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Tuesday, November 30, 2010

LVAD Advice and Talking About Palliative Medicine Boards

Two posts have recently received a little more attention and I wanted to bring them back to everyone's attention if you had not seen the discussions.

The first is a post called "Holiday Heart"  from August 2010 written by Holly Yang.  Anon posted this comment which i thought might get better attention if it got bumped up to a post:

My hospital began LVAD-DT procedures recently. Our inpatient Palliative Medicine Department has been invited by the CV surgeons to participate in their pre-op inter-disciplinary patient evaluation process.
Our discussions re the old adage of "Hope for the Best; Prepare for the Worst", a phrase I never like to use, seems to be now changed in a nuanced way in the process of goals of care discussions with these patients. They have already experienced years of frustrating medical care and are very aware of their limited treatment options. Thus, some are hanging on to a thin thread of hope of this procedure as their last and saving option.
I wish to ask about how do others approach the subjects of hopes, wishes, goals, fears, scenario planning and related topics in the context of the person facing an LVAD procedure? I appreciate any comments.

Any suggestions for our fellow Pallimed reader? Feel free to comment on the original post.

Also a few anonymous commenters have taken to my "Good Luck on Boards" post to start a conversation about board prep and the test. If you needed a space to discuss this it is available, but please do not disclose anything about the questions or answers directly. and keep the comments constructive.

Tuesday, November 30, 2010 by Christian Sinclair ·

Are You Glad Darvocet Got Pulled by the FDA? Are You Sure?

I know many palliative care practitioners were cheering the news that the world's least effective opioid propoxyphene (Darvocet (w/ APAP) /Darvon)  (similar efficacy to acetaminophen) is being pulled off the market by the FDA.  Along with meperdine (Demerol) I am not sure if a medicine exists that produces as much disdain as propoxyphene amongst palliative care clinicians.

But let's look a little closer as to why this happened.  The FDA cites the increasing cardiotoxicity and risk of heart arrythmias in a post-market study conducted by Xanodyne.  It is a little difficult to find out more exact information since the study is not published but lets do a little Scooby Doo-like sleuthing.

  • Propoxyphene is a synthetic derivative of methadone.
  • Methadone causes QT prolongation of questionable clinical significance in palliative care patients.
  • QT prolongation is a risk factor for ventricular arrhythmias.

Searching beyond just the press releases and news articles I found this FDA memo from Dr. Sharon Hertz *(Deputy Division Director Division of Anesthesia and Analgesia Products) noting that Xanodyne was asked to do a Thorough QT study. Never heard of that before? Well all new drugs since 2005 have had to pass through one before being approved. Given this increased risk of QT prolongation and the fear of resulting ventricular arrhythmias, the risk of the drug started to overwhelm the very minimal benefit it offered.
Interestingly the FDA has no evidence of QT Prolongation Adverse Event related deaths with Propoxyphene. Here is a quote from the memo: (emphasis mine)
At the 2009 advisory committee meeting, FDA staff shared postmarket data that have been suggestive, but inconclusive, about the risk for propoxyphene-related cardiac toxicity when used at therapeutic doses. No cases of torsades de pointes (TdP) causally associated with propoxyphene have been reported despite extensive use for many years. In an analysis of serious adverse events reported to the Adverse Event Reporting System (AERS) covering the period from marketing to February 2, 2005 (approximately 33 years), there were 91 U.S. deaths associated with Darvocet, the most commonly dispensed formulation of propoxyphene.  Most of the reports identified opioid drug overdoses in individuals with profiles of drug dependency, in which there was coingestion of multiple medications, or in those attempting suicide.
What is really interesting about this memo is section on page 20, where they discuss QT studies of other opiate agonists. 6 lines of the report are redacted and in the whole 20 pages there is not one mention of methadone despite nearly all other opioids being mentioned. Redaction? Should we call Wikileaks founder Julian Assange?

So in the end I am not sure if propoxyphene being removed is really about cardiotoxicity and QT, minimal effectiveness, abuse and overdose potential or a combination of all of the above.

Well all this may be a whole lot of nothing but my real concern is that methadone may be a drug in the crosshairs of the FDA soon. It already has four strikes against it:
1) documented QT prolongation
2) stigma of heroin treatment programs
3) accelerating percent of all deaths related to opioids
4) methadone could be considered an orphan drug

And evidence of  methadone being a very useful medication is possibly not strong enough to overcome these issues. So while we can cheer propoxyphene disappearing we should also be cautious and gather better evidence for the medications we wish to keep in our arsenal to ensure good pain control for years to come.

