Mastodon 09_10 ~ Pallimed

Thursday, October 29, 2009

Dialysis, function, and how you spend your time

Two related articles on dialysis in older patients, as I alluded to in last week's post:

First is from the NEJM and looks at functional status in older adults residing in nursing homes before and after initiating dialysis. It uses data from the Minimum Data Set and the US Renal Data System, and looks at all ~3700 patients (mean age 73 years, 60% women, 64% white) residing in US NHs 1998-2000 who initiated dialysis while in a NH. They compared functional status (essentially a composite measure of ADLs) before and after dialysis initiation.

Gross survival outcomes are presented: 24, 41, 51, and 58% of patients had died by 3, 6, 9, and 12 months, respectively. (So: worse survival than many metastatic cancers, and being a NH resident and initiating dialysis is almost a hospice-qualifying event, at least by prognostic criteria.)

In addition, most patients' functional status declined, whether or not they survived, and by 12 months only 15% of patients had intact functional status; everyone else was dead or with diminished functional status. With complicated modeling, they indicate that the rate of functional decline increased rapidly just prior to initiating dialysis, leveled off for ~3 months afterwards, then steadily declined again.

(One major caution here - these functional status findings only describe patients who remained in a NH (such that MDS data were available), and so don't include those who were discharged home (the mortality data include everyone initiating dialysis). They note that for the 12 month functional status measurement, they were missing data on over 700 patients, at least some of whom one imagines rehab'd ok and went home with stable if not improved functional status. They do note, without presenting their data, that the results were similar if they assumed all those who went home as having 'maintained' functional status, but it's not clear how many patients this actually represents. I can't imagine the results would be unchanged if it was most of those 700.)

So, as best as can be told, for frail older patients (assuming residence in a NH as a proxy for frailty), initiation of dialysis does not seem to improve quality of life, at least as measured by functional status. This is an important, and thought-provoking finding. As a palliative consultant, I see these patients all the time (frail, older patients, who initiate dialysis and really not much gets better: still weak, still debilitated, lots of catheter/access complications, in and out of acute care settings with infections, pnemonias, and vascular events). I assumed however I was seeing a small, self-selected section of these patients - the minority who don't do well after dialysis initiation - but these data suggest this minority is not small, and is perhaps the norm (again, with the caveat that these are NH residents, and not representative of all 73 year olds who initiate dialysis).

As an aside, I'll also cheer the authors for throwing in this sentence in their discussion about why dialysis might not improve function in most frail older patients: 'Finally, kidney failure may be a reflection of terminal multiorgan dysfunction rather than a primary cause of functional decline, and thus the initiation of dialysis may not rescue patients from an inevitable decline.' This 'whole-organism' concept, that death may not just be a result of organ failure (which if it was then presumably one just needs to fix/replace/circumvent those organs and people will be fine), struck me as a bit subversive.

The second paper is from the Clinical Journal of the American Society of Nephrology and tries to compare outcomes between older adults (over 70 years) with ESRD who initiate dialysis and those who don't. It comes from a single institution in the UK, and it should be noted addresses a different population (ie not just NH residents) than the NEJM one.

The study involves comparing patients in this institution's ESRD referral clinic who are 'dialysis-ready' (essentially an estimated glomerular filtration rate of 10.8ml/min or less) who choose to proceed with dialysis vs. those who don't. Those who don't at this institution receive what they call maximum conservative management, which was not strictly controlled in this descriptive study, but per their report commonly involves interventions to maintain adequate serum hemoglobin, loop diuretics, potassium restriction, as well as end of life counseling (why they call this MCM I'm not sure - it just seems like good management of ESRD without dialysis to me - promoting symptom alleviating and modestly life-prolonging treatments - perhaps this is distinction with a strictly symptom alleviating/very conservative approach?).

Patients who received dialysis (n=173, mean age 76 years) were compared with the 29 patients who did not (mean age 82 years). To compare survival after dialysis initiation, they created a model which predicted when the MCM patients 'would have' started dialysis had they chosen to (ie, at the same eGFR as the actual dialysis group), to make the survival comparisons as valid as possible. Despite the age differences, comorbidity (using the Charlson Comorbidity Index) was similar between groups, as were baseline hemoglobin and albumin (two well established prognostic markers in ESRD). It's important however, when reading the results below, that there was nothing controlled or experimental about these data: this is simply a description of what happened to those who sought dialysis vs. those who didn't at this center.

Median survival in the dialysis group was 38 months vs 14 months in the MCM group. The authors also do a variety of analyses to look at how those months were spent in the different group, how they differed, as well as how the different groups died. The MCM group had a far less medicalized last 14 months: 40% died at home or hospice vs. 70% of dialysis patients. Rates of hospitalization were different: 25 days/patient/year in the dialysis group vs. 16 in the MCM. Of most interest, they measured days of 'institutionalization' (essentially days of hospitalization plus days spent receiving hemodialysis - they included HD days as full days with the idea that many of their older patients essentially devote the entire day to HD - transport to and from and receiving HD can take the better part of a day, etc.) between groups. Patients receiving hemodialysis were 173 per patient per year (e.g. 47% of days) vs. 16 (4.3% of days) in the MCM group.

