Some Highlights from the Web

Nothing too hard hitting in this one, those last two posts wore me out. And I like many other fellowship program directors around the country are busy getting our fellowship applications ready for the first round of accreditations due in the next several weeks.

The Happy Hospitalist found a picture on Flickr took a picture from his service reflecting what he sees regularly. His blog post was then picked up by the WSJ Health Blog. The title of his post was "87 years old" and the caption read: A photo worth a thousand words. Now…. multiply by five. One hospital. One service. One day. Mine. This is American health care. It inspired very different takes on his own blog and on the WSJ Health Blog. Read the comments for a pulse of American view points on aggressive ICU care for the elderly.

The WSJ Health Blog also rediscovered a 2006 National Geographic image about the likely causes of death. The image is called the 'death spiral' although it is really more like a Venn Diagram and each circle within representing the likelihood of occurrence based on the size. The line on the outside...that represents the risk of dying if you are living. Mortality risk 1 in 1. Kind of like the satirical paper The Onion reminded us in 1997.

House calls may be making a comeback as featured in the Boston Globe op-ed, but as many hospice physicians know, there are already a lot of us making these home visits. It is always a delight to see people's expressions when they hear you make house calls. Many really don't believe you until you show up at their home.

On the heels of the Medicare Hospice cuts post, comes this study alerted to us by an anonymous poster that demonstrates wide regional variations in hospice density. Unfortunately it was only a paper presentation and not yet published so all we have to go on is the press release text and a small image map, without a clear legend. I am still having trouble with this paragraph in the press release:

On average, the study found, counties have 2.1 hospices located within their borders, but the number ranges from none to 125. When the researchers looked at 60-mile-radius service areas — the range recommended by the National Hospice and Palliative Care Organization — the average number of hospices serving a county was just over 52. But it ranged widely – from none to 280.

Maybe Dr. Silveira could let us in on what the colors mean, if anyone knows her tell her to drop by and fill us in. (She is the winner of the 2006 AAHPM Award for Young Investigators BTW) Dr. Silveira emailed me the key below.

The colors 'categories' on the map mean the following:
> red - highest hospice availability (taking into account 60mi service area around each office)
> orange -medium
> cream - average
> light blue - low availability
> dark blue - lowest availability
(added April 4/22)

The AAHPM opened the first call for the Annual Assembly 2009 in Austin, TX. I will have an upcoming post on how to submit a proposal to a conference, and will welcome any tips from long time presenters to help anyone relatively new to the process. Also, I will make a plea for someone to submit a Philosophy talk about death and dying so I can go to it next year. We need some contemplative/insightful talks at AAHPM next year. If you do propose it and it gets accepted, I promise to plug your talk here before the next conference and get hundreds of people to show up. Well...at least I promise I will show up.

The Hospice Foundation of America has a good hospice news blog that covers focuses on slightly different topics than we do here. I wanted to alert our readers to a two great links HFA Blog highlighted (1, 2). The Concord Monitor received a Pulitzer Prize for Photography for a series on a dying woman's wish to leave a final gift to her children. There is a wonderful narrated slideshow of the prize winning photographs accompanying the article. The second item is a Guardian (UK) photo exhibit of people photographed alive and on the day they died. Wonderful, touching images that are currently on display at the Wellcome Collection.

And you may have heard about bloggers writing until they die. Well, Drew, Tom and I are doing OK, so don't worry about us!

NOTE: Correction made 4/15/08 in second paragraph. Added hospice color key 4/22/08

Antibiotics and Treating Infections in the Elderly

1)
The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)

The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patients with advanced dementia.

The study did not have data representing success of treatment for each course, which makes hampers clinical relevance. If we had information that indicated say 80% of the UTI's were cured, but only 35% of respiratory infections improved or similar info, we could have more informed discussions with staff and family. Also this article does not have information on symptom improvement, since antibiotics may have improved symptoms (although data in elderly says this is not a major effect), but that would be difficult to get workable objective data from someone who by inclusion criteria cannot communicate.

