Mastodon 10_03 ~ Pallimed

Tuesday, March 30, 2010

Origins: Physical Medicine and Rehabilitation to Palliative Medicine

In an effort to better understand what guides people to practice in hospice and palliative medicine, we are beginning a new series called 'Origins' featuring doctors from different primary specialties.  Obviously the majority of physicians in the field are from Internal Medicine and Family Medicine (as evidenced from the first year of board certification in 2008.)

The first edition of Origins is written by my colleague Pam Harris, MD who is an associate medical director with me at Kansas City Hospice and an ordained minister.  She recently passed her Physical Medicine and Rehabilitation boards and is board certified in HPM. 

To contribute to an upcoming Origins blog post please email me at We need representatives from any of the following specialties: psych, neuro, anesthesiology, radiology, EM, surgery, OB/GYN. 

Take it away Pam!

Thanks to my friends and colleagues at Pallimed for the opportunity to launch its “unconventional” guest blog event!

“Why would a Physical Medicine and Rehabilitation (PMR) physician specialize in hospice and palliative medicine (HPM)—isn’t that the exact opposite of what you were trained to do?”

I get that question a lot, especially from my PMR colleagues. My dearly beloved mentor looked at me with disappointment when I went to seminary [as those great theologians, the Grateful Dead, once said, “What a long strange trip it’s been”], but he looked at me with absolute unbelief when I told him that I was going to work for hospice. It was almost as if he believed that all my training to that point had been a waste of time.

On the contrary, PMR physicians are perfectly suited for HPM! Here are the top 5 reasons why:
  1. Physiatrists always bring friends. PMR was developed as an interdisciplinary field, complete with team meetings.
  2. We look comprehensively at the patient and family in the entire community and psychosocial context. We can’t treat patients in isolation from their support system/caregivers and we can’t treat the patient/family unit without considering their larger environment.
  3. Physiatrists are experts at musculoskeletal and neurologic physical diagnosis, pain management, bowel and bladder programs, skin care/wound management, and community resources to support our patients and families. Sound familiar?
  4. We’re all about improving quality of life and maximizing function. Even at the end of life, there is room for targeted therapies that help patients do the things that they want and need to do as long as possible and that teach caregivers how to care for patients in ways that protect both the patient and the caregiver.
  5. Physiatrists frequently provide care to patients with progressively degenerative and disabling conditions, adjusting treatment plans as diseases progress and patient abilities change. A Physiatrist can help provide valuable prognostic information to patients and families to help them make informed decisions about their therapy options.
I believe the biggest barrier to physiatrists considering practices in HPM is the false belief that rehabilitation and palliative care are opposites. (We rehabilitate until we can’t rehabilitate any longer and only then do we consider palliative care.)

Newer concepts of HPM look at palliation as an integral part of care, with the proportion of curative or restorative/rehabilitative interventions varying with the patient’s disease, goals, and preferences regarding care. There is an art as much as a science to navigating this spectrum of rehabilitation and palliation. It is OK to acknowledge that not everything is “fixable”, even with maximum therapies and treatment of mood disorders such as depression that might affect participation. If something is not working, it is OK to stop doing it and to re-evaluate goals/treatment plans. Not all patients, even those with excellent rehabilitation potential, want to spend their time and energy trying to achieve the goals we encourage them to adopt.

It’s important that we help patients balance their expenditure of time and energy against their likely payoff (e.g. likely function or choice of living arrangement), helping patients understand implications of their choices within their community and psychosocial support structure. Physiatrists are perfectly situated to help patients through this process.

I would encourage my PMR colleagues to consider HPM certification—tests this fall and in 2012 are available to candidates without fellowship training along an experiential pathway. You can find requirements on the official American Board of Physical Medicine and Rehabilitation webpage here. Contact your local hospices about opportunities for clinical practice experience—it could open new doors for your practice. After all, with all our experience, how can we help but grow up to be palliative care docs? ;)

Tuesday, March 30, 2010 by Christian Sinclair ·

Fear of morphine persists in around the globe

Last summer I had the distinct pleasure of hosting three medical students from Tongji University Medical School, Shanghai for a month elective in palliative care. The three students voraciously absorbed information about tending to patients with life-limiting illness - including communicating difficult news, negotiating goals of care, basic and complex symptom management. We reflected on the differences in practice and in palliative care medical education between UMass and Tongji U in Shanghai.

They were frankly surprised by how commonly morphine was prescribed for severe cancer pain. In China, they shared with me, meperidine is the drug of choice. I was equally stunned by their response as they were to our prescribing practices, to say the least. I wondered how much this was their level of experience versus a more general practice in China. Not long after, Supportive Care in Cancer published an article reviewing just this issue.

Physicians (including internists, surgeons, breast cancer specialists, gynecologists, orthopedists) from four tertiary care hospitals in Changchun (Northern China) and Changsha (Southern China) were surveyed, and the 201 of the 210 selected responded (97.5% response rate). The questionnaire evaluated 3 general categories:
  1. Knowledge of WHO guidelines and preference with drug choice for cancer pain management;
  2. Knowledge of cancer pain management and actual morphine utilization patterns;
  3. Physician perception of factors impeding use of morphine in clinical practice.
A brief overview of the results: Close to 50% of physicians had comprehensive understanding of the WHO guidelines. The drug of choice for severe cancer pain was meperidine (pethidine). Only 33.8% understood basic principles of opioid dosing (such as the lack of a maximal dose of morphine - despite China's State Food & Drug Administration officially supporting this fact since 2000), and this knowledge gap did not correlate with experience level of the physician, but rather with whether physicians had received specific training on opioids. The principle barriers to prescribing morphine included lack of training in cancer pain management, fear of addiction or diversion, and personal preference. Certainly, China's government has been on the forefront of supporting WHO initiatives in this arena and has one of the highest world-wide levels of access of opioids for severe pain.

Since that time, I have reflected on this data with trainees from different countries, including Peru and Korea - similar perceptions arise by the physicians reflecting on practice standards in their home countries. Experiences by colleagues teaching around the world suggest similar knowledge gaps, and fortunately, like this study suggests: providing education on cancer pain management quickly changes knowledge and practice by clinicians who have access to morphine and other opioids.