Mashing these findings together, they conclude that for their patients, nearly all of the survival increase with dialysis can be accounted for by days in the hospital or actually receiving dialysis: nearly every day gained by dialysis is a day spent receiving dialysis (or in the hospital with complications of dialysis/other comorbidities). To be fair, they gained probably 3 months of institution free days too, but still a far less gain than the ~2 years when looking strictly at gross survival.

So not a banner day for dialysis in above 70 set. The results speak for themselves, I think, and I'll refer you to some of the links below to better discussions of the palliative care implications of this than I can muster now. The one thing I'll muse about, is what should we be telling our patients? Or, how can we counsel our patients about this? Despite what the death panelists seem to believe, no one out there is going to grab these findings to suggest dialysis shouldn't be offered to older patients (and for those who fear 'socialized medicine,' one should reflect that the 2nd paper, which involved dialysis hundreds of 70+ year olds, involved residents of the UK). However, we should be trying our best to honestly counsel them about the limitations of dialysis: it might not improve your function, it involves a lot of medicalization of what are likely your final few years, etc.

I was talking with some folks the other day about whether it made sense to show patients videos of 'actual' CPR when discussing code status, and we talked about the work of Angelo Volandes who is working on that very thing (see here - the videos aren't available for public viewing as far as I can tell), and I wonder if 'living with frailty and ESRD-HD' might be a good topic for video advance care planning?

Thanks to Dr. Eric Cohen for sharing the CJASN paper with me.
See also Alex Smith's discussion of the NEJM paper at GeriPal, as well as the accompanying editorial in NEJM, both of which more directly discuss the role of palliative care in all this.
Image, Semipermeable Membrane, is from Wikipedia.

Thursday, October 29, 2009 by Drew Rosielle MD ·

Friday, October 23, 2009

Dementia as a terminal illness

NEJM has an important paper about the natural history of advanced dementia. The data come from a prospective study (2003-7) of patients with advanced dementia residing in 22 nursing homes in the Boston area. 'Advanced' dementia here means patients with a Cognitive Performance Scale (part of the MDS) of 5 or greater. A CPS of 5 corresponds to a mean Mini-Mental State Examination of 5 (+/- 5 SD): ie, the vast majority of these patients then had a MMSE of less than 10. Inclusion criteria also included 'profound cognitive deficits (inability to recognize family members), minimal verbal communication, total functional dependence, incontinence of urine and stool, and inability to ambulate independently.'

The data were collected in a variety of ways in the study: after enrollment incident complications were determined by chart review; pain and dyspnea, agitation, and aspiration were determined by regular interviews with the patient's NH care providers and nurses. One of the categories they measured by chart review was 'eating problems' which they defined as: 'documentation of weight loss, swallowing or chewing problems, refusal to eat or drink, suspected dehydration, and persistently reduced oral intake.'

~320 (56% of patients who met the inclusion criteria) were enrolled: mean age 85 years, 89% white, 85% female, most with Alzheimer's-type dementia. The median time subjects had lived in a NH was 3 years.

They present some general survival data, as well as data on 'complications' during the study. Median survival was 478 days, with 54% of patients dying in the 18 month study window, and 25% dying within 6 months. So - a sick group of people - although this doesn't tell you much more since patients were enrolled regardless of how long they had dementia or had lived in a NH.

But things get more interesting. Many patients had dementia associated complications, which were associated with worse prognoses. 41% had pneumonia (leading to a 47% 6 month mortality after an episode of pneumonia), 53% a febrile episode (45% 6 month mortality), and 86% had an eating problem (38% 6 month mortality). These mortality rates were much higher when compared to patients who did not have those 'complications.' In fact the 500 day survival for the (small number of) patients who had no eating problems was over 90%, suggesting to me that eating problems are the hallmark of the 'terminal phase' (exceedingly likely to die within 2 years) of dementia.

Pain, agitation, and dyspnea were all quite common, 'burdensome interventions' (parenteral therapies, hospitalizations, ED visits, tube feeding, etc.) occured in 40% of patients in the 3 months prior to death. Only 30% of patients who died were enrolled in hospice. Which, yes, seems appalling but also reflects the reality that 'hospice-like-care' frequently occurs in NH for patients with dementia without formal hospice enrollment.

Truly appalling was the only 18% of proxies who reported receiving prognostic information from a physician, and only 32% reported receiving counseling about the expected complications of advanced dementia. Breaks your heart. Despite this, about 80% of proxies reported that they thought they understood the expected complications. Subjects whose proxies reported knowing the expected complications of dementia received fewer burdensome interventions in the last 3 months of life, as did those who thought their loved one had less than 6 months to live. They note that reporting a prognostic conversation with a physician did not make any difference in rates of burdensome interventions that they could tell: it was the expectation of a short prognosis and the knowledge itself of complications (regardless of where that knowledge came from) which were associated with the different outcomes.

So, further corroborating data that knowledge of prognosis (in its broadest sense - not just time but what is expected to occur) changes care at the end of life. What excites me about this and similar findings (and there has been a fair amount of research indicating that prognostic knowledge is associated** with better care at life's end) is that it is something we can change. Or, it seems like something we can change, as at least these data indicate we continue to do a piss poor job of telling people what is likely to happen to them or their loved ones. Frankly, prognostic knowledge is one of the only things I know of which has routinely been shown to effect end of life care for the better (I expect to be shouted at in the comments for this statement) which makes me wonder that all the fancy palliative/end of life care quality measures that have recently been promulgated should be reduced to: tell patients what the future likely holds for them, offer options.