Despite this information, one cannot conclusively make an across the board declaration that patients with advanced dementia should never get antibiotics. We don't yet know what the outcomes might be for those that had antibiotics withheld. There is a general understanding that fever and likely infections are a common pathway towards death for advanced dementia patients. The optimal strategy is not yet clear, and these issues must be decided on an individual basis with open discussions of goals of care. But this study may help nursing home staff, and hospice and palliative medicine staff make more judicious use of a minimally efficacious treatment, that as a secondary gain could potentially help public health by decreasing antibiotic resistance in the community. I would imagine this second point is a bit more challenging to ethically justify. Autonomy versus Distributive Justice...en garde!

Interestingly the CDC is debating on how to advocate influenza immunization of all school age children to protect the children, but also to decrease influenza deaths/infections in the older community. The CDC are not necessarily advocating we "treat the children to save the elderly." So it is interesting this Archives of Internal Medicine study could be spun as "Don't treat the elderly to save the children." I realize I am making broad generalizations, but it is interesting the eerie similarities between the two circumstances. The editorial for this article is highly recommended as well.

(Thanks to Pallimed reader Maria F for the tip!)

D'Agata, E., Mitchell, S.L. (2008). Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104

I have had so many things crossing my desk that I have wanted to share, that I have to clear some of these out.

For our chaplain readers, you may be interested in the recent Religious Landscape Survey by the Pew Forum on Religion and Public Life. The site has some good demographic maps to look at the different faith communities in the US and by states. The full report is here. The media's take on this has been focused on how people change religions more often.

The British Medical Journal recently published a clinical review on treatment of adult depression. Dr. Shock (a blogger) reviews it nicely. Obviously the article is not focused on palliative medicine, but a good general background on current views on depression management (and not just pharmacological management). But before you prescribe that Prozac, a recent study (free pdf) in PLoS Medicine suggests that antidepressants may be no better than placebo. James Hrynyshyn at Island of Doubt has a nice blog post summarizing the study and the drug-placebo controversy.

Thomas LeBlanc and Amy Abernathy (of PC-FACS) explore research in hospice patients in an ethics forum for American Medical News. A good conversational review on a desperately needed area.

And finally with the recent movie "The Bucket List" about making a list of things to do before you die comes this very helpful blog post about priorities in life and how to 'manage' your bucket list.

The Changing Faces of Death; Pal-Pourri; Pallimed Party

There have been a few pieces in the media recently that have caught my eye in regards to how we as a society look at death and dying. The Montreal Gazette published an opinion article with the title "What if we could choose our time to die?" The author, Hugh Anderson, writes the piece in response to letters from his previous piece about growing old. He never makes a strong statement about hastened death, but his title alone is provocative to start a few conversations.

What if we took our current concepts of medical care and instead had a very open approach to time of death, similar, for example, to our medical approach to time of birth. Time of birth used to be wholly a natural event, for better or for worse, but the advancement of modern C-sections, medicines & delivery techniques changed the natural prognosis (expected timing and medical outcomes) for births. What would our current system of hospice, palliative medicine, and intensive care units look like if in 1950 American society determined choosing the time of your own death was an inalienable right? I doubt if we took the quick road to death that the modern hospice movement would have evolved as it did. Would this change our approach to organ transplants as well? What other areas of medicine would be vastly different because of this massive social change? If there are any literary minded Pallimed readers who would be interested in doing some creative writing, we could collaborate on an alternate history of the approach to death in American society. Exploring alternate history is a wonderful tool for insight into current situations and values via taking what we hold as normal and turning it completely around. I think you could take this idea and explore it in various outcomes, from dytopia to utopia. Obviously movies like Soylent Green and books like The Giver explore some of the social ramifications of euthanasia, but a focus solely on our medical culture would be an interesting approach as well. (Disclaimer: Not endorsing hastened death, physician-assisted suicide or euthanasia, just using these examples to explore the deep intricacies of such a profound part of life. Besides, Hugh brought it up, not me. I can't help wanting to share some potentially provocative ideas. Great dinner conversation!)

