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Thursday, May 10, 2012

Hospice Nurses Are So Important

Author with Ruth H, one of my first nurse mentors
by Christian Sinclair

As many of you in health care are probably familiar, this week is National Nurse's Week capped by National Nurse's Day on Saturday May 12th, the birthday of Florence Nightingale.  Most health care organizations do small things to recognize the important role nurses fill, but after this week it goes back to the regular grind.

Since completing a hospice and palliative medicine fellowship, I have been privileged to work alongside fantastic nurses who have been wonderful teachers, mentors, clinicians, and leaders.  I am especially reminded because in the past two weeks I have had several interactions with nurses from my past education and work experiences.  These chance meetings reinforced how indebted I am to the many hospice nurses who have helped form my approach to patients and families.

I was the sole fellow at the Hospice and Palliative CareCenter in Winston-Salem NC in 2003-4.  Dr. Dick Stephenson was a exemplary fellowship director, but there was not the luxury of numerous physician faculty many programs have today, so there was a lot of on-the-job training. I loved this experience and would not trade it for anything. By default, my key teachers were the people I worked with every day.  The hospice nurses at the Kate B. Reynolds hospice house, in IDG and traveling around central North Carolina to patients homes were the most experienced and available clinicians. I could ask them so many questions about patient and family communication, medication side effects, wound

As I began to get back into my Pallimed blogging mode, I will work the rest of the year to find more nursing related research, news articles and leadership stories.  Also in a small token of recognition I am making a $100 donation to the Hospice and Palliative Nurses Foundation in honor of National Nurse's Week and I would encourage any other doctors who read this to do the same. I know I am not the only doctor who has been influenced by great hospice and palliative nurses.**

So thank you to Ruth, Becky, Elaine, Tiffany, Sally, Maria, Pat, Michelle, Janet, Melissa, Sue, Karen, Jennifer and many other hospice and palliative nurses who have taught me so many useful things over the years, and have been willing to listen to me spout off about ABHR gel and other esoteric topics.  I am a better physician and a better person because I have worked with all of you.

If you are interested in hospice and palliative nursing, please check out the HPNA (Hospice and Palliative Nurse's Association)

Christian Sinclair, MD is the editor of @Pallimed and a palliative care doctor at the University of Kansas.

*No, the photo has not been Instagram'd, it was scanned from a time when I did not have a digital camera!
**If you email me that you have donated any amount I will update this post to show others how many doctors have participated. You can choose to have Anon, First name only or full name recognition.

Thursday, May 10, 2012 by Christian Sinclair ·

Friday, May 4, 2012

Fellowship Match: Geriatrics in, Palliative Medicine up Next?

[Ed. note: This post is a reimagining of a post at Geripal. Same facts - some simliar sentences - wholly different approach.]

This week the American Geriatric Society is holding their annual meeting and they announced they will now do a fellowship match starting with the 2014 academic year. This is huge news for geriatrics since they have been without a match since they were first officially recognized by the ACGME in 1988. It also serves as an important benchmark for palliative medicine fellowships.

Why is this important news? Both fellowships have a lot in common and hopefully directors at geriatrics programs can work with their HPM colleagues to accelerate working through the complexities of getting a HPM match. We have seen posts on GeriPal and Pallimed about the frustrations caused by not having a match.

With Geriatrics now having a match, hopefully our field will be inspired to do the same in a rapid manner. This should be easier because we have gotten past the toddler years as a subspecialty. Can you believe it was only 6 short years since ACGME officially recognized HPM? We now have over 70 HPM fellowships and a few score that have been existence under voluntary guidelines for more than a decade.

The match offers many benefits to future fellows: more opportunity to see other programs besides their home program, and more clarity on the timelines on when programs will take applications, interview, and make offers. With all these benefits it is surprising to me that out of nearly 150 recognized specialties only 50 or so participate in a match.  Thankfully our field is marching towards a match, but it is not as easy as one might think. 