**Getting off my bandwagon for a moment, one should reflect on the 'associated' there. As with the Coping With Cancer Study (see 7th paragraph down), there is always the possibility here that this association can be accounted for not by causation (prognostic knowledge --> different decisions --> better end of life care) but by a confounder which makes patients/families much more open to talking about prognosis/reporting prognostic knowledge/conversations/impressions. That is: confounder --> more likely to engage a clinician about prognosis and/or report in a research environment prognostic knowledge + also more likely to choose 'gentler' end of life care --> better end of life care. What that confounder is I'm not sure exactly but I wonder if it's some generalized 'more comfortable with death and dying and talking about it.' The question I'd like to see answered is one that can get at causation. That's unlikely to happen in a controlled trial (at least with real-life terminally ill patients) of course.

All this aside, the more data we have showing that prognostic knowledge changes outcomes (improves them) the better, and the studies like this not only sharpen this knowledge for clinicians but for patients as well (see here).

See also this associated and very pro-palliative care editorial.
Our pals at GeriPal (funny) blogged about the same article as well and talk a little about the Medicare Hospice Benefit and these findings.
The same NEJM issue also had a fascinating study on dialysis in older patients and next week I plan on blogging on that and another paper on dialysis in advanced age. Mag Citrate will return; I know how much everyone loves it so.

Friday, October 23, 2009 by Drew Rosielle MD ·

Wednesday, October 21, 2009

Hospital at Home for Decompensated Heart Failure

Imagine the year is 2022. You're a palliative care practitioner working with a hospital based team. An emergency department physician calls you to see an 83 year old man with stage D congestive heart failure who came to the hospital with a several day history of worsening dyspnea and orthopnea. He had two admissions earlier in the year. After the last one, he spent three weeks in a skilled nursing facility before returning home semi-independently. Upon evaluation of the patient, he tells you that his main goals are to be at home with his family and dog, Miffy, but he also hopes that he'll be able to sleep without awakening with dyspnea so frequently and wants to do everything "within reason" to live until his granddaughter graduates from college in four months. He has a POLST form that indicates he wishes to be DNR, and this has already been confirmed by EMS and the ED physician. Your interdisciplinary team evaluates the patient, and finds that he has excellent support from his wife and three daughters as well as a couple of neighbors. After extensive discussion, it is decided that the patient will be discharged home from the emergency department with follow-up later in the day from your colleague who is currently on service with an affiliated hospital-at-home program. Your colleague sees him daily for four days and then every other day for two weeks. He also receives daily nursing visits for the first 14 days. He returns to his baseline and afterwards, he receives intermittent home nursing.

Far-fetched? Perhaps. But a prospective, randomized controlled trial from Torino, Italy recently published in the Archives of Internal Medicine suggests that it may be possible to provide hospital-at-home care to geriatric patients with decompensated CHF without worsening six month mortality and possibly improving certain quality of life indicators (compared to routine hospital care).

The study included patients older than 75 with stage C congestive heart failure and New York Heart Association class III or IV symptoms who had an acute decompensation of CHF requiring hospitalization. Patients were excluded if they lacked family support, required mechanical ventilation, lived outside of the catchment area, or had severe comorbidities. Of 528 potential subjects, only 101 were randomized.

  • 15% of patients in each group died (p = .83). This was the primary outcome.

  • Statistically significant differences in favor of hospital at home (all outcomes at 6 months after admission): Geriatric Depression Scale, Mini-nutritional Assessment, and Nottingham Health Profile (looking at overall quality of life)

  • No statistically significant difference: Measures of functionality and mini mental state exam.

  • Patients at home received a mean of 20 days of hospital-like care versus a mean of 11 days for hospitalized patients.

  • Fewer patients in the hospital at home group were readmitted to the hospital within six months, but this was not statistically significant. The number of days between hospital discharge and readmission was greater in the hospital at home group.

  • No patients in the hospital at home group were institutionalized after discharge while 16% of hospitalized patients required some form of nursing facility after hospitalization.

  • Hospital at home cost less overall ($2604.46 for each patient treated at home vs. $3027.78 for those hospitalized).

  • Stress levels were higher for family members of hospital at home patients.
Limitations in interpretation and application in the United States include the fact the study was done in Italy and the team applying the intervention is well-established (in existence for 20 years and providing care for over 1000 patients over the last ten years). An associated editorial does note that there are examples of hospital-at-home programs in the United States (Johns Hopkins, Presbyterian Healthcare Services in Albuquerque, and the VA in Portland, OR) but it's unclear how these programs differ in structure and services provided. (The Hopkins website references a study from JAGS indicating that caregiver stress may be less in their hospital-at-home program than for caregivers of hospitalized patients in contrast with the current study.)