Speaking of how society feels about death, the Supreme Court heard a potential landmark case (Baze v. Rees, 2008) today noting the 3-drug lethal injection (thiopental, pancuronium, potassium) is unconstitutional because of the potential for severe pain without the ability to identify it (secondary to the paralytic). You can read the transcripts of the oral arguments here for you legal junkies. What is interesting is to read some of the amicus briefs in support, opposition and neutral positions. The American Society of Anesthesiologists weighs in as well as heavyweight medical ethicists/palliativists Robert Truog, Bernard Lo, and Margaret Campbell (with fellow critical care providers and ethicists.) One of the arguments heard today for changing lethal injection is to co-opt the methods for hastened death in the Netherlands or Oregon, by using inordinately large amounts of barbiturates. How would this change the debate on physician assisted suicide if it was a similar clinical approach to capital punishment?

Wired Magazine had a recent article showing us that death is nothing we need to worry about because of some new miracle drugs that focus on our mitochondria. Some great quotes are found in the article from bench researchers:

"They die of natural death ....probably their heart stops to beat!" wrote Fontana of the rodents in his and other studies, which betray little evidence of the histopathological lesions -- tissue and organ damage or abnormality -- mentioned by Bartke. "The animal drops dead and we cannot really know why.... One expanation (sic) is the failure of the electrical conductive system of the heart because of metabolic alterations.... No pain, no suffering, no medical and social cost for society!"

Well this post is already getting too long so I won't comment on the broad assumptions in the last part. Maybe it is because I fear I might lose my job if this comes true. But it did make me chuckle to think of how these little mice will change lifetimes of angst about death.

YouTube clip of Ingmar Bergman's The Seventh Seal - Knight Facing Death in Chess
(wait until about 2 minutes in, there are some great lines here)

• Did not see much press (unfortunately) about Dr. Byock's initiative for Reclaiming the End of Life and discussing this with Presidential candidates at town hall meetings. Since the NH primary should soon be over and the last news report on the website is Sep 2007, we might not see more action from this until the Presidential election in November.
  

• Speaking of politics, political candidates are (sadly) bringing up the unfortunate case of the 17 year old who died while awaiting a liver transplant as a way to point out failures in our current medical system. While most media outlets seemed to pitch the most emotional part of the story ("A girl was denied a life-saving treatment by an evil insurance company"), Maggie Mahar at Health Beat does a great job of highlighting the complex ethical issues in this case that has some good teaching points for palliative care (prognostic accuracy, second opinions, goals of care, etc.) There were not easy answers in this case, and there are many tragedies here as well, which now seems to by devolving into finger pointing.
  

• Feedback on some of the DonorsChoose Projects are included in the comments section. Thanks to all of those who participated on behalf of Pallimed!
  

• Winners of the HPCFUSA BOOK and Coffee Mugs will be contacted soon and later announced.

Pallimed will be represented at AAHPM by Drew and Christian so due to popular demand, we will be having another Pallimed Gathering @ AAHPM in Tampa, FL. We do not have the location yet, but we have planned on Friday night Feb 01, so mark your calendars and bring your friends. We had a great turnout last year, and hope to meet more Pallimed readers this year. Look here for more info soon.

Challenging ethics dogma; ethics of discharging opioid addicts; Pal-Pourri

1)

Some of you may have read “Salon,” a new monthly opinion column in Canadian Medical Association Journal (CMAJ). At least some of them appear to be intentionally provocative. This month’s is a case in point. “Biothethics? A Grand Idea” pretty much lambasts the basis of modern medical ethics in North America as an invention of “medical amateurs” and based on “simplistic readings of enlightenment philosophers.” The author, a bioethicist, has “never found the standard principles of bioethics useful in my work.”

Specifically, the crown jewels of autonomy & self determination are pretty much fictions. We are social creatures and cannot separate the individual from family, community, and medical institutions. Self determination is based on knowledge and knowledge on experience. How can a patient practice meaningful self determination when s/he cannot truly understand the choices to be made? Beneficence? You can almost hear the “Oh, pu-leeze!” “Bioethics is mostly a rationale for institutional objectives rather than patient desires and needs.”

This one-page article is adapted from the author’s longer article (which I haven’t read), “Bioethics as Ideology: Conditional and Unconditional Values” in Journal of Medicine & Philosophy. Of necessity, then, it is an oversimplification. If you are up for a challenge of your basic ethical training or assumptions, this sounds like an interesting read. The author doesn't want to jettison bioethics. He just thinks it needs to be reborn.