I applaud the efforts by Open Society Institute, Institute for Palliative Medicine, Institute Catalan de Oncologia (a palliative medicine WHO demonstration site), and the International Association for Hospice and Palliative Care in increasing expertise in pain management and palliative care across the globe. These groups have lead educational and consulting sessions in host countries, funded and invited physician leaders from across the globe to study with Palliative Care experts and take their knowledge home. Young physicians and medical students interested in International Medicine may want to consider HPM as a specialty because of the opportunity for international collaboration. Holly Yang MD - a good friend, excellent teacher, and Midwesterner-turned-California-surfer - is a great example of the upcoming Palliative Care physicians (HPM-LEAD participant) delving into international medicine by teaching international fellows at San Diego Hospice and traveling across the Globe to "spread the knowledge" of this field, promising to continue and to expand upon the work of current leaders in this field like Frank Ferris MD and Kathy Foley MD.

I will be traveling to Shanghai this spring, and look forwards to sharing what I've learned from our Chinese colleagues upon my return.
ResearchBlogging.orgYanjun, S., Changli, W., Ling, W., Woo, J., Sabrina, K., Chang, L., & Lei, Z. (2009). A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China Supportive Care in Cancer DOI: 10.1007/s00520-009-0768-2

by Unknown ·

Wednesday, March 24, 2010

Grand Rounds (Non-palliative) is Up

A great supporter of hospice and palliative care related info, blogger/plastic surgeon/quilter, Ramona Bates hosts Grand Rounds (the general medicine one, not the palliative care one) showcasing the best of blog posts from the last week on her blog called 'Suture for a Living.'

She has a few palliative care related links in her Grand Rounds this week. My favorite being CancerDoc with his post "Denmark" about what one of his patients taught him.

Go support a surgeon who supports palliative care and find some other great blogs out there.

Wednesday, March 24, 2010 by Christian Sinclair ·

Pallimed Cited in the NEJM; Pallimed Readers Stand Up!

This post was chosen as an Editor's Selection for ResearchBlogging.orgI am very pleased to announce that Pallimed has officially been cited in the New England Journal of Medicine! (members only).

The letter to the editor was written by my colleague at the University of Kansas, Lindy Landzaat, DO (a 2009 Harvard HPM Fellowship grad) based on Drew's post about Continuous-Flow Left Ventricular Assist Devices (LVAD).  This came about because I knew of Lindy's interest in LVAD's since she had presented at the 2009 Case Conference in Austin on the topic, and encouraged her to write the letter after reading Drew's post.  The three of us worked on it over the next week with Lindy doing the bulk of the work.  It was submitted in mid-December and we got word soon after that it was approved for publication with a few minor revisions.

One important piece to include was a citation to the Pallimed since it really demonstrated the source of some of the viewpoints and allowed an expansion on the subject that a letter to the editor word limit would not allow.

Here is the sentence from the letter to the editor that was referenced:

Though left ventricular assist devices are increasingly helpful and reliable, they still represent a form of life support with a specific set of burdens and complications, particularly as patients die: difficult decisions for patients, families, and doctors surrounding planned device discontinuation; device failure; symptom-management issues; and coordinating end-of-life care that honors patients' wishes and values. 2

And here is how the citation looks:
2. Rosielle D. Rise of the machines. In: Rosielle D, Sinclair C, eds. Pallimed: a hospice & palliative medicine blog. (Accessed March 4, 2010, at
(More on citing a blog in this Pallimed post. If you ever cite a blog it is always nice to leave a mention on the blog referenced.)

Pallimed Readers Stand Up!

Now this is not the first time a blog has been cited in a medical journal (Geripal had a reference in Lancet in Sep 2009 [damn upstarts!]), but I am also hoping that it will not be the last.  This moment raises many important issues about the exchange of ideas and blogs:
  • Transports information from blogs to the relatively insulated world of medical journals
  • Gains increased awareness about palliative care issues by keeping them in medical journals via letters to the editors, editorials
  • Reinforces blogging as a scholarly effort
  • Increases awareness of journal readers that blogs are a credible source of informal and post-publication peer review
  • Achieves formal archiving in the medical institutional memory of  important points brought up in blogs
  • Allows blog readers a streamlined path towards increasing publications
  • Crosslinks open access (blogs) with paywall access content

So earlier Wednesday night I spoke with Eric Widera of GeriPal and we have decided to start a workgroup to help help translate information from palliative care related blogs into academic journals.  This is a work in progress and open to any readers that would like to participate.  Some ideas of how it might work:

Any post on Pallimed or GeriPal (or another blog if you are interested) that cites a recent journal article is eligible.
  • If you find a post that resonates with you and you want to write up a letter to the editor, just comment on the article and email the author of the post. (If you don't know who that is email me at
  • Gather the deadline, word count, submission instruction info for the cited journal
  • Within a week after the post is up (or sooner if necessary) the final authors for the letter will be confirmed and work will proceed by email to submit before the deadline.
With enough effort behind this we could start a listing of letters to the editor or editorials that were seeded by a blog post and demonstrate the effort of the crowd as a whole to contribute to medical information exchange.  But you must be the catalyst.  We have nearly 3000 subscribers, so if only 5% of our readers were interested in doing this we would have 150 people nearly continuously as a loose group working on letters.  That could be huge!

What we need from you:
  • More ideas on how this could (or could not) work
  • Your willingness to contribute and write a letter based off already formed themes.
  • Your desire to be first author on letters to many top notch journals
  • A cool name for this workgroup/project including some of the following words or phrases: blogs, social media, translation, stupendous, project, workgroup, GeriPal, Pallimed, awesome,add your own.
So are you in?
ResearchBlogging.orgLandzaat, L, Sinclair, CT, & Rosielle, D (2010). Continuous-Flow Left Ventricular Assist Device New England Journal of Medicine

by Christian Sinclair ·

Symptoms, Suffering, Parents and Pediatric Palliative Care in End-Stage Cancer, Part 2