In my hypothetical scenario above, the practitioner is a palliative care specialist. Why? Well, mainly because that's the lens through which I see the world. Certainly the outcomes that were significant carry much valence in the world of palliative care, so why not make this a palliative care intervention if that's who is interested in providing the service or if a geriatrics service isn't available? I will go to bed dreaming* of health care reform that allows for a more sensible hospice benefit which is more fluid with other home-based services (such as interventions like this) and which doesn't force the "terrible choice." The current hospice model might have a lot to offer in terms of helping to reduce the stress of family caregivers of a hospital-at-home patient.

Of special note is the fact that patients in the hospital-at-home group received acute services longer than the hospitalized group, but the latter group was at higher risk for requiring post-discharge nursing facility care. This turns the concept of "throughput" on it's head. DRG's and SNF's were introduced as cost-saving mechanisms for Medicare. A byproduct over the years is the intense pressure for hospitals to move patients rapidly through the system (not for the sake of the patient, but for the sake of the system). Could the hospital-at-home model represent another opportunity for Medicare to offer patients greater choice while perhaps saving money? The business model likely isn't there yet, but perhaps this will be a "disruptive technology" of the future. I'll remain hopeful without holding my breath.

*Okay, I really don't like dreaming about work.

Wednesday, October 21, 2009 by Lyle Fettig ·

NYT on Prison Hospice Inmate Volunteers

The New York Times continues its coverage of hospice and palliative care related issues with a compelling report (with associated audio slideshow) on a volunteer hospice service at Coxsackie Correctional Facility in upstate New York. The article discusses the aging of the prison population, but mainly focuses on the experiences of inmates who have volunteered to provide support for dying inmates at the facility. Some of the lessons the inmate volunteers learn are not unique and might be extrapolated to all who provide care for the dying:
  • Being in the presence of a dying person can be transformative. You likely will have moments that remind you how fragile life truly is and will learn to value it more than you did previously. Convicted murderer John Henson poignantly describes his personal version of this lesson.
“I was just thinking about why I’m in here and the person’s life that I took,” he said. “And sitting with this person for the first time and actually seeing death firsthand, being right there, my hand in his hand, watching him take his last breath, just caused me to say, ‘Wow, who the hell are you? Who were you to do this to somebody else?’”
  • Attention to suffering at the end of life is a human right that everyone deserves and empathy is a key component. Benny Lee is another inmate who describes his attitude toward the death of even friends as "callous" before his hospice volunteer experience. Now, through his experience he's been able to see the suffering that death can entail and seems to have a growing understanding of the salutary experience of empathy.

  • Premature reassurance of dying patients is non-beneficial (and usually, the reassurance is a response to the reassurer's emotions rather than the patient's). Wensley Roberts is yet another inmate volunteer who tells Allen Jacobs to "man up" as Jacobs faces death. Jacobs rebukes Roberts emotionally, asking Roberts if he wants to die in prison. When Roberts answers "no," Jacobs anger evolves into sadness as he states the nearly universal fear amongst prisoners of dying in prison.
In addition to talking to volunteers, staff at the prison were interviewed about the program. The deputy superintendent for health services talks about some resentment of the prison guards that "people in prison for horrendous crimes getting better medical care than their families," (referring to the volunteer program which includes around the clock companionship near the end of life). Really? Rather, I suspect that some of them don't agree with the claim about this stuff being a human right, and I'm dubious about any claim that the circumstances of care might be better for prisoners than non-prisoners just based on the presence of a volunteer program. However, I know from professional experience that some prison guards can exhibit tremendous compassion. (I work at a hospital that accepts the state's prisoners for hospitalization needs. The patients' guards in the hospital usually come from the patient's correctional facility and sometimes have valuable personal information about incapacitated prisoners, including what the prisoner's main concerns have been.)

The director of nursing, Kathleen Allan, also is indirectly quoted as saying:
...the inmate volunteers bond with the patients in a way that staff members cannot, taking on “the touchy-feely thing” that may be inappropriate between inmates and prison workers.
I could see the potential for "bonding" between inmates that may not be possible with prison staff, but am I being Pollyannish to expect that there might be room for some display of empathy (that "touchy feely thing") by prison staff, especially the medical staff? If the inmate is fighting you to get out of his handcuffs or verbally abusing you, that's one thing, but if he's laying in bed in tears because he can't see his long-lost daughter and he's expressing remorse for his crime, doesn't that call for a different response? Empathy does not cross the line in this case, but a person needs to know how to express it, and it will come to no surprise to any that I have no idea what role empathy is given in the day-to-day jobs of prison guards. Empathy can play a role in conflict deescalation, so would seem to be a vital skill for a guard to employ.

At one time, Coxsackie did have an outside hospice agency that provided care for inmates. Eventually, they switched to the inmate volunteer program, ditching the agency. One might mistakenly conclude from the article that the hospice agency merely provided the same services as the inmate volunteer program (only with non-prisoners), and the article implies that the change was only for the better AND it might have saved money. In not having an expert interdisciplinary team (hospice nurses, social workers, chaplains, their own volunteers, medical director oversight, etc) managing the patient something was lost, no matter how impressive the benefits of the inmate volunteer program have been.

Lastly, Allan does talk about some very real problems that are faced in caring for dying prisoners, including drug diversion (with some inmate volunteers involved) and victimization of the dying. You don't have to be a prisoner to be at risk for these issues, though.