2)
Here’s one from our recurring substance abuse theme: Peggy Compton, a nurse researcher and addictionologist, has written a commentary for Pain Treatment Topics on the ethics and practical effect of discharging patients prescribed opioids who show signs of substance abuse. For those unfamiliar with the issue: there are some (many?) pain practices that essentially have a zero tolerance policy for "aberrant" drug-related behaviors. They are sometimes referred to as "One Strike Policies." Noncompliance with a treatment plan or opioid "contract" or behaviors that appear on a list of "aberrant behaviors" is regarded as prima facie evidence of "addiction." The knee-jerk reaction is too often to stop prescribing opioids and refer the patient elsewhere--in other words, to discharge the patient.

Compton's thesis is that pain and substance abuse/addiction need to be treated simultaneously. The two disorders are chronic diseases that play out in context with each other. Primary care, pain, and psychiatry/addiction treatment partnerships are the optimal team approach. If the patient is discharged for noncompliance or aberrant behavior, neither the pain nor the addiction will be appropriately addressed. Practical approaches are discussed. This approach is not unique to Compton, but it is the first article I have seen to focus on this one topic.

Pain Treatment Topics is an excellent source of information on pain of all types. Almost all resources listed are readily accessible. Some, like Compton’s commentary, are exclusive to this site. Pain Treatment Topics has just announced the launch of a new section on pain in palliative care. So far it is light on content, but I assume that the thoroughness with which other subtopics are treated will be continued with this one.

Compton has also just published an article on urine toxicology in chronic opioid analgesic therapy.

Herbal and Dietary Supplement-Drug Interactions in Patients with Chronic Illnesses--American Family Physician.

The Nov/Dec issue of Journal of Hospital Medicine (a new journal for hospitalists entering its 2nd year) has several articles of interest to palliativists (to use Christian’s term).

OK, I know we don’t usually highlight stuff in palliative care journals, but . . . Have any of our readers used the Mini-Suffering State Scale? It was developed in Israel and used to assess and prognosticate survival in advanced dementia. A new study in American Journal of Hospice and Palliative Medicine uses it with advanced cancer patients. The authors report that it can be potentially used to prognosticate survival and anticipated level of care.

Here's one we missed last month--A new report from the IOM: Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.

Pain management for elders; Pal-pourri

(Editor's note: Tom posted this on Saturday but it never got distributed by Feedblitz, our email updater, so I'm re-posting it on 12/3/7 in order for it be sent out for those of you who read the blog only via email.)

A Sebastiano Mercadante review is something that always catches my eye. He tends to be thorough and to look at the evidence critically. His recent article in Drugs and Aging on pain management in elderly cancer patients continues the trend. Edoardo Arcuri, a frequent collaborator, is co-author. Another Mercadante characteristic is a willingness to criticize other clinicians. The article cites, among the barriers to adequate management of pain in elders, a study finding that hospice nurses caring for the elderly "are almost twice as likely to incorrectly leave pain off a problem list than to incorrectly ascribe pain to a patient not reporting it." Even more pointed is a zinger at physician "unwillingness" to monitor opioid-related adverse effects.

The article also asks some important questions related to common assumptions about pain and elders: Do older patients feel less pain? Are they more sensitive to analgesics? In general, the answer to both questions is: the evidence is lacking, is unclear, or is contradicatory. The clinical bottom line, then, is: begin at lower doses than one would for younger adults, but be prepared to titrate to patient response. Unfortunately, they do not specify what "lower" means, but most clinicians start at 50% of the "usual" starting dose for opioids. They also say, however, that a cautious approach should not become one of "wasting time" when pain is acute. Pain can be aggressively managed and doses tritrated upward as needed as long as monitoring is frequent and appropriate to the patient's condition.

They particularly counsel caution with traditional (nonselective) NSAIDs because of the higher incidence of severe adverse effects as age increases. "NSAID renal toxicity may appear at lower doses in the elderly with subclinical renal insufficiency."

