinician? It means, rather than giving information, attending to family members' emotions. It means acknowledging that “this is scary,” or that things are not going the way that they want. It means not fighting with them about the facts about what might happen and joining them on the emotional plane: This is not what we wanted to have happen, and, in fact, there is a part of us who, like them, wishes the better story would come true.

When people feel heard and appreciated, their emotions often decrease making them more able to think through the facts. They are able to think about situations that otherwise would be too frightening, scary or sad. They can begin to consider what their loved one would say about this new situation.

I know this is a long answer to my resident’s question, probably more information than he or you wanted. So I will end with a suggestion: If it feels like the conversation you are having with the family is a battle, if it feels like they are not listening to you or do not want to attend to what you are telling them, or they keep asking the same questions, think about what the affective plane of the conversation is. Try to identify the emotions that the family is expressing and see if you can acknowledge or name the situation for them. Stop trying to convince them and try to join them on that plane to see if you can help move the conversation from a fight over who is “right” to jointly confronting the situation they are facing.

Thanks to Debbie Seltzer for her editing and Tony Back, James Tulsky and Kelly Edwards ( for helping me realize this and figure out how to teach about it.

Original Case by Robert Arnold, MD, Edited by Christian Sinclair, MD
University of Pittsburgh Medical Center

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 may have been changed by Pallimed editors to help with anonymity. Links and small edits are made for clarity and to abide by Pallimed editorial standards.

Image: iStockPhoto

Wednesday, December 3, 2014 by Pallimed Editor ·

Sunday, November 30, 2014

Developmental Life Cycles: Working with Pediatric and Geriatric Populations

 A Conversation between Two Specialists

At both ends of the generational pendulum lie two groups that may seem to be daunting to some: children and the senior population.  These are specialty populations because there are unique considerations with aspects of their medical care, especially within the framework of palliative and hospice care.

Here Allie Shukraft, pediatric palliative care social worker, and Lizzy Miles, geriatrics hospice social worker, discuss some of the differences and similarities between these two seemingly divergent specialty populations. Allie and Lizzy also describe their social worker roles as they relate to their patient groups.

This article about Developmental Life Cycles is the first article in a series of planned joint conversations into these populations.

Allie: For children, developmental stages are different than adults, but basic needs are the same. There is a wide range in understanding and experience in pediatrics, and this can impact the tasks and goals that the family chooses to strive for. However, the needs are much the same as those of any age: to be loved, to have understanding, and to be unafraid. Luckily, most children have their parents and siblings, if not a floor full of caring staff-members throughout their palliative course.

Lizzy: I agree with the "needs" for any age. I do think that applies to my patients as well. As far as development cycles go, gerontology is a newer area of study than pediatrics. In gerontology, developmental cycles are not as clearly defined as they are with children. You could ask five different experts and get five different answers. We don’t categorize our patients by age because our clients do not use their age to define themselves. My favorite intervention with elders is Dignity Therapy, developed by Harvey Chochinov. The premise is simple: to see patients as they see themselves. Our patients don't see themselves as infirm, they remember when they rode motorcycles or traveled to some foreign country at the drop of a hat. Their approach to their dying is going to be less about their age and more about their general philosophy towards life.

The best thing we can do for our gerontology clients is to get to know them and have them feel that we "know" them as well.

Could you give me some examples of how your approach might differ based on developmental cycle for children?

Allie: Well, children are going to differ greatly in their own view of death. Some of this will be along developmental lines, and some on experiential lines. If the child has already experienced a death, such as a pet or a family member, for example, this loss can color how the child views death and the words that he uses to describe it. At various stages, the concept may be too abstract for them to fully comprehend, or may include magical thinking to explain concepts beyond their understanding. There are some great resources out there for more specific information, such as The Dougy Center, which has a list of stages and understanding.  When looking at the child’s own death, there is often a great deal of fear especially if the family won’t talk about it. Here children might express a desire to stay awake out of fear they will die in their sleep, or an unwillingness to be separated from their parents.

The social worker’s role is to try to get everyone in the family talking honestly about death so that the child can express and worries or fears that he may have and the team, particularly the parents, can talk about how to address these issues. One approach for a 9-year-old, for example, might be to try to get him to talk about what death is and why he thinks he is dying. Developmentally he is starting to have a concrete understanding the permanence of death but is likely to have fears about death being something painful or that will involve harm to his body. Talking through what we know will happen and what we hope will happen allows us to combine the medical with the metaphysical and bring in his parents’ (or his own) spirituality and belief systems.

​Lizzy: I'm glad you brought up spirituality because a person's spirituality (or non-belief) can definitely be an influential factor on their views of dying. While not directly tied to a developmental stage, my experience has shown that the older the client is, the more likely they are to have a strong religious orientation and/or church affiliation. A belief in heaven does not necessarily mean a greater acceptance of death though. Also, we still need to assess spirituality and not make assumptions, because I have seen 99 year old non-believers too.

When I think about the different generations within gerontology and approach towards death, I would also want to acknowledge that an older age does not guarantee an acceptance of death. The process of dying can still be a scary concept ever for elders who have lived a long life and have a strong "faith."

You mentioned previous experiences with death. I always ask my hospice patients what experience they have had with other people dying, especially looking for firsthand bedside experience. If the patient had been bedside and it was a peaceful moment with their loved one, they may be less afraid. If they have not had experience, then I can share with them my own assurances from my work at the bedside. My role is to provide assurance that we will control symptoms and that a peaceful death is possible.

Allie: When looking at a pediatric death, we are also fortunate on the inpatient side to (typically) have access to certified child life specialists (CCLS) who have education in childhood development, medical play and education, and legacy-building. Using these skills they take the lead in memory-making for the child and family, helping the child to make gifts for his or her family such as hand molds or footprints.  Some even write songs as part of their legacy with our music therapist.  In this way, although they have less life to review that adult patients, they are still able to leave an indelible mark for their families that keeps their stories going.

Allie Shukraft, LCSWA, MSW, MAT, is a pediatric palliative care social worker for Carolinas Healthcare System in Charlotte, NC where she loves reading and walking with her dogs. Although she is still learning how to use it, you can find her on Twitter (@alifrumcally).

Lizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio best known for bringing the Death Cafe concept to the United States. You can find her on Twitter @LizzyMiles_MSW

Photo Credit: cabancreative via Compfight cc

Sunday, November 30, 2014 by Lizzy Miles ·

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