A couple of weeks ago I posted on the Archives of Pediatrics and Adolescent Medicine article “Considerations About Hastening Death Among Parents of Children Who Die of Cancer." That study and the study I’m writing about here are retrospective cross-sectional surveys of parents whose children died of cancer at least one year previously. Joanne Wolfe, MD, MPH of the Dana Farber Cancer Institute, Boston was on both research teams.
This study, "Symptoms and suffering at the end of life in children with cancer: an Australian perspective" was published in the Medical Journal of Australia in mid-January. The abstract is here.
In the study’s introduction, it was pointed out that previous international studies may not apply to the Australian milieu since compared to many other developed countries there are system limitations in access to experimental cancer treatments and fewer pediatric oncologists available, also Australia's population is dispersed over huge physical distances, which leads to the development of local and regional treatment centers.
Here are some data highlights:
  • Offered out-of-hospital palliative care: 82%, 75% opted in. Satisfaction rating of very good or excellent for out-of-hospital palliative care: 74%
  • 47% received cancer-directed therapy in the last month of life, with 33% experiencing significant side effects. The perceived goal of cancer-directed therapy was 33% palliation, 12% extending life, 12% ensuring everything had been done. Children who received cancer-directed therapy during the end-of-life period suffered from a greater number of symptoms than those who did not receive treatment (p = 0.03).
  • 63% had time to plan death location, of these 89% preferred to have the child die at home, and of these all except two died in the planned location; 61% died at home. Of those children who died in-hospital, almost 25% died in an ICU. Life-sustaining treatments were pursued in only 8%.
  • Descriptive statistics were presented about symptoms, suffering, treatment and treatment success. It was notable that there was a significant gap between symptom treatment and treatment success. Despite this, 83% reported the death of their child was somewhat or very peaceful.
In conclusion, the authors noted “relatively high rates of death at home and low rates of heroic medical interventions suggest a realistic approach to care of children with cancer at end of life. However, many Australian children who die of cancer suffer from unresolved symptoms. Greater care should be paid to palliative care for these children.”
Some thoughts
"Making the decision to have a child is momentous. It is to decide forever to have your heart go walking around outside your body." ~ Elizabeth Stone

I think that taken together these two studies highlight the problems of under-treatment and late-treatment of symptoms in children with end-stage cancer, as well as importance of appropriate, anticipatory information for and communication with parents and caregivers. What caught my eye about these studies is that they were conducted and published at all, and upon further consideration, that they made it through the IRB process (having sat on one). I think that illness, suffering and death of children are psychologically white-hot. They touch upon our hopes, fears, guilt and shame, as health care professionals, and even more personally as family members ourselves, and as human beings.

I for one experienced the post-natal death of a sibling when I was seven-year-old; I rotated in the PICU, and routinely worked in a busy, urban children’s hospital emergency department; my young-adult son is training in the Army National Guard at this writing. The death of children, its memory, and the threat of death can loom very large indeed.
One appealing fantasy that may be afoot, which I know I can entertain, is that if we were just having EOL discussions earlier, and better prognoses where being made, and change of goals were initiated sooner, and these hospice -appropriate patients were enrolled in hospice earlier, then these kids and their families would suffer less. Certainly not very parsimonious, these are a lot of complex conditions. Even if we were able to smooth this terrible path some, and see greater and earlier enrollments into hospice, there is still the dying, the dying child and the child dying from cancer.
The expectation that we would be able to attain ideal symptom control if we were just given a fair shot, in a process as chaotic, dynamic and malignant as end-stage, pediatric cancer, is I think a fantasy. Alternatively there is doing one’s best by a patient, attending to the symptoms and the suffering in a context that is congruent and meaningful that is perhaps healing and even protective, especially for surviving parents, siblings, and other caregivers.
The Australian situation is different from other parts of the developed world as noted above. Perhaps an analogy might be drawn to the health care situation in rural and remote portions of the United States, where there are logistical barriers and cultural differences, and so the experience, meaning and memory may be different. That being said, even in the face of a yawning gap between symptom treatment and symptom treatment success, these parents were largely satisfied with the palliative care they received, and recalled the death of their child as being somewhat or very peaceful.
I think that there is a strong place for information, appropriate expectations, empowerment, good will, attention, professionalism and narrative to make a crucial difference in the experience of suffering, dying and grief, even, or especially in the case of children. That imperfect work is ours.
ResearchBlogging.orgHeath JA, Clarke NE, Donath SM, McCarthy M, Anderson VA, & Wolfe J (2010). Symptoms and suffering at the end of life in children with cancer: an Australian perspective. The Medical journal of Australia, 192 (2), 71-5 PMID: 20078405

by Brian McMichael, M.D. ·

Friday, March 19, 2010

Emergency Room Visits by Patients with Cancer Near End of LIfe

EmergencyImage by xparxy via Flickr
[Editor's Note (C.S.) - I would like to introduce Suzana Makowski, MD, MMM, FACP as the newest blogger to the Pallimed team. Suzana and I go back a few years when we first met at the AAHPM Annual Assembly in New Orleans. She has tremendous enthusiasm for hospice and palliative medicine and her insights reach beyond the traditional evidence-based medicine approach. She is the newly elected co-chair for the Humanities and Spirituality SIG for AAHPM and the founder of the Lois Green palliative faculty development initiative. You can also find her on Twitter if you are so inclined (@suzanakm). She will be blogging on the main blog and occasionally on the Arts and Humanities blog also. Please help me in welcoming Suzana!]

Thank you Christian! And of course to Palladius and to Patrick for welcoming me to Pallimed with a rich choice of articles to share. Somehow it seems fitting that my first post refer to an article from Canada – now that Vancouver has been warmed up by the Winter Olympics just a year before that city-of-my-dreams will be swarmed by thousands at the AAHPM assembly next year. Well, in full disclosure, the study was not conducted in Vancouver, but rather in Ontario.

During this time, when the House and Senate continue to debate healthcare reform, when policy-discussions surrounding palliative care are challenged by the tension between the quality and quantity of care, an article emerges from CAMJ (with free online full pdf access) that challenges us to rethink how to focus our resources for patients with serious, end-stage cancer. Taking the IOM’s definition of quality care as “the right care at the right time in the right place,” this article explores how and why patients with serious cancers and their caregivers seek help through the emergency rooms and boldly asks the question whether this is the best care the patient could be receiving.

The point of transition from home to hospital is usually the emergency room. It is a place, as a patient of mine admitted for severe breathlessness, in hospital with a chest tube explained, is never a place you want to spend much time, especially if you aren’t feeling well. “I try anything to avoid waiting hours first in the waiting room, and then on a thin mattress in the hallway or room whose walls are build by wisps of curtain, sometimes waiting for hours in close proximity with strangers.”

We know already that most people want to be at home with family at the end-of-life, we also know that most end up in hospital or institution. We have hypothesized that increasing access and enrollment to hospices might help people meet this goal. This article seeks to understand how frequently and why patients with end-stage cancer choose to go to the ER.