To read more about prison hospices, see The National Prison Hospice Association website. Also, see a couple of past posts related to the prison population here and here.

by Lyle Fettig ·

Tuesday, October 13, 2009

Mag Citrate 2: JCO edition

From my back-log of Journal of Clinical Oncology issues.

First is an editorial about health related quality of life, cancer survival, and research (free full-text here). (It's a response to this paper about HRQOL predicting survial in early stage head and neck cancer; I think most readers will find the editorial more interesting.) The editorial starts out reluctantly lamenting that the cancer research world only became interested in HRQOL as a research outcome because there has been some off/on suggestion that it predicts survival, and not because HRQOL is an end/outcome of importance by itself. It gives a little of the history of these investigations, ponders what the clinical utility of measuring HRQOL could be with regards to prognostication, and argues that patients care about more than survival and so should should cancer researchers.

What it doesn't address, and which is something I struggle with, is whether HRQOL is a fancified version of performance status (and if you look at most of the HRQOL scales - EORTC QLQ, SF-30, etc., most of the domains are to do with functional status; not all, but most). Either way, HRQOL scales are rarefied abstractions, which clearly are measuring something, but what that is I don't really know and have not been convinced (yet) that it is something materially different than functional status.

There's a fascinating study about prevailing end of life ethical dilemmas in Taiwan. Fascinating for many reasons, one of which is the opportunity to read the text of the Taiwanese 'Natural Death Act' which essentially gave legal clarification to doctors and patients that it was ok to stop unwanted/unhelpful medical treatments as patients die, and established some sort of protocol for doing it (you can read the act with the online article). I'm not sure how this is actually done in real life, but reading the act you get the sense that if patients want 'hospice-palliative care' they have to sign a form saying that (of course you do in the US too, to receive hospice benefits). It also has language which seems to say that doctors should only inform patients of their (presumably terminal) condition if the patient has 'clearly' expressed a wish for such knowledge (one can argue whether this is good or bad, but it's notable to see it in a law).

The prevailing ethical dilemmas that the researchers found (by surveying doctors and oncology nurses in Taiwan) were very familiar (artificial nutrition/hydration, patients wanting alternative treatments, etc.). The top one, by far, was truth-telling, which is certainly an issue here, but perhaps more acutely in Taiwan.

There is also a 'big picture' discussion on 'palliative cancer care', originating from an ASCO taskforce, and looking back over the last 10 years since a prior ASCO statement on palliative cancer care. Most of it is laudatory about ASCO accomplishments in the last decade, with a couple zingers thrown in (this was my favorite):

Although there has been an overall increase in the use of hospice services, ASCO has not actively pursued strategies that would increase acceptance and lead to earlier referral to afford patients and families optimal value from the Medicare Hospice Benefit and other hospice-related health care coverage.
The rest of the paper outlines what ASCO aspires to do in the next ten years, with a heavy focus on integrating 'palliative cancer care' in cancer centers worldwide. All swell, but there is a distinct lack of mention of palliative care specialist services (a lot of talk of providing palliative cancer care across the continuum, some mention that specialists should be available 'when necessary,' but a noticeable absence of a hearty endorsement for the universal availability of specialist level palliative care for cancer patients). The taskforce is mostly palliative specialists who are/were practicing oncologists as well, and I don't know if I'm over-reading this absence, and if I'm not I assume it's due to ASCO discomfort with the idea and not the authors'.

This aside, most exciting to me was their recommendations for the next 10 years of goals in education, including recommending to ACGME that all onc fellows have one month training in palliative care. That would be welcomed.

And on the supportive cancer side of things, the most recent issue is dedicated to thrombosis in cancer patients, with review articles on prevention, treatment, biology, etc. I just read the consensus paper (which is a narrative summary of consensus guidelines): basically yes you probably should give prophylaxis to hospitalized cancer patients, and low molecular weight heparin is the drug of choice for treatment of VTE. They outline a research agenda: no mention about the kinda hot topic of VTE prophylaxis and treatment in dying patients and hospice patients.

Tuesday, October 13, 2009 by Drew Rosielle MD ·

Tom Quinn

Tom Quinn, our 3rd contributor to the blog, is leaving Pallimed. I want to acknowledge the wonderful work he has done for the blog over the years, and thank him personally for his contributions, wisdom, and equanimity. ...As well as recall fondly the day last March when we received our award at AAHPM that Russell Portenoy called him both a doctor and a 'young man.'

If you're a late-comer to Pallimed - you can peruse Tom's posts here or via the label cloud on the left.

Thanks Tom - look forward to talking with you in the comments and hope to work again with you again someday.

by Drew Rosielle MD ·

Onion on Death Panels

It was inevitable that The Onion would tackle the 'death panel' debacle, which they did this last week with:

Obama: Health Care Plan Would Give Seniors Right To Choose How They Are Killed

It's as obnoxious as you'd expect from The Onion...
Obama also accused his opponents of using scare tactics to score political points, manipulating seniors' fears with misinformation about their upcoming state-mandated deaths.
Etc. Etc. I usually really like Onion's pieces to do with death/dying/etc. (and still maintain this video [blog post here; direct link to video here] is one of the most profound satires on America's relationship with health & death I've ever seen).