In the section on opioid elimination they point out that due to decreased muscle mass, serum creatinine is a less reliable predictor of glomerular filtration than in younger patients. Excretion may therefore be slower than predicted by serum creatine values.

Required skills for successful pharmacologic management of pain:

1. objectively assess functional age
2. understand the impact of coexisting conditions
3. carefully manage the number and type of medications taken concurrently
4. adequately communicate with patients and relatives

Other specific points:

• pain assessments and use of analgesics tends to decline as patients get older: those over 85 are at greater risk than those at 65, but there is no evidence that pain is experienced less


• there is great variability in physiologic and functional aging--the rate of decline is variable


• "the hypothesis that elders have a higher threshold for pain has not been supported"
• "no physiologic changes in pain perception in the elderly have been demonstrated"


• in general, elders require lower doses of opioids, but "only careful titration based on individual response can ensure that patients receive the level of analgesia that they require"


• elders do not have a greater incidence of side offects with opioids, but when they occur they tend to be more severe
• "the rate of drug delivery rather than the absolute dose over time was seen to influence both analgesia and side effects" (translation: increased dosing interval for immediate release opioids may be necessary)


• renal function is more important than hepatic function in the development of toxicity from morphine (glucoronidation can occur even in fairly advanced hepatic dysfunction)

It seems to be a common rule of thumb in this country (at least in the academic medical centers of my acquaintence) that hydromorphone is the preferred "first choice" opioid for elders or the first alternative should toxicities to morphine develop. This point is not even addressed in the article. Except for potency, they seem to indicate that morphine and hydromorphone are about the same. Oxycodone is recommended as a good alternative because the "pharmacokinetics of oxycodone are mostly independent of age, renal function, and serum albumin." Of course, parenteral oxycodone is available in Europe, but not in North America. Transdermal fentanyl is also said to be worthy of consideration for patients with chronic pain and reduced renal clearance, because it "might be better tolerated than morphine because of lack of accumulation of important metabolites." They caution, however, that the decreased lean body mass to fat ratio may may "facilitate fentanyl accumulation once fat and muscle stores are saturated."

This may be one of those articles to consider for Drew's famous Teaching File. It requires a close read, but provides an excellent "if you only have time to read one article" resource.

December 1 is World AIDS Day.

A research team at the Mayo Clinic presented findings this week at the meeting of the Radiological Society of North America on its study of cryoablation for pain resulting from metastatic bone tumors. 34 patients with 10 different tumor types were treated. 80% reported "clinically significant" pain reducation that persisted at 24 weeks after the procedure. Next up: a multi-institutional study that compares cryoablation head to head with radiation therapy.

A study (secondary analysis of a bisphosphnate study) published online ahead of print in Cancer this week again highlights the disparity between Caucasian and non-Caucasion patients in pain from advanced cancer. This study found that in a large international (19 countries!) cohort of women with metastatic breast cancer non-Causasian women (82% of whom were from the US) reached a pain level of 7 or higher (Brief Pain Inventory) significantly earlier than white women. They suggest that race be considered a risk factor for pain and that clinicians be prepared for aggressive and earlier intervention for pain in non-Caucasian women.

An article in the October issue of the Fordham Law Review uses the recent trial of a doctor accused of murdering/euthanizing her patients during the Katrina disaster to launch a discussion of intent and the use of "risky pain medication" at the end of life. It's pretty dense & legalistic (oh yeah, its the Fordham Law Review) but essentially defends judicious use of pain medication at the end of life (for pain) and "terminal sedation" [there are plenty of other terms that can be used; this one is particularly loaded] for intractable symptoms. Many people, of course, have raised the ethical issue that intent is difficult for a 3rd party to determine. In a criminal trial, a prosecutor has to convince a jury that the intent was to hasten death. My own opinion: since there is no evidence that appropriately titrated analgesics and sedatives hasten death--and evidence is accumulating (examples here and here) that they don't--double effect is not usually necessary as an ethical basis for defending the use of either class of drug in patients near death and experiencing severe symptoms.