So this begs the question… what percentage of patients with cancer visit the emergency room during the last 6 months and 2 weeks of life?
Of the 91,561 patients who died of cancer between 2002 and 2005, 84% of patients visited the ER in the 6 months prior to death and 34% of patients visited in the last two weeks before death.  They outline the principle reasons for emergency room visits: primary cancer (mostly lung cancer), uncontrolled symptoms (pain, dyspnea and other non-pain symptoms), caregiver fatigue, and infection.
Top reasons for ER visits among patients with cancer:

While many of the patients studied ended up admitted to hospital, the authors – and I believe, rightly so – postulate that most may have avoided acute-level care had the quality and quantity of care had adequately supported the needs of both patient and caregiver. Instead of emergency room care, most of these patients required “either additional support to remain at home or direct transfer to a palliative care unit or residential hospice.”

Barbera and colleagues suggest that “comprehensive and coordinated” palliative care could serve the needs of most of these patients and their caregivers and meet this demand for quality and quantity of care, allowing patients to have symptoms tended to at home, in clinics, or in in-patient or residential hospice facilities.

Knowing why patients come to the emergency rooms allows us – Barbera proposes – to better define what we can do and how we can focus our efforts to help prevent many of these ER visits. In particular, they recommend the following:

1- Impeccable symptom management facilitated by sharing standardized, comprehensive symptom assessment and clinical guidelines;

2- Fluid medical records to allow for improved continuity of care (EMR?);

3- Caregiver education, to help them anticipate and cope with crises;

4- More robust and broad-reaching advance directives;

5- Increase palliative care workforce to improve access to experts in management of complex symptoms, as well as technical/mechanical needs of patients with complex/serious illness at home.

In addition to the above, I suggest adding to the list:

6- Engage the Emergency Medicine Physicians, NPs, PAs, nurses and social workers, to gain expertise in palliative care. For starters: EPEC-EM provides a broad foundation of knowledge in palliative care to emergency room clinicians. For those who want to take it up a notch: EM is one of the 9 primary specialties that recognize HPM as a subspecialty. Building this workforce could help address the needs of many of these patients once they have arrived in the ED. Any HPM board certified EM docs out there to comment?

7- Consider comprehensive palliative care medical homes that provide comprehensive palliative care seamlessly across healthcare settings. Support these initiatives with health policy innovation and reform and in doing so improve quality of care while decreasing cost. Compare emergency room use patterns in similar patient populations between communities with comprehensive palliative/hospice care programs and those without such robust programs as part of the cost-effectiveness research initiatives supported by the Senate.

Perhaps by expanding access to expertise in palliative care, across healthcare settings, people with end-stage cancer and their families would have the support needed to tend to their care – even if complex – and could avoid emergency room visits and hospitalizations.

ResearchBlogging.orgBarbera, L., Taylor, C., & Dudgeon, D. (2010). Why do patients with cancer visit the emergency department near the end of life? Canadian Medical Association Journal DOI: 10.1503/cmaj.091187

Friday, March 19, 2010 by Unknown ·

Review of the Social Media Session at the AAHPM HPNA Annual Assembly

**Warning long post but good info!**

Well now that I am starting to get back to a normal speed I wanted to start posting some of the slides and general feedback from the special session on Social Media at the Annual Assembly in Boston on March 5th.

As we mentioned in the earlier post, we were all excited and impressed with the over 140 people who showed up. Honestly we were not sure what to expect, but at one point thought we would have more people on the panel than in the audience. So more than 20 would have been great!

First here are the results of the survey taken before the session. We also took a poll of people that were at the session and about 40% self-identified as beginner users of social media and another 40% identified as intermediate, the rest we assume are advanced or people who never raise their hands when asked questions at conferences.

AAHPM HPNA Social Media Wkshp Survey Results
View more documents from Christian Sinclair, MD.

Here is the slidedeck from Alex Smith, MD (UCSF/GeriPal)
And then I followed with my slides. (Christian Sinclair, MD - (KC Hospice/Pallimed)
Social Media In Palliative Care Communities 2 of 3 - Sinclair
Here are links to articles describing many of the ways networking and social media are effective (terms taken from my slidedeck):
Information asymmetry

Mass amateurization
Social media
Social networking
Metcalfe’s Law
Small world phenomenon
FOAF effect
Ambient awareness
Power-law distribution (aka The Long Tail)

And finally Eric Widera, MD (UCSF/GeriPal) finished the presentation with his slides.
After that we took some questions and I did see one person with a video camera, so if you tell me who you are I might get permission from the AAHPM and HPNA to post the video here (or on their blogs).

Overall, it seemed well received.  Eric even promised to dust off his Twitter account and has been Tweeting ever since.  After the talk we got to meet a lot of bloggers and Twitter users face to face which is always nice.  We would like to do this again next year in Vancouver with maybe some small breakout sessions on how-to.  Also in the next week or two we will announce the first ever TweetChat for hospice and palliative medicine professionals.

Here are the tweets from the session which may give you an idea of the key points (sorry for the length - RT = Re-tweet which meant there is more agreement/endorsement for the idea):
brimcmike: At Social Media In Palliative Care session in Boston-fashion there's Dunkin' Donuts® HPMAssembly hospice

suzanakm: social media in palliative care meeting: I'm sitting at table with Geripal, Pallimed, Pallimed Arts bloggers! About 75 people here!

suzanakm: Reason to blog about palliative care: "Sara Palin writing about death panels on facebook"

suzanakm: reason to blog and use social media - to network with others in the field, exchange ideas.

brimcmike: RT @suzanakm Reason to blog about palliative care: "Sara Palin writing about death panels on facebook"

suzanakm: 1 concern for community surveyed about sm: privacy issues - patients/families, from private people on the web.

suzanakm: putting your name out there is important - transparency of members helps build the network.

suzanakm: Concerns from audience: Palliative care physician already works 60 hrs a week, why should I add more hrs to day w/ blogs?

suzanakm: Interest in research in power of social media for palliative care

suzanakm: audience concern about sm: "I get overwhelmed by email, how do I prevent getting overwhelmed by twitter?"

brimcmike: At Social Media in Palliative Care session one :) concern about using social media

suzanakm:  audience concern: online distractions seem to easy - how do I avoid getting "addicted" by facebook, twitter friends?

suzanakm: RT @brimcmike: At Social Media in Palliative Care session one :) concern about using social media

suzanakm: @brimcmike Thanks for tweeting the social media meeting!

suzanakm: - "Connected" by N. Christakis - highly recommended book about connectivity, online and off.

brimcmike: RT @suzanakm Q. how do I avoid getting "addicted" by facebook twitter friends? A. It's more of a pseudo-Addiction

ozmosis: Agreed! RT: @suzanakm - putting your name out there is important - transparency of members helps build the network.

brimcmike: RT @suzanakm: : audience concern about sm: "I get overwhelmed by email, how do I prevent getting overwhelmed by twitter?"