ResearchBlogging.orgBeaver, W. (1984). Analgesic Efficacy of Dextropropoxyphene and Dextropropoxyphene-containing Combinations: a Review Human and Experimental Toxicology, 3 (1 suppl), 191-220 DOI: 10.1177/096032718400300118

Collins, S., Edwards, J., Moore, R.,  McQuay, H. (1998). Single-dose dextropropoxyphene in post-operative pain: a quantitative systematic review European Journal of Clinical Pharmacology, 54 (2), 107-112 DOI: 10.1007/s002280050430

Ripamonti, C., Bianchi, M., Bruera, E. (2004). Methadone: An Orphan Drug? Journal of Palliative Medicine, 7 (1), 73-74 DOI: 10.1089/109662104322737278

** Yes the Deputy Direcotr in charge of pain medicine at the FDA is Dr. Hertz. Ha!

by Christian Sinclair ·

Changes at the blog

After 5+ years of doing this, and much deliberation, I am stepping aside from being the editor of Pallimed.  If you hadn't already noticed, Christian, Pallimed's co-editor, has really been the energy behind the success of the blog for well over a year now, and I am grateful he has agreed to continue to lead the blog.  Thanks, friend.  I plan on remaining a contributor.

For those of you who know me - don't worry - everything is fine.  Between my kids getting older and staying up later, and a whole set of new (& welcome, & engaging) challenges & projects with my move to Minnesota, I have needed to closely examine my priorities and for now stepping away from the blog makes the most sense. 

Thanks to all the readers and supporters of the blog for your generosity and wisdom over the years.  See you in the comments.


by Drew Rosielle MD ·

Monday, November 29, 2010

Palliative Care and Accountable Care Organizations - URGENT Call for Comments

With health care reform and Medicare budget cutting being the latest buzz in Washington DC, we need to be very proactive in making sure palliative care (including hospice) gets 1) included in a fair and professional manner  and 2) not let other people narrowly define us and misinform the public who we are or what we do.

But this is going to take some work, you must not just read this email/post and say, "Yeah! People need to make sure Palliative care is represented" and then wait for other people to do it for you.  So go to GeriPal and read Eric Widera's latest post on Accountable Care Organizations and how to advocate for palliative care issues to be represented.  After you are done commenting tell 4 other people about it and then follow-up to make sure they commented.

For some background on this, Eric and I had a conference call with Diane Meier, Alex Smith and Phil Rodgers. Some of the very enlightening things from Diane from her time in Washington was that all of these comments are read and carbon copied ones tend to not get as much value as the original well-crafted ones.  You are not just sending your words into some bureaucratic abyss.

Diane also shared that there will be many, many more of these opportunities to comment to all sorts of different committees and agencies so we should be prepared for a sustained response.  Knowledge of when and how to comment is not always reliable, so Geripal and Pallimed are working on someway to help our readers stay informed. Any ideas you have please share with us as we plan to have a more comprehensive solution in 2011 and will be looking for some input and volunteers to assist.

Some things that we brainstormed:

  • Website to direct people where/how/why to comment along with ways to share what you wrote so others could learn, critique, and support each other. 
  • Entertaining slides/videos/podcasts that help to explain the alphabet soup of the agencies receiving our comments
  • A way to report success to encourage people to continue to writing/advocating
Yes I know policy can be boring, but you may recall that the Medicare Hospice Benefit was once just policy discussion and now look where we are.  And FDA taking liquid morphine off the market was just policy but look what amount of change we were able to evoke.

Monday, November 29, 2010 by Christian Sinclair ·

Thursday, November 25, 2010

Engage with Grace 2010 - Things we are grateful for this year

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.


We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team.

Thursday, November 25, 2010 by Christian Sinclair ·

Sunday, November 21, 2010

Facing Death Online Community Viewing

(Welcome to viewers of "Facing Death" from Frontline PBS from the Sunday Nov 21 Community Viewing) (Transcript embedded below)

If you found the discussions and topics in this show provocative and interesting and want to learn more about medical decision making and palliative care, here are a few suggested links from us here at Pallimed to some of the best material on the web. (You can also find some good links at the official PBS Frontline page also.)

Organizations (Twitter profiles)
-For health care professionals

-For the public

Excellent Palliative Care Blogs (Click here for a full list of updated hospice and palliative blogs)

Weekly Hospice and Palliative Medicine (#HPM) Tweetchat - Wednesday 9p ET

Key People in Palliative Care on Twitter

Support National Hospice and Palliative Care Month with a Twibbon on Twitter and Facebook.
Be a Fan of National Hospice and Palliative Care Month on Facebook to find other advocates.

Sunday, November 21, 2010 by Christian Sinclair ·

Saturday, November 20, 2010

Prognostic Tool in Pediatric Oncological Hospice

In the December 1st issue of Pediatric Blood and Cancer is an article that presents the validation of a prognostic tool in pediatric hospice care. The study was produced by a team from the Hospital A.C. Camargo, a large cancer center in São Paulo, Brazil. Their overall survival rate in the treatment of pediatric cancers is just over 75%, roughly on par with those in the United States at approximately 80%. At this institution, a nurse-led, multidisciplinary palliative care team was developed in 1999. Patients are referred to it when 3 pediatric oncologists reach a consensus that a particular patient has no chance for a cure.