This one, if you read it, is really brutal, and perhaps hits too close to home (not in its accuracy, but insofar as there are people out there - and these people include our patients/their families - who believe something close to this could happen). I'm curious as to others' reactions to this.

by Drew Rosielle MD ·

Educational Exchange & Other Sundries at AAHPM

There is a late entry (at least as far as application deadlines go) for next year's AAHPM annual assembly: an "Interactive Educational Exchange: Sharing Innovative Teaching Materials and Methods." The organizers of this session are looking for submissions of innovative educational projects/materials/etc. Unfortunately, there is no website where you can get the submission forms, etc. so you'll have to email one of the organizers of the Exchange (see below). Below is from the organizers (note that you'll have to contact them for the actual submission forms). If you have any problems, let me know. Should be a great session, and if successful hopefully a version of this can continue for future meetings.

We want to call your attention to a new interdisciplinary educational scholarship opportunity at the 2010 Annual Assembly in Boston. We are soliciting submissions for the "Interactive Educational Exchange: Sharing Innovative Teaching Materials and Methods," an hour-long session at the Annual Assembly in which selected educators or trainees will share novel curricula, teaching methods or evaluation tools with the larger palliative care community. We encourage you to review the attached documents-- The Call for Submissions, The Submission Form, and the Submission Example-- and consider submitting your own materials or forwarding this email to colleagues who might be interested. Selected abstracts will be presented in a brief, oral presentation and structured interactive format. Trainees are encouraged to submit with mentors. Those who have already submitted an educational abstract for the Call for Scientific Abstracts may also submit to this venue, if additional criteria are met. The deadline for submissions is October 30, 2009. We thank you for supporting our goal of promoting the sharing of and dissemination of palliative care educational materials and hope to see you or some of your colleagues at the session. Please be in touch with us if you have any questions.
You can contact Laura Morrison, M.D. at lmorriso [at] bcm [dot] tmc [dot] edu for the submission materials.

Next year's assembly will also have a dedicated forum (which takes place over the whole day on Saturday) specifically directed at medical students (for dirt cheap as well - $25 - which includes a membership in AAHPM). If you know any students showing interest in HPM as a career path I would let them know about this and encourage attendance. There is a link to a Word doc outlining the day here. Given that we might be facing significant workforce problems in the future, especially as grandfathering (for board eligibility) is going away in a few years, interesting medical students in our profession now is critically important.

While we're on the subject of late deadlines for AAHPM/Boston - the case conference (given by fellows and other trainees) submission deadline has not closed yet - it's November 3rd.

by Drew Rosielle MD ·

Sunday, October 11, 2009

PBS NOW Gundersen Lutheran Hospital & Advanced Care Planning

With a tagline like: "What exactly is a death panel?" PBS is starting to sound like an afternoon tabloid show, but they end up covering the topic very well in the 25 minute clip now available online.  I am sure many palliative care people are familiar with the Gundersen Lutheran "Respecting Choices" project to increase the communication and recognition of advanced care planning through living wills, health care power of attorney's, POLST's and consultation with medical staff.  If you are not familiar with it here is a brief background:

The program started in the early 90's with an oncologist, nurse practioner, and a clinical ethicist, who is also featured in the video clip (Bud Hammes, Ph.D.).  And within two years they had a 85% penetration of advanced directives and a shocking 95% were found in the chart.  I say shocking because if you have ever spent more than a week on a palliative care team you realize you may be the first one to ask more than one question about advanced directives and your team is the one who actually gets the information in the chart.  There are similar projects based off of "Respecting Choices" sprouting up around the US and also internationally.

The clip also featured a palliative care doctor making home visits!  Awesome!

The only slight but important error in the clip mentioned by the reporter and Hammes was that Medicare does not reimburse for having these conversations.  That is actually not true.  Medicare does reimburse for these conversations indirectly via physicians billing for time spent with patient and family.  A longer conversation means a physician could bill using a prolonged service code.  Billing by complexity will always bring in more revenues compared to billing by time so it basically undermines good communication by nudging a medical system towards seeing more patients in shorter amounts of time and then billing for the higher complexity.  So the bill tried to set up a unique reimbursement structure which the details of relative compensation compared to complexity or time based billing were still unclear.  Regardless that section of the bill is not in the Senate version and is still (I think) in the House version and is now political poison given the hyperbole.

Sunday, October 11, 2009 by Christian Sinclair ·

Palliative Care Grand Rounds 1.9 - GeriPal

Geripal has done a excellent job with October's edition of Palliative Care Grand Rounds, the monthly best of the Palliative Care blogs (not to be confused with what I posted last week which was the weekly best of all medicine blogs).

Eric Widera and Alex Smith give you a cleanly organized overview that you should spend a little time with this week.  If you have any interesting posts send them on to Amber Wollesen and Amy Clarkson who will be hosting at Pallimed: Arts and Humanities the first Wednesday in November.