Clarksondoc: RT @suzanakm: social media in palliative care meeting: I'm with Geripal, Pallimed, Pallimed Arts bloggers! About 75 people here!

suzanakm: - @ctsinclair started blogging as a "solo" fellow - in order to be less isolated & to break through information heirarchy

jsperber: Session is packed! : RT @AAHPM Social media in palliative care communities, room 206 at 7 am

brimcmike: Social Media in Palliative Care session @ctsinclair: Cause and Effect; Power; Info Decentralization

suzanakm: - social media helps diverse information bypass traditional barriers to "getting ideas out there" - increases creativity

brimcmike: At Social Media in Palliative Care session @ctsinclair: Info Revolution à la Alvin Toffler 3rd Wave

brimcmike: At Social Media in Palliative Care session: Now publish in Beta for editing Instead of edit then publish

brimcmike: At Social Media in Palliative Care session: Facebook population greater than U.S. population

suzanakm: Social Media meeting: @ctsinclair - Metcalf's law- power of a network is only as powerful as the activity and size of its members

brimcmike: Social Media in Palliative Care session @ctsinclair: Power of a Network is a Function of the # of users

suzanakm: - 6 degrees of separation from Kevin Bacon is not pase - its now 3 degrees from @ctsinclair

brimcmike: Social Media in Palliative Care @ctsinclair: SM assists in appropriate policy influence earlier and faster

suzanakm: @ctsinclair calls for a social media strategy for AAHPM and our affiliated journals

brimcmike: Social Media in Palliative Care session Perfection is the enemy of good enough in SM

suzanakm: Perfection is the enemy of effectiveness in social media - its a very different organism from a research publication

brimcmike: Social Media in Palliative Care session Individual participation not obligatory in SM

suzanakm: while social media is not obligatory (like email) it is our responsibility - our presence counters misinformation online

brimcmike: Social Media in Palliative Care session Community engagement IS necessary in SM

drosielle:  Widera just called tweeting the butt of all jokes at soc media panel. He didn't mean it.

suzanakm: @ewidera is demonstrating the degress of separation from @dianeemeier demonstrating power of twitter

brimcmike: Social Media in #Palliative Care Session: Online Presence: Connect, Follow, Comment, Tweet, Blog

suzanakm: RT @brimcmike: Social Media in #Palliative Care Session: Online Presence: Connect, Follow, Comment, Tweet, Blog

suzanakm: #aahpm social media in palliative care: every month palliative care grand rounds is posted on a different blog.

suzanakm: social media in palliative: @ewidera participation helps create a voice that allows us to correct misinformation, share good info

brimcmike: Social Media in Palliative Care Session: @suzanakm Movement Web 1.0 Static/Unidirectional;Web 2.0 Dynamic/Engagement

ozmosis: Engagement is key RT @brimcmike: Social Media in Palliative Care session Community engagement IS necessary in SM
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by Christian Sinclair ·

Palliative Care: (Un?)-Necessary Specialty

For long-time readers of Pallimed, it would be obvious to most of you that palliative care is important enough to require dedicated specialized instruction to ensure the highest quality symptom management, skilled patient and family communication and balanced discussions of transitions in goals of medical care.

One of the web's more popular doctor bloggers, the anonymous* Dr. Lucy Hornstein (aka #1 Dinosaur - her blogging pseudonym), recently posted an entry titled: Palliative Care: An Unnecessary Specialty.

Now before you get too mad or defensive (like I first did), go read the post and the comments.  She is a family medicine doctor and the main thrust of the article (despite the provocative title) is that all doctors and especially primary care doctors should be skilled in palliative care.  A lot of the arguments come down to the frustration over too much specialization. An excerpt:

Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.
I would agree that palliative care is practiced by many good clinicians (primary and specialist) every day whether they call it 'palliative care' or not.  In fact this is one of my main teaching points to students and colleagues about the ubiquitous (and not foreign) nature of palliative care.  I applaud the many health care professionals who focus on alleviating symptoms, talk with patients and families in a way that is open and clear, and effectively understand the patient's values to help in transitioning goals from curative to palliative at the right time for the patient.

But there are a lot of patients and families who are not getting these services whether the case is simple or complex.  Thus the field of palliative care was born.

And the funny thing about this post is...#1 Dinosaur likes palliative care so much, she is thinking of becoming a hospice and palliative care doctor.

(And a quick side social media side story.
  • I saw a Tweet from Dr. Scott Lake (@doclake): This blog will make u mad "Palliative Care: An Unnecessary Specialty" hoping someone more eloquent than I will respond
  • I replied on Twitter: RT @doclake This blog will make u mad "Palliative Care: An Unnecessary Specialty" "I haven't read it yet & already mad" 
  • I read the blog post and using 'Share This' connected to my Gmail account was quickly able to email it to Drew Rosielle, Steve Smith (AAHPM CEO) and Eric Widera (GeriPal) (all on Twitter, but I knew they might see it faster this way)
  • Total time to now: 50 seconds
  • I commented on the blog post (5 minutes)
  • Meanwhile...Steve Smith had contacted Laura Davis (at AAHPM) who got in touch with Sean Morrison (President of the AAHPM) who wrote a great comment less than an hour after I first read about it.

Hopefully this illustration of how the networks connected to pass this information is helpful to see why we need our networks to be full, diverse, integrated and intact before we actually need them.  See you on Twitter.)
*Late edit 3/19/2010 Apparently she was once anonymous and now revealed since she wrote a book.

by Christian Sinclair ·

Wednesday, March 17, 2010

Cancer Reporting in the Media - Guess what they report on?