AAHPM Pre-Conference Preview Part 1 (AAHPM Sessions)

Early this year I posted a preview section for the AAHPM/HPNA conference in Salt Lake City. Of course last year when I decided to post it, it was too late for people to people to change their registered pre-conferences, so this year I am going to cover the pre-conferences early enough to give you some thoughts on what might interest you. Today, I highlight the AAHPM pre-cons, later the HPNA pre-cons.

I started doing the preview because one of my favorite things about conferences is talking to other people to see what they are interested in, so feel free to tell us what you are going to and why. If you are giving any of these talks, I encourage you to leave some comments to get more people aware of your talk. There are some good ones!

Wednesday January 30th, 2008
8am-Noon

Hospice Medical Director Course Module B - Regulatory Issues

The AAHPM includes this as part of a series (A,B,C) with the other sessions usually taught at Current Concepts or other times throughout the year. Since I completed a palliative medicine fellowship, I have not seen the need to go to this, although there may be some tips to be picked up here. I have not heard anyone ever rave about the regulatory module (YAWN! (but important if any Medicare officials are reading this blog!)) , but I think that is probably due to the nature of having an important foundation in hospice regulations if you plan on being a hospice medical director. Regulations...you gotta know them, you may not like them, you may think they don't make sense, but they are here to stay. Until they change next year.

Quality Measures for Hospice & Palliative Care
by Dy, Hanson, Asch, Wenger, Walling

To me quality indicators are just a little more exciting then regulatory issues. So my review will be biased a certain direction. (I would be happy to hear form any self-described policy afficianados, who want to comment on the importance of these and advocate for more people going to this session.) A lot of important work went into creating these standards and I hope our field will be better off for applying a structure, but part of the cynic in me worries about creating an administrative framework that has minimal bearing into clinical practice. This session will talk about PEACE, ACOVE, and ASSIST, of which I am familiar with none, and also features speakers who I am not familiar with so this anemic review will end. Now. (Please enlighten if you know more about this session)

Moving Beyond "I Hate These Discussions": Gratifying Tools to Facilitate Patient and Family Decision Making Near the End of Life
by Menkin and Weiner

Ah the dreaded words 'role play' are stuck at the end of this description. But fear not! Role play should never keep you from going to a session. You should jump at the chance to ply your skills in front of people who could give some great feedback. One of my favorite things about role play is that it gives you the opportunity to mess up really bad. And often times if you do the first role play with intentionally making it a horrible horrible situation, you can highlight the obvious things that did not work and refine from there. While I am not familiar with these speakers the idea of giving structure to family decision making is a good topic for all. A theme which resonates in the pre-cons. With a structure guiding you, one is allowed improvise with more confidence as the situation changes, which is one of the most important factors to becoming a skilled clinician.

Opioid Dosing Strategies and Toxicity
by Davis, Lasheen, Walsh, LeGrand

Is it just me, or does that list not seem impressive if you leave out first names. Davis means nothing to me, unless I see Mellar in front of it, same with Walsh without the Declan, and LeGrand is unique enough to stand alone. The good folks at Cleveland Clinic return with a comprehensive opioid talk. A good one for feeling more confident in titration and conversions which is something all good palliative care practitioners should feel comfortable with. While MD based, I think this could be very beneficial for nurses as well since they often are catalysts in titrating opioids and the first line in the home at observing potential toxicities.

Discipline-Specific Leadership Skills Development
(Physician 8-Noon, SW 8a-5p, Nurse 6p-10p)

While the brochure is lacking in faculty lists and has a generic description these sessions look to be a pretty good deal for junior leaders (or soon-to-be leaders) in our field. I'll tell you that being such a new field there will be lots of room and need for leadership in the coming years at national, regional and local levels. Networking and career development sessions such as these and the more in-depth Harvard PCEP are great opportunities that compresses and shares many years of experience in just a few hours. For more info on each one, click on the link for the discipline above. These are sponsored by the College of Palliative Care and have NO FEE!! Thanks CPC!

1-5pm

Essential Grant Writing Skills for Junior Investigators
by Casarett, Ferrell, Tulsky, Kramer, Bakos

Also a NO FEE talk, this talk is a similar theme to pre-cons in the past few years. We got to build our research base people! Hopefully many will get inspired and do some great non-observational research (i.e. RCT's and treatment trials). I found this talk very helpful/inspirational in the past, but the one thing this talk will likely not get you is an infrastructure to do research, so hopefully you already have one in place, because you won't learn how to make you community hospice into a research institute in the next 24 months. Great speakers by the way and always nice to have Alexis Bakos from the NIH to help get us the inside scoop.