Read more »

Saturday, November 20, 2010 by Brian McMichael, M.D. ·

How much is enough? Dartmouth Atlas Documents Medicare Cancer Care Variations in Last Month of Life

For those of you wondering what to do with all of your free time now that the boards are over, I highly recommend immersing yourself for an hour or two in the maps, graphs, and tables of the Dartmouth Atlas’ first comprehensive report on end of life care for patients with advanced cancer. The premise of the Dartmouth Atlas is that the large local variations in health care services which Dartmouth has documented, are caused by supply (more surgeons=more surgeries; more hospital beds=more hospital days) and by local patterns and customs of care, NOT by evidence-based care delivered to achieve better outcomes. The Dartmouth Institute researchers assert that
Our findings point to important opportunities to improve not only the quality of care (by ensuring that effective care is reliably delivered) but also to reduce the costs of care (by reducing avoidable hospitalizations and unnecessary specialist visits).”[1]

Read more »

by Dale Lupu, PhD ·

Sunday, November 14, 2010

Good luck on boards!!

Just a quick little note of encouragement to all the doctors out there preparing for the 2010 hospice and palliative medicine boards.  Keep studying, you will do great!  If anyone has any stats about number of people taking the test that would be great to post here!

Sunday, November 14, 2010 by Christian Sinclair ·

"Facing Death" on PBS Frontline

PBS Frontline is known for in depth documentaries on important issues of the day, often focusing on specific narratives about individuals to help illustrate the larger dilemmas at hand.  They have covered palliative related topics like geriatrics, Parkinson's, suicide tourism and the gaps in US health care, but next week is one that seems to be right in the palliative care wheelhouse; "Facing Death" focuses on the life and death decisions in the ICU.  And to be more specific the Mount Sinai ICU.

Interestingly PBS Frontline has decided to air the episode during Thanksgiving week, maybe in hopes like the Sesame Street episode on the Death of Mr. Hooper, it will spur family discussions about what one values and what choices your family would make in similar situations.  But lucky for you, the internet has made time and space bend so you can actually watch the full episode right now online.   Or you can wait until next Sunday  the 21st at 9p ET when you can watch it simultaneously with hospice and palliative care advocates online at Twebevent. You do not need to be on Twitter (unless you want to participate) to watch the stream of comments.

The PBS Frontline site also has extra materials, interviews and footage so make sure to explore the main site, leave comments and share with your teams.  If anyone would like to post a review of the show here to Pallimed, please email them to me and I will post them next week.  The deadline is Nov 22nd at noon CT. I will accept reviews that are anonymous if well written. If you don't want to leave a full review please feel free to post comments here.    I would love to hear your comments on the choice of title, how palliative care is portrayed, if this is helpful for education to health care professionals or patients and families.

by Christian Sinclair ·

HPM on Wikipedia

I've grumbled umpteen times that Wikipedia ought get a "Hospice and Palliative Medicine" article written. As it stood when HPM, as a subspecialty, was the intended idea, writers would usually cobble together links to the separate "Hospice" and "Palliative Care" articles. Then I suddenly remembered that we are Wikipedia, and such an article wasn't going to write itself. So I clicked the letters in red of an unwritten article, and wrote one.

Since this is a pretty active Web-2.0 community aligned with the "collaborative, publish first, refine on the go" paradigm, I thought I would turn it over to all y'all to grow it from an initial stub into its full-blossomed elaboration.

So sign in and edit as you see fit, and let's see what we come up with. Also go through the various other, related articles and fine tune the links in the web of Wikipedia knowledge.


by Brian McMichael, M.D. ·

Wednesday, November 3, 2010

Cartography of EOL Pain

Alex Smith and Eric Widera of GeriPal fame, et al., have just published an article in Annals of Internal Medicine, The Epidemiology of Pain During the Last 2 Years of Life. The L.A. Times article is here. Little is known for certain about the contours of this landscape; so, let's explore.

This was an observational study gleaned from the Health and Retirement Study, a nationally representative survey of community-living adults. The subjects were deceased who, either the subject or proxy, had been interviewed once within the last 24 months of life. The subjects were divided into 24 consecutive cohorts on the basis of the number of months between the interview and death. The prevalence and time-course of clinically significant pain (experienced often and as moderate-to-severe) were described and analyzed with respect to demographic, socioeconomic and clinical factors. These data were modeled and adjusted for the different factors.

Read more »

Wednesday, November 3, 2010 by Brian McMichael, M.D. ·

National Hospice and Palliative Care Month

As many of you know November is Hospice and Palliative Care Month.  You probably saw the announcement from your organization or an email from NHPCO, SWHPN, AAHPM or HPNA and thought 'Well isn't that nice!'

And then you probably moved on with your day.

Well it is time to not be passive about this.  You now have an excuse to talk about hospice and palliative care to everyone you see all month long.  In a long elevator ride with no one talking? Perfect! You can just bust out with:
"Hey did you know November is National Hospice and Palliative Care Month?  I wonder if when they were picking months they chose it because of Thanksgiving and getting together with family or maybe the symbolism of summer changing to winter? What do you think?"

Read more »

by Christian Sinclair ·

Palliative Care Grand Rounds Up at Compassion and Choices

Compassion and Choices has the latest edition of Palliative Care Grand Rounds up Wednesday morning.  Head on over to their very active blog and check out the links to the best of the hospice and palliative care blogopshere in their 'Patient Empowerment' edition.

by Christian Sinclair ·

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