This is a photograph of the Chicago River dyed...Image via Wikipedia
St. Patrick's day is good for celebrating your Irish heritage or fondness for food coloring, but it may have a new tradition, the release of major Palliative Care articles. Three major articles came out this week. Today JAMA published "Availability and Integration of Palliative Care at US Cancer Centers", yesterday the Archives of Internal Medicine released "Cancer and the Media: How Does the News Report on Treatment and Outcomes?" and on the 15th CMAJ released "Why do patients with cancer visit the emergency department near the end of life?"

So why the St. Patrick's day logjam of articles? Some may say it is mere coincidence, but I think there may be some meta-meaning here. By the power of Grayskull Wikipedia I found that St. Patrick is very likely two different people, one of which is named Palladius...very similar to 'palliative'...which is why I am sure the editors of these three journals got together to plan this bounty of articles. (I guess the New England Journal of Medicine missed the conference call). We will see if next year the same thing happens. Enough conspiracy talk...

This Archives of Internal Medicine study by Fischman, Have and Casarett shines a light on the bias present in the media towards the 'fight' against cancer. (other good blog posts on words used in cancer: Drew Rosielle on 'Hope' and GeriPal on 'fighting cancer')  The researchers looked at 8 newspapers (Chicago Sun-Times, Chicago Tribune, Daily-Herald Chicago, New York Daily, New York Post, New York Times, Philadelphia Daily News , Philadelphia Inquirer) and 5 magazines (Newsweek, Parade, People, Redbook, Time). (What no Washington Post or Cosmo?)

The main points in the articles that were coded if they were mentioned were:
  • Survival
  • Mortality
  • Aggressive/curative
  • Treatment failures
  • Adverse events
  • Palliative focus

The researchers found a very significant bias towards reporting cures/survivors (32%) over deaths (8%) and sadly only 2% that mentioned both. Also they found that adverse events and treatment failures were rarely reported (both less than 30%).

And of course the result you have been waiting for, 11 articles out of 436 (3%) mentioned aggressive and pallaitive measures and only 2 (two, dos, deux, zwei!) of the articles focused exclusively on end of life care exclusively. Well the researches only searched from 2005-7 and so they missed the whole past year of New York Times articles we have been writing about. Still it is shocking in 'cancer focused' articles only 0.5% mention end-of-life care exclusively?!

Pallimed was initially focused on EBM style analysis of palliative care articles, but we have expanded our scope to report on palliative care in the media also, and this study justifies the importance of getting the story about good palliative care into the main media news cycles. It is not just enough that there are articles about cancer treatments (mainly read by cancer patients and their families) or articles about hospice or palliative care programs (read by hospice and palliative care staff and families with hospice experience.) We need articles that combine the two so people are equally exposed to the balance of treatments that exist out there. Few patients or families facing cancer diagnoses will choose to read the 'hospice is valuable' headline when juxtaposed with a 'new cancer treatment' headline.

But it is important to understand the view of the journalist and editors as well. 'New cancer treatment' headlines may sell more copies than 'hospice is valuable' headlines. Also a new treatment being available is news because it is new, different, interesting. Having articles about how people have poor survival with a cancer diagnosis is not new, different or interesting. Palliative care and hospice organizations need to make sure the journalists and editors hear the great stories we see every day in our work. The human interest perspective is very powerful. Some hospices are better at connecting with the media than others. Maybe it was time we all had a lesson in how to best interact professionally with the media.

For reference I have uploaded a slidedeck I gave at the NHPCO conference in 2007 titled: Working With the Media: How to Reach the Widest Audience Possible. It is embedded below.
If you know of any other good media resources for medical professionals please comment below.  Hospice Foundation of America also posted about this today.

ResearchBlogging.orgFishman, J., Ten Have, T., & Casarett, D. (2010). Cancer and the Media: How Does the News Report on Treatment and Outcomes? Archives of Internal Medicine, 170 (6), 515-518 DOI: 10.1001/archinternmed.2010.11
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Wednesday, March 17, 2010 by Christian Sinclair ·

Palliative Care in Cancer Centers - Horses of many different colors

The third Palliative Care related article released for St. Patrick's (Palladius) day is a article that speaks to what many of us in the field know already:

Palliative Care is a chameleon: it looks different depending on the background of the institution.

But as the editor-in-chief of the Lancet has said: "It is not true, until it is published." Well JAMA has published a little bit of truth with the article: "Availability and Integration of Palliative Care at US Cancer Centers."  We have already known from CAPC data about a variability in access among states. This data helps underscore the variability in palliative care services, staffing, education and research at major cancer centers in the US.
I won't belabor the data here as it is relayed well in the abstract. But a few things impressed me about the study. It made a strong effort to differentiate between the simple question of 'Do you have a palliative care program?' which in a few institutions I have seen consists of a well stocked brochure rack and a single staff member (usually a nurse) who has 20 other job responsibilities that are prioritized by the administration above palliative care. Instead the authors focused on the structure, process and outcomes (also known as a Donabedian tripartite division, but of course you already knew that.)

Also a question to cancer center executive about barriers to palliative care seemed to be somewhat contradictory to other findings. Thee highest rated barriers (around 50-60%) were:
  • limited institutional budgets
  • poor reimbursement
  • limited trained palliative care staff
despite 89% of cancer centers surveyed claiming to have palliative care programs. And conversely very few center executives (less than 10%) reported the following as barriers:
  • limited palliative care needs
  • lack of evidence for palliative care
  • palliative care may increase mortality
  • palliative care may affect national rating
  • palliative care available but not utilized

So if I understand this right, 89% of cancer center executives have palliative care programs with staff who get paid from the budget but the around 60% feel the biggest barrier to getting palliative care access is that there is no budget/reimbursement or staff?

Couldn't be the culture of cure (see the media study), or the fact they are a tertiary referral center focused on the 'save'? Or the drive to get more patients enrolled in experimental drug trials which is a major source of funding/prestige? Or that palliative care may still not be well integrated into the culture?

I'm merely speculating here, but I think there is a juicy qualitative/anthropological study in this data.

One last thing...only 57% of NCI Cancer Centers had board certified palliative medicine physicians. And the data was collected in 2009. Come on people get board certified in hospice and pallaitive medicine this fall.