Mediating Ethical Dilemmas at the End of Life
by Williams and Arnold

While no class on ethics will ever tell you the answer to every ethical dilemma you have encountered, having a structural framework that is clinically applicable and teachable (as this session promises) is a great tool for our field. I am not sure what a MB ChB is, but Charlotte Williams, MBchB from UAB joins Bob Arnold for what looks to be a new and invigorating addition to the pre-cons.

"Is There Something I Should Know About Your Beliefs that Will Help Me in Your Care?" Talking to Patients About Their Beliefs and Spiritual Concerns
by Pulchalski, Blatt, Lunsford, Baird

FICA is your friend. No really. This is a great tool, and this session will highlight this tool and other strategies and themes. I have not yet had the pleasure to hear Christine Puchalski speak, but I have heard good things about her sessions in the past. This session should be a good one, and if you think you know FICA, they will likely expand your understanding and flexibility in approaching this powerful subject. I just hope the session has a wide audience and attracts more than just the choir (sorry) so that some people become more comfortable about spirituality and medicine.

Alternatives to Oral Opioid Therapy for Refractory Pain Conditions
by Yellig, Fine, Panchal

In under 4 hours, this session will cover some very interesting areas, such as ketamine, and interventional pain techniques. I find these sessions very intellectually stimulating but I shortly after being inspired at the session, I realize all the work I may have to do once I am back in my local environs to ally with the interventionalists or get staff more familiar with ketamine for pain control. I would like to see more appropriate and early access to nerve blocks and the like in our field, but I worry if our field will start to subspecialize even more.

Overheard conversation at AAHPM/HPNA in 2015:

Sue: "Hi! I'm a Spiritual Palliativist."
Tom: "Nice to meet you. I am an Interventional Palliativist. Have you met Joe? He is our new Conversational Palliativist."

Sorry that became more of an editorial. Final verdict: looks like a good session.

I will review the HPNA pre-cons in the next couple of days. And I am by far not the final word on any of these. Pick what interests you and feel free to offer comments about why you are going to any of the above session.

• Interesting Quote of the Month with Palliative Care Influences:

  “Life is not what we experience, it is what we remember and how we remember in order to retell it.” - Gabriel Garcia Marquez, Living to Tell The Tale
  

• Pallimed represent! I (Christian) will be at the Cachexia Conference in Tampa next week. I will have a Pallimed sticker on my badge, so feel free to come say hi if you see me, or post a comment or email me if you are going to be there and want to got to a Tampa Bay Lightning game Thursday night. I plan to report back from the conference to tell all Pallimed readers how to defeat cachexia!
  

• Tom recently posted some info on "disadvantaged dying." Pallimed reader K Jacobs chimed in with this link to the AAIDD position statement on EOL care in the disadvantaged.
  

• Edwin Leap, MD reflects on witnessing the impact of death in the ED, and how it seems like an alternate universe when he comes home to his family. I think this is something that could be echoed loudly by our field. Seeing death on a regular basis in our work makes little things in life much more valuable. It would be great to see some more palliative care oriented blogs to balance out the ED ones. (via Kevin MD)
  

Dying a Secular Death; Hospice Documentary; Pal-Pourri

#1) Dying a Secular Death
The process of dying and the final result are often times that people reflect on some of the deeper religious issues. People of strong faith find great support or maybe difficult questions to their beliefs, people who never had a traditional belief go back to their family roots or adventure out to discover religions that they have never been exposed to. Whatever the experience near the end of life a common recurring theme is belief, religion, spirituality, whatever you want to call it.