I have been in discussions at meetings with over 40 fellowship directors in the room who are all desiring great candidates in a fairly small pool.  When the match comes up, the tension in the room can rival a challenging family meeting when you start talking about what dates work, and how soon to implement a program.  One thing nearly everyone agreed on is the importance of a match for fairness to programs and applicants.  The challenge is more in taking a good idea and making it reality.
If you may not understand why this is important, I again encourage you to read Brian McMichael’s post on what it is like to be an applicant in the current system:

“My [application] process was cut short by a spoils-to-the-swift ethic. Because of the asynchronous timelines, I had to decline interview offers from programs I was very interested in. Given the inherent power disparity in the roles and the dynamics involved, I did not believe I had the latitude to walk away from offers from great programs in order to "explore my options" further. Perhaps my issue, but I doubt mine alone."
It is sad that this is the first impression that we give applicants coming to the field. I am happy that Geriatrics has accomplished this and that we now realize we do not have to wait 24 years for palliative medicine to do the same.  We will do better.

[Ed. note:  I appreciate what GeriPal and Eric Widera have accomplished and their ongoing contributions to the field.  I enjoy working with him and the writers at Geripal.  These words represent no one but myself.  This is not a war between us, so please  don't make it out as such.  This is more of a creative writing exercise because after reading his post I felt insulted.  Not as a board member, or as a blogger, but as a member of this field.  We have studious people accomplishing great things in palliative medicine and hospice organizations.  We are not perfect and it is good to encourage us to do better, but language matters.  Our work makes this clear. - Christian Sinclair]

Friday, May 4, 2012 by Christian Sinclair ·

Tuesday, May 1, 2012

Blogs to Boards: Question 8

This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  

We welcome comments about any aspects of the questions or the answers/discussions.  The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.

Mr. Smith is a 72 year old patient was admitted to hospital from his nursing home for respiratory distress due to CHF exacerbation. Despite aggressive diuresis attempts, his respiratory distress continued and his urine output remained minimal (~30ml/day). 

PMH: heart failure, moderate dementia, renal insufficiency 

Home medications: furosemide 40mg po bid, metoprolol 25mg bid, donepezil 10mg daily, olanzapine 5mg qhs.

After a conversation with his son (health care proxy) the patient was "made CMO" (comfort measures only) by the hospitalist service and resident team two days ago. He was then started on a morphine drip “titrate by 1mg as needed for pain or shortness of breath”, his donepezil, olanzapine and diuretics continued, other medications stopped. 

His intern calls in a panic: “We promised to make him comfortable, that he would die in 2 days, but he is still alive and the family does not know why he is in such pain – even with light touch – crying out & jerking.”

What is your recommendation? 

a) Stop morphine drip and start fentanyl and lorazepam prn
b) Increase morphine and olanzapine
c) Increase morphine and add lorazepam prn
d) Stop morphine drip and start fentanyl, increase olanzapine


Tuesday, May 1, 2012 by Christian Sinclair ·

What is the right age for kids to go to a funeral?

If you have worked in hospice for a few weeks or health care for a few years you will probably come across this question at some point.  What is the right age to take children* to a funeral? This question is asked of everyone involved with the care of the patient not just the social worker or chaplain who you might think are natural targets for such a question.  Deeper underneath this question are ones that children may naturally have about illness, death and dying.  And of course these may be questions the parent do not feel ready to answer, thus the solicitation of guidance.