(Image from

ResearchBlogging.orgDavid Hui, MD, MSc, Ahmed Elsayem, MD, Maxine De La Cruz, MD, Ann Berger, MD, Donna S. Zhukovsky, MD, Shana Palla, MS, Avery Evans, Nada Fadul, MD J. Lynn Palmer, PhD; Eduardo Bruera, MD (2010). Availability and Integration of Palliative Care at US Cancer Centers JAMA, 303 (11), 1054-1061

by Christian Sinclair ·

Sunday, March 14, 2010

Three Excellent Blog Posts For our Field

I couldn't wait until next month's palliative care grand rounds and so I had to post a link to each of these three wonderful blog posts to make sure you knew about them.

One from Joanne Kenen at The New Health Dialgoue from the New America Foundation:

In the article "This is Why We Need Palliative Care" Joanne comments on an article in the journal Health Affairs called "Shock Me, Tube Me, Line Me." An exceprt from her post:

End of life, he writes, can be done better. He’s correct. It can. "Give me a motorized wheelchair and a feeding tube if I need them, along with a tracheostomy to help me breathe and dialysis to filter out toxins. Those do nothing to stop a good mind and a strong spirit, while permitting both to overcome obstacles of blood and flesh." That's his opinion and his wish.

And two from GeriPal:

Patrice Villars a nurse practioner writes on "Maintaining Relationships: Stop Using the Words ‘Terminal’, ‘Dying’, ‘Hospice’, ‘Advance Directives’ and ‘Bereavement’ that Push Others Away"

An exceprt from GeriPal:
Our audience – patients and families – often don’t want to hear about dying. Death and dying is scary. Scary equals reactionary sound bites (i.e. death panels) that can dash any hope we have of reasonable reform and ongoing open relationships. (Ex. Advance directives talks with your physician = dying = fear = death panel = killing Granny and babies with Down’s syndrome). And guess what other words also equal death to our audience? Terminal. Advance directives. End-of-life. Hospice. Yes, and even bereavement. As long as the majority of our patients/families (to say nothing of our health care colleagues) associate palliative care with dying, they will not have access to our services.

Whoa, this is a lot to take in. You mean don’t use the words we have been using for decades to demystify the fear and denial of death in our culture? Isn’t this who we are? What about the movement we have come to birth, nurture and protect? Really, stop using those words?
11 comments on that one so you know it got people stirred up.

Brad Stuart, MD has an enthusiastic rallying cry for palliative care, hospice and health care reform titled: "Talking Palliative Care and Death: Get Up, Stand Up, Grow Up"

An excerpt:
"Why has dying become “radioactive?” Because Sarah Palin, PR master, made it that way with her Death Panel comment on Facebook. With one (more) semi-conscious crazy-ass remark she made “fear of death” the brand for all end-of-life considerations. And because optics is everything in our surface-obsessed culture, the world bought it. Are we following the world on this one? Uh-oh – I smell fear in the room. In fact a subtle scent of fear pervaded many of the meeting rooms in the Hyde Center last week. Did you notice?

and later...

Let’s talk bottom lines. Below are four fundamental reasons why I believe palliative care is critically important to health care reform. Forget radioactive. Talk about it. Just persevere. Outlast the resistance: this is a basic spiritual principle. Don’t be cowed. If the system is to wake up, that process needs to start in our own minds.
These three articles are as important to our field as any editorial written in JPSM, JPM, NEJM or JAMA.  And now you can make your voice heard go comment on these posts! Share them with your boss and team.

Sunday, March 14, 2010 by Christian Sinclair ·

Facebook Friends with a Dying Patient (Via NYTimes)

If you want a better story about the potential for social media to be another tool for connecting people to each other, you won't have to look much further than Daniela Lamas' essay in the New York Times this past week.

As a medical resident she tells of a critically ill man using his laptop frequently in his ICU bed to update his Facebook status. Through a very simple exchange at the bedside, they became friends on Facebook, a new relationship which became much more complex.

The essay is short, but packs several difficult questions that Daniela elucidates very well in the essay. Read it and bring it to your team to see if they have had a similar experience. You may be surprised.

(Photo by Flickr user: brykmantra)

(By the way, I have started a new NYT label.  If anyone wants to help find all the NYT posts and help us label them, that would be great!)

by Christian Sinclair ·

Tuesday, March 9, 2010

Implantable Cardiac Defibrillators- Hospice Role in Deactivation?

The Annals of Internal Medicine published a survey of hospices regarding their experience with patients who have implantable cardiac defibrillators. (See here for a brief explanation of these devices.)

The survey, conducted by Dr. Nathan Goldstein and colleagues, was directed at hospice administrators with instructions for that person to speak with the clinical staff. Of the 414 hospices that responded (a little less than half of those surveyed), 97% reported having patient(s) with ICDs, 58% reported having at least one patient who was shocked in the last year, and 42% of patients had the device deactivated.

Having a policy on ICD deactivation correlated with patients actually having the devices deactivated (73% of patients enrolled in hospices which had a policy vs. 38% in those without a policy; P < 0.001). The investigators include a sample hospice ICD deactivation policy in the web appendix. They rightly point out that it's impossible to know from this study whether the above correlation indicates a cause-effect relationship. Hopefully, further research is forthcoming. Policy/procedure + education seems to be the key. Without the former, you probably risk having a nurse not having the proper tools/avenues to do what she knows. Without the latter, you risk having inappropriate delays in identifying patients for deactivation and unused or improperly used magnet.

Envision a theoretical scenario: A person with hours to days to live is sent home from the hospital with an active ICD. The ICD has not discharged previously. A hospice nurse frantically calls the medical director during her enrollment visit at the patient's home (on the same day of hospital discharge) because the patient is comatose and has been shocked several times. Perhaps if a hospice policy dictates that nurses seeing patients with ICDs should always have a magnet, this type of scenario could be averted or easily managed. Maybe the magnets are inexpensive enough that every nurse should have one in their car (even though it's not an every day occurence?)

The main point of this case is that someone should have thought about deactivation before the patient was sent home. I hypothesize that most hospice patients with ICDs were hospitalized shortly before hospice enrollment. Regardless of whether this is true, I'll surmise that there is usually plenty of time for the cardiologist/internist/palliative care clinician to come up with a plan for ICD deactivation with the patient or family. Consideration of a hospice referral should trigger any of the above providers to readdress the goals of ICD and consider deactivation, but in many patients, it's appropriate to have this conversation well before hospice referral. So in an ideal world (we're working on it), it should be a non-issue for most patients once they are enrolled in hospice. Goldstein has previously identified barriers that may prevent physicians from bringing up this topic. Maybe hospice nurses don't share these barriers.