If you want the latest schedule or want to look through archives of past Palliative Care Grand Rounds go to  If you are interested in hosting you can always email me

by Christian Sinclair ·

Top Comments & Posts for September 2009

Top Blog Posts (most viewed) from September 2009:
  1. Refining Treatment Preferences for Patients Who Want "Everything"
  2. 'Exceptional Rationalization, Denial and Resistance Techniques'
  3. Onsolis and FDA Opioid REMS: Is this the future of opioid prescribing?
  4. Huckabee, Kennedy and the Politics of Distortion
  5. Death Panel Concerns in the UK with the Liverpool Care Pathway

Top Commented Articles from August 2009:
  1. Onsolis and FDA Opioid REMS: Is this the future of opioid prescribing? - 12 comments
  2. Huckabee, Kennedy and the Politics of Distortion - 9 comments
  3. Hospice and Palliative Care Formulary, 2nd Edition - 5 comments
  4. Refining Treatment Preferences for Patients Who Want "Everything" - 5 comments
  5. Death Panel Concerns in the UK with the Liverpool Care Pathway - 4 comments
Featured Commentary from Pallimed Readers:
Anonynmous on Huckabee, Kennedy and the Politics of Distortion:
While Drew, Ron, and most of us, in the field are preaching to the choir, the PR train has left the station. The bigger problem, however, is that the train does not have an engineer on board - since G Beck's GOP is (wisely) cheering from a safe distance. We and only we are to blame for the public lack of understating what Palliative Medicine is: we were suppoosed to be the engineer. Having marketed the specialty with avoidant strategies (we are not, aah so not about dying) the mis-marketing has caught up with us.

Mike Bevins MD, PhD said on Death Panel Concerns in the UK with the Liverpool Care Pathway:
I wish they had written more in the letter, but I think they do have a point. They allude to "algorithmic banking," and we are living in an age of algorithmic medicine, where consensus guidelines and algorithms often become the standard of care, with the implication that one need only follow the algorithm to give good care. This is an example of what sociologists call the degradation of work (a too-prejorative term in my opinion), wherein complex tasks are subdivided, standardized and reduced so they can be performed by less-skilled (and lower paid) workers. This is easiest to see in manufacturing, where the previously complex job of crafting an object is divided into relatively simple tasks.

Phil Rodgers said on PC Trial in JAMA:
There is a risk, however, that a high-profile portrayal of 'palliative care' as a narrow, almost ancillary intervention with such a modest impact (mood and QOL effects notwithstanding) will lead some to doubt the effectiveness of our practice, particularly if they have pre-existing skepticism about HPM. Disease management programs are not only fading from CMS favor, but they are on the chopping block at many institutions.

Alex Smith said on Refining Treatment Preferences for Patients Who Want "Everything":
The article is thoughtfully done, and raises a different set of questions for me. 1) How can we translate these nuanced communication strategies into actionable language? These article reveals the limits of our language - "do everything", "full code", and "DNR." Yet the need to be nuanced needs to be balanced against the need for ease of communication during patient handoffs and when the patient is crashing.2) I completely agree with the authors approach to communication in an idealized form. However, imagine the intern, on admitting night, at 1am, with an unfamiliar patient, trying to establish "code status." That patient is going to be full code. These conversations take time, and I think we need to move away from having these rushed and nearly meaningless conversations on the day of admission, toward having more meaningful substantive conversations over the course of the hospitalization.

Jerry said on ICU Delirium and Prognosis: (I had to put this one in as a best comment!)
I gotta make more regular visits to your site, Drew. You folks do really good work.
I'm glad to have found this here. My ICU colleagues and I get so focused on the immediate challenges that we lose sight of the larger picture.
Lastly, lots of good back and forth on the Onsolis and REMS post so I won't post any here. It is best to read the whole exchange.

Thanks for all the comments and keep them coming!

by Christian Sinclair ·

Tuesday, October 6, 2009

Grand Rounds Vol 6, No 3: The Art of Medicine and Nursing

Welcome to Grand Rounds, a weekly round-up of the best of the medical blogosphere.  We here at Pallimed (Drew, Lyle, Amy, Amber and myself) are honored to be hosting Grand Rounds for the 3rd time.  For the history books here are the 2007 (theme: prognostication) and 2008 editions.  The theme this week is "The Art of Medicine and Nursing" in honor of our sister blog Pallimed: Arts and Humanities

Art Theory
Last week's grand rounds was especially insightful courtesy of everyone's favorite Dutch medical librarian/blogger Laika (aka Jacqueline).  This week she has outdone herself with a wonderful post entitled Of Art & Medicine.  A must-read post especially for the fact you will always know the difference between Geneeskunst and Geneeskunde.  She deftly transforms "Art of Medicine" into "Art in Medicine" and "Medicine in Art"

Dr. Rob channels his inner Theodore Geisel to give us a Seussian poem on Health Care Reform. A sample:

A plan that is public creates great distress,
Just growing the government won’t fix this mess!
Absolute power just leads to excess!
(But what’s their alternative’s anyone’s guess)
Dr. Maurice Bernstein of the comment magnet site Bioethics Discussion Blog shares a poem he wrote about doctors reflecting on the care they have given.  
There was a phone Call from Doctor Smith
Did I interrupt Mary
To take the call
As though more
Hospice chaplain Ken Bradstock of Rainy Nights shares a short poem about a pediatric patient. 