You can break down the basic answers in a couple of categories that all have their pros and cons.
  • No. Absolutely no! - Obviously this answer doesn't take into account any of the unique aspects noted below that may influence the decision.  This response often comes from the feeling that protecting children form the sadder, darker sides of life is the best thing to do.  But this may come at a price later, when the child grows up and really has a less nuanced and full understanding of how death fits with life.  Finding the teachable moment as a parent is one of the trickiest skills to master.
  • Yes. Absolutely yes! - Well if absolute one way isn't so smart, absolute in the other direction must be brilliant. (Only in politics, am I right?) Sadly an always yes statement falls into a similar trap of missing the unique identifiers which guide the most beneficial path.  Forcing children to learn about something can backfire if they are not prepared.
  • How mature is the child? - Well if you cannot answer the question with an answer, then try a question.  I have heard this often and used it occasionally.  Assessing for a child's maturity and more importantly understanding of the concept of death is not the simplest task.  Sometimes my 6 year old is very mature, often times she is not. The inherently relative nature of the question may not always be helpful. 
  • Was the child close to the person? - Closeness to the deceased may or may not be a great indicator of readiness to attend a funeral.  But if the child is cl
  • What does the child want to do? This is the BEST RESPONSE IN MY OPINION. It empowers the child to have a say in this very important family event.  From this you can get a sense if the kid feels obligated, indifferent, overwhelmed from the entire situation.  In fact with death and dying discussions with children (and even adults) the best advice I was ever given was to ask what questions they have and answer them simply and leave room for more questions and discussion.  Do not try and be an expert and explain everything to a child.  They will let you know where they want to go with the conversation if you let them.
Other considerations:
  • Plan for a separate viewing and/or ceremony for children - If you are not sure how the child may react many funeral homes can work with you and have a smaller viewing or plan a ceremony to honor the loved one.  This way the child is included but does not have to be subjected to the pressure of a larger group and the Aunt who just never has the right thing to say. 
  • Access your hospice experts - Even if you have not had services provided by a hospice agency, you can usually reach out to one of the bigger ones in your community and ask to talk to a bereavement counselor and possibly a child-teen specialist.  They have a great knowledge base and can connect families with resources in their community which focus on grief and loss challenges of kids and their families.  Comfort Zone Camp is a great example that runs multiple camps nationwide.

Kansas City Star Mom2Mom poll
What got me thinking about this post was two things.  First, my 6 year old twins have known for a while that daddy works at hospice and helps people who may die.  They ask about graveyards and what happens to people in the ground there.  They have not yet had a chance to attend a funeral, but it is something I have thought about how I would answer personally.  And this morning I was pleased to see this question in my local Kansas City Star paper.  The polled mothers from their Mom2Mom micro-site.  about their thoughts and I was pleased to see this subject as part of the local Kansas City Star newspaper poll to mothers.  As always the comments illuminate the discussion. Some excerpts:
  • I've tried to teach my kids (even when I can tell they don't want to hear it) that everything living will die someday. Death is part of life ("Circle of life, Simba"). That discussion is wasted if they're too young to comprehend.
  • I was 8 when I went to my first funeral and it was my father's and it was very uncofortable/terrible experience for me. Still to this day I remember the image of my fathers's body in the casket and the memory of seeing my father like that haunted me!
Are there any tips you might share?

*I use the term broadly here to even reach to young adult.


ResearchBlogging.orgBlack, D. (1998). Coping with loss: Bereavement in childhood BMJ, 316 (7135), 931-933 DOI: 10.1136/bmj.316.7135.931 (Open Access PDF)

Holland, J. (2004). Should Children Attend Their Parent's Funerals? Pastoral Care in Education, 22 (1), 10-14 DOI: 10.1111/j.0264-3944.2004.00281.x (Open Access PDF referring to this study)

by Christian Sinclair ·

Facebook adds Organ Donor Status

As you may have heard Facebook is going public as early as next week.  In a curious (or expected) show of goodwill and an attempt to make use of Google's (slightly ironic) mantra "Don't be evil," Facebook CEO Mark Zuckerberg announced that today you can add your organ donor status to your Facebook profile.  This will be an interesting social experiment in the wild to see if organ donation could go viral.  Palliative care clinicians will all recognize the issue with a shortage of potential organs for those in need.  We talk to patients and families all the time that are holding on to hope for a possible transplant. 

One quality measure as you can see from the picture above is the link to actual state registries.

Could something like this work for advance directives like durable power of attorney or a living will?  In addition to listing family you could also list who your DPOA was.  It may even lead to an interesting study to see how networked DPOA's are and even if they might be able to find each other better and talk about how to be a better DPOA. I'm unsure if I will post my organ donor status on Facebook.  I post a whole lot of other things, but this feels like it crosses a different threshold.

What will you do if you are on Facebook? (I already know what everyone who is anti-Facebook is going to say, but you can share your thoughts too of course!) Is Facebook the right platform to merge online registries for health issues that are struggling to get more traction?  You want to be where the eyeballs are right?

The New York Times and The Atlantic cover the issue in more detail if you are interested.

by Christian Sinclair ·

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