Does your hospital, cardiology service, or palliative care team have a policy or procedure for these discussions?

Even if every physician could manage this conversation, some patients would elect to keep the device programmed for discharge at the time of hospice referral. Because of this and the fact that the ideal world won't arrive soon enough, hospices should definitely get to work on their ICD policies and procedures.

Here's more information on deactivating an ICD. (Disclaimer: I have not independently verified the veracity of this information although I do have direct experience with deactivating the Boston Scientific ICD and the instructions listed seem correct- when this device emits a faint beeping sound after a magnet is placed over it, you know it is deactivated. A large household magnet can work but it's probably most effective to have an ICD magnet on hand.)

P.S. The Population-based Palliative Care Research Network (PoPCRN) assisted with the development of this survey. Check them out if you haven't heard of them. PoPCRN's director, Dr. Jean Kutner, just won an AAHPM Distinguished Service Award at the Annual Assembly. Congrats!

Tuesday, March 9, 2010 by Lyle Fettig ·

Fraudulent Pain Researcher Convicted

Anesthesiologist Dr. Scott Reuben, a prominent pain researcher, has been convicted of falsifying medical research studies.

From BMJ article:

Dr Reuben’s published studies concerned use of multimodal analgesia (a combination of non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors) to manage pain after surgery. The US Department of Justice, which prosecuted him, said that his papers suggested that "multimodal analgesia would be as effective for pain, promote long-term healing, and avoid some of the side effects associated with opioid therapy."
Sadly, he's authored 21 papers in the last 15 years per the BMJ article. Per a Google Scholar search, his name appears to be on many papers.

Here's an AP link in case you can't access the BMJ article.

by Lyle Fettig ·

Symptoms, Suffering, Parents and Pediatric Palliative Care in End-Stage Cancer, Part 1

Dying children present some of the most distressing scenarios for families and clinicians alike. In pediatric patients with advanced cancer there are a variety of forces and goals in-play. Two recently published studies look at the palliative care of children with end-stage cancer and the perceptions and concerns of their parents. Both studies are retrospective, cross-sectional surveys of parents whose children died of cancer at least one year previously. Joanne Wolfe, MD, MPH of the Dana Farber Cancer Institute, Boston was on both research teams.
The one that I will cover first is currently pretty hot in the media. The second is an Australian study that I will cover in another post.

"Considerations About Hastening Death Among Parents of Children Who Die of Cancer" was published as this month’s Journal Club article in Archives of Pediatrics and Adolescent Medicine. The abstract is here, with links to full text html, pdf and free PPT teaching slides. There is a link to video of Dr. Wolfe discussing the study on the Dana Farber Institute Press Release webpage.
This study interviews 141 subjects, with concomitant medical record review.
Data presented included:
Reported Experience with Hastening Death (HD)
The 4 Questions:
"During your child's end-of-life care period, did you or a family member ever consider asking someone on the care team to give him/her or give you or the family member medications to intentionally end his/her life?”
"When your child was receiving end-of-life care, did you or a family member ever discuss intentionally ending his/her life?"
"Did you or a family member ask someone on your child's care team to give him/her medications or to give you or the family member medications to intentionally end his/her life?"
"Did a member of your child's care team give your child medications or did you or a family member give him/her medications to intentionally end his/her life?"

19 (13%, about 1 in every 8) said they had thought about asking a doctor to hasten their child's death
13 (9%, almost 1 in every 10) actually discussed it with caregivers
5 (4%) explicitly asked a clinician for medications to end the child’s life
3 (2%) reported that their child’s life was intentionally ended with medication. In all three cases the medication used was morphine.
Current Views About HD:
Retrospective Hypothetical Scenarios
36% (49 of 136, about 1 in every 3) in retrospect, would have considered discussing HD under certain circumstances with a breakdown of scenarios given.
Uncontrollable pain was the most common circumstance to elicit a hypothetical consideration of HD. 15% would have considered HD for non-physical suffering.
Only 2 parents would have considered HD in circumstances not directly related to the child’s experience, (family witnessing suffering or medical costs).
Endorsement of HD in Vignettes
94% endorsed proportionately intensive symptom management for a terminally ill child with uncontrolled excruciating pain, while only 54% did so in the case of coma; these results did not change when adjusting for race and religiousness.
50% (1 in every 2) endorsed HD in at least one vignette. 59% would agree with a physician discussing HD in the case of a child with terminal cancer in pain or coma.
Of the 19 who considered HD during their child’s EOL course 16 (84%) endorsed HD in vignettes.
In general, being white (not Hispanic) and being not very religious were associated with endorsing HD in vignettes.
In the discussion it was noted that these data are similar to those encountered among the U.S. public with regard to HD and adults at EOL. Existing expert recommendations that it is best for clinicians to have self-awareness of their own attitudes toward HD, and then to hold open, non-judgmental discussions with family members are reiterated. The data suggest that if physical suffering is identified, most parents are open to having discussions about options including legal and effective alternatives, e.g., proportionately intensive symptom management and palliative sedation (both of which imply consideration of the principle of double effect). It was noted that given the sensitive nature of the topic and social desirability bias that HD discussions may have been underreported.
Time magazine covers the article here.
Some thoughts

I think this study highlights the systemic and intrinsic problems in caring for pediatric cancer patients, those of late-treatment and under-treatment of distressing symptoms especially at EOL. In the absence of information on palliative care options, parents are likely to consider HD as a desperate exit plan. It is likely that more than 13% of parents actually consider HD at one point or another. Having a discussion, earlier rather than later, about planning for contingencies of extraordinary symptom presentations, including those that might include significant suffering, is likely to impart important and reassuring information, as well as proactively relieve this likely-to-emerge existential distress for caregivers.
I will continue in this vein in the next post in this two-part series.

On a related note, Dr. Robert Macauley, Pediatrician on the Pediatric Advanced Care Team at Vermont Children's Hospital at Fletcher Allen Health Care wrote an Op-Ed piece in the Burlington, VT Free Press, My Turn: Open palliative care to children.

Dussel V, Joffe S, Hilden JM, Watterson-Schaeffer J, Weeks JC, & Wolfe J (2010). Considerations about hastening death among parents of children who die of cancer. Archives of pediatrics & adolescent medicine, 164 (3), 231-7 PMID: 20194255

by Brian McMichael, M.D. ·

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