Dr. Charles sent me one post but as I explored the rest of his blog I found a far more suitable candidate for grand rounds and substituted his post on the Dialogues with Darwin exhibit.
"I came away from the exhibit with a great respect for Darwin as a synthesizer of ideas. Among the disparate influences in his life that led to his unifying theory, one can count his grandfather’s poetry, his early training in geology and his correspondence with geologist Charles Lyell, his legendary voyages aboard the H.M.S. Beagle collecting and comparing biological specimens, his reading of Thomas Malthus and economic theory, and even his study of theology."
Cooking challenges the taste buds and if these three geriatric/palliative UCSF doctors from the blog GeriPal are willing to taste test Bowel Meds on video, then I would invite them to my test kitchen any day. By the way, GeriPal is one of the best new medical blogs out there, lots of comments and discussion with excellent topics. (Geripal is also hosting Palliative Care Grand Rounds tomorrow!)


Reading the rest of Dr. Charles blog allowed me to find this wonderful site from radiologist Steven N. Myers.  He features x-ray images of flowers and of course since this is Pallimed I wanted to feature this particular plant which has lead to great advances in pain control (and some problems too of course). 

17th Century author Sir Thomas Brown shared this reason why dealing with end of life issues is so difficult(via the excellent and highly recommended Medical Futility blog):
"The long habit of life indisposeth us to death."

Grey's Anatomy utilized the DABDA theory as part of a recent show.  Don't know DABDA?  Angela Morrow at's Palliative Care blog does. (Hint: Kubler-Ross)

Ink Art
Although lengthy the NYU Literature, Arts and Medicine Blog continues to reward patient readers with a post about Dr. Fleischmann and the Art and Medicine in Terezin.  This post is part of a larger exhibit:
"depicting the practice of medicine in one of the most notorious "ghettoes" of World War II.  Terezin (or Theriesenstadt) served as a "model camp," infamously shown to visitors who were impressed by the seemingly decent living conditions. But the inmates knew all too well its sinister alter-ego as a transfer point: a limbo between their former lives and their ultimate fate."
NYU also has the best online database ever for literature, arts and medicine.

Would you get the Wilderness Medicine Logo as a tattoo?  Paul Auerbach of Medicine for the Outdoors is considering it even after reporting on Mycobaterium in the ink for tattoos.

Dr. Charles again with a post on colorblindness and gene therapy.

Dr. Ramona Bates from Suture for a Living made a quilt for the psychiatrist bloogger Intueri and sold it on Etsy to donate funds for the Multiple Sclerosis society on behalf on Intueri.  Medical bloggers are such cool people!

Graphic Design
Dr. Shock (Walter van der Broek, a Dutch psychiatrist) gives us a great breakdown of the ins and outs of PubMed's redesign.  Graphic design is so important in making something functional while still appealing to the eye.  Sadly it is under utilized in EMR's! Dr. Shock has some of the most wide ranging and interesting insights on medical issues IMHO.

Dr. Wes describes 'The Final Opus' in an ode to the well-orchestrated maneuvers of a medical team.
"It was midnight and the Emergency Room door opened like a curtain on a Broadway. A lone man sat in blue at the countertop, writing. Behind him, the chorus, working feverishly on the protagonist - the script rehearsed a thousand times before.
Clothes off, Story?, facemask, C-collar, endotracheal tube, breath sounds, telemetry, IV’s, blood work, pulse ox, Stop."
Martial arts could be considered a form of dance if you consider all body movement a form of dance.  Frances Shani Parker of the Hospice and Nursing Home Blog highlights some seniors learning Cane-Fu.

Public Speaking and Debate
Yes this is a lost art in medicine given the ubiquity of Bad PowerPoint. So please all medical educators take some hints from Six Minutes: A Public Speaking and Presentation Skills blog with weekly Friday wrap-ups of the best speaking tips.

Things not to say in the ED if you want to be take seriously via Life in the Fast Lane blogger Peter Allely. Some good ones:
  • ‘I have a really high pain threshold.’
  • ‘I fell over in the shower.’
  • ‘I was painting in the nude.’
Best Off Topic Blog Posts (i.e I couldn't force an artistic theme on them)

DB and his Medical Rants picks off one of my favorite topics: Degradation of Medical Notes

Bongi of other things amanzi demonstrates creativity in getting Dermabond off eyelashes.

Dr. Wes with an excellent transmogrification of the legal profession and ICD-10 gives us ICLD-10 in his post "If Lawyers billed like doctors."

Marya Zilberberg at Healthcare etc. argues about what to do when the best evidence is not available to base your medical practice.
"But, let's not be fooled: most of the time what we end up practicing is absence-of-evidence based medicine. Question your doctors closely to distinguish between the two, as this distinction is the key to rational decision making."
Dr. Joel Topf of Precious Body Fluids (excellent blog name!) discusses one of the troubling consequences of hearing esteemed professors lecture on the Pharma sponsored circuit.
"It is illustrative of what is wrong with academic nephrology. Dr. Arruda hates the first slide in his deck. Why doesn't he remove/fix/change the slide? Because the slide deck has been vetted by the FDA and Otsuka's lawyers. He can't change it. He has signed a contract saying he won't change it."
Thanks for reading and thanks to all who submitted. You will find all other posts that were submitted but didn't quite make the theme in the first comment on this post.  Join us next Tuesday at Survive The Journey.

Tuesday, October 6, 2009 by Christian Sinclair ·

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