Hospices and palliative care teams embrace this discovery of spirituality and are usually very open to all faiths. Most HPM practitioners I have worked with are eager to learn about different traditions and backgrounds and how those beliefs are important to their patients. But I have seen hospice and palliative care teams struggle occasionally when working with those without a traditional faith, specifically atheists and agnostics. Maybe it is the lack of a framework or belief in the afterlife that is common to so many religions, maybe it is the long-held negative yet erroneous view of atheists as people without morals, I am not sure what it is exactly. Without a common traditional religious structure to find common language care for the unbelieving patient can be more difficult for some. And I don't think the answer is as simple as, "Well at least they don't need to see a chaplain."

A reader tipped me off to a score of essays published in Free Inquiry magazine (Oct/Nov 2007) about experiencing the end-of life from a secular/atheist perspective. Most of the essays address the survivors issues such as how to have a ceremony without the religious infused language, or even whether to have one at all. I have read most of the essays and there are not many that give voice to the dying person's view on unbelief as they are dying, which is a shame, but understandably a hard task to do given that dying patients rarely write essays.

There are surely some to skip, such as the one on Cyronics, but others seem to give some good general advice from the bereaved. Some of the best quotes I think can be applied to all patients and families in general.

Janet Factor writes in "The Gift of A Wise Man":

"...the price of love is loss. No matter how happy, no matter how perfect and true the love, it will one day end in tears, for we cannot escape our own mortality."

"Without the understanding that we are mortal, we cannot appropriately value our own lives."

Richard T Hull in "Celebrate the Myriad Ways":

"We could have taken offense at much of what went on at the service and much of what was said to us before or afterwards. But it occurred to us that uncritically accepting the outpouring of others’ consolations was the essence of what it is to be a humanist: one who seeks to understand and celebrate the myriad ways in which humans try to deal with the tragedies and stresses of life."

Jean Kazaz in "People Don't Die, Do They?":

"Tolstoy’s terror of death did not subside until he underwent a religious conversion that convinced him that there really is more life after death. Nothing else would calm the panic that he so artfully projected into the character of Ivan Ilyich. My children were much more Tolstoyan three-year-olds than I ever dreamed I would have, but, in the end, they didn’t need Tolstoy’s solution. The subject simply went away."

The essays are all available free online, or you could possibly find Free Inquiry magazine in a large bookstore. (It took me going to three different bookstores to find this magazine.)

Also note the recent JPM article by Marilyn Smith-Stoner, RN on End-of-Life Preferences for Atheists for further info.

(Thanks for the tip Kathleen J)

#2) Hospice Documentary - 203 Days

Bailey Barash, a documentary filmmaker, has a great 30 minute documentary about the last 203 Days of Sarah Neider, a hospice patient. You can watch the film for free, but if you are involved in end-of-life education at any level, I highly recommend you pick up a DVD (Pallimed is getting no kickbacks, FYI). And you are supporting a filmmaker who is a hospice volunteer, and encourage others to focus on telling these great stories that we all see everyday. It is important to note the filmmaker has a lot of production experience including being an Executive Producer for CNN, so this is not just an amateur production.

After watching the film, it was easy to see how easily the short film could fit into hospice agency orientations, fellowship programs, Hospice 101 talks with medical/nursing students, whatever. The basic story live of a hospice patients last several months reviewed in under 30 minutes makes this a valuable resource to our field.

->AAHPM and HPNA have selected the 9 cases to be presented at the Annual Assembly by HPM practitioners in training (RN, DO, MD, etc.). It was a lot of fun reading the cases and there were a lot of good ones, so it was hard to select the final 9 (up from only 6 cases we were slotted for initially!) You can read more about the process at the unofficial AAHPM PIT-SIG Blog.

->Grand Rounds was recently covering pain issues at Counting Sheep (a nurse anesthetist blog)

->ERNursey and SICU Queen get into it about over-treatment in the hospital. Warning some language may not be suitable for all ages.

->Andy Billings, Susan Block and the faculty at Harvard are at it again. They have finished yet another year of PCEP, which is a great opportunity for HPM practitioners of all levels, and have now decided to tackle another working conference with the Harvard Medical School Palliative Medicine Leadership Forum for Junior Faculty Leadership Retreat. The deadline is December 7th, so get crackin'. The applications for PCEP are due January 15th, 2008 for the next session too. PCEP (Palliative Care in Education and Practice) is a great educational and networking resource. To show you how much fun it is I made a video after my experience in 2004.