Friday, August 31, 2018

Book Review: My Father’s Wake: How the Irish teach us to live, love and die by Kevin Toolis

by Rebecca Gagne Henderson (@RebeccaGagne)

The tone and theme of this book is set with the profound and moving epigraph from the Iliad:

“The generations of men are like generations of leaves. The wind scatters one year’s leaves on to the earth, but when Spring comes the luxuriant forest produces other leaves; so it is with generations of men, one grows as the other comes to an end”. Iliad 6 --145

The book is titled My Father’s Wake: How the Irish teach us to live, love and die. Mr. Toolis is a writer, journalist and award-winning filmmaker and documentarian. His family has lived for two centuries in a small seaside village on the Irish Isle of Achill. His childhood in a provincially engrained Irish island culture coupled with his expanding cosmopolitan world experience influences a broadening view of life and death culture. This Homeric journey through the author’s memoirs of witnessing death experiences in a variety of circumstances is written through a decidedly Western and Celtic prism. He blends the realities of his real-world journalistic experiences of war, famine, natural disaster and death with an elegant overlay of the humanities and culture.

Toolis offers us an historic autobiography of the wake through the ages, but it is much more than that alone. He reminds us of what we have lost and surrendered to medicine and technology, or as he refers to it; “The Western Death Machine”. While we palliative care types attempt to imbue sacredness at the bedside which should accompany each death, it is only a sad token -- a shadow -- of what was once a familial and communal sacrament. His depiction of the ancient ritual of the wake and other customs is not sentimental, but an unflinching description of death, grief, and mourning. He draws an analogy between physical exercise and the wake as training for our own deaths -- a way to help us exercise our own anxiety of death. The book follows the author's personal experiences with family members dying through his childhood and young adult life. His description of the collective experience of his father’s death, wake and funeral are poetic and unforgettable. The book then moves to innovative illustrations of death in our current Western culture which may be novel even to us in palliative care.

As an American of Irish-Mexican descent (please recall the affinity that the Mexican people have with death, dying and ancestors), even I learned of ancient rituals and terminology related to death, dying and grief. Over 25 years I of working in palliative care I recognize many of these rituals as they transcend culture and are simply human, for example, the term “keening” which is used to describe wailing women. Toolis explains that often times keening women are hired to wail and “sing” at wakes. This behavior can be seen at Egyptian funerals as coffins are marched through the streets to a final resting place. The description of keening women evoked a memory of an experience I had several years ago. We had been caring for a young West African, Muslim man. As he was nearing death his sister began to wail and fall to the floor. It occurred to me that she was “falling out”. “Falling out” is a grief reaction which I had previously only witnessed in some African-American traditions and communities. This response demonstrates a possible shared cultural grief characteristic which managed to survive hardship and separation over centuries, oceans, and continents and illustrates how deeply culture runs within our human experience. As we all know, there is more we have in common than there are differences.

The author’s experience as a journalist covering many incidents of death, war and terrorism forms his view of death, which may also happen with our work in hospice or palliative care. We wonder about our own deaths; after all of this, will we be the ones to suffer terminal agitation, denial and death anxiety? Toolis describes this phenomenon with aplomb and reflects our own fears, dreams and nightmares.

My Father's Wake: How the Irish teach us to live, love, and die is a beautifully written work which deserves our attention. There are portions of this book which should be required reading for medical and nursing students. My hope is that many of you will read this book and share your thoughts.

Rebecca Gagne Henderson is a palliative APRN in CT. All work and no play makes Rebecca a very dull girl. When not at work Rebecca is occupied with her PhD work. Perhaps she will finish by retirement age which is two years closer than my last post.

To read more book reviews on Pallimed, click here. To see more posts by Rebecca Gagne Henderson, click here. (Links are Amazon Affiliate links which support Pallimed. Also, please shop at your local bookstore.)

Photo credit: Graveyard by Kevin Toolis, used with permission.

Friday, August 31, 2018 by Pallimed Editor ·

Monday, August 27, 2018

Evidence-Based Prognostication

by Christian Sinclair (@ctsinclair)

We are prognosticating beings. It is how we survive. Many everyday decisions begin with an estimation of likely future outcomes. If my first clinic appointment is at 9:15am, and my drive from the hospital to the clinic usually takes 25 minutes, then I need to leave by 8:50am at the latest to give myself time to spare for bad traffic light timing, lack of a good parking spot or some other problem that may delay my arrival. I make my estimates, and go with the safest choice. I could go with my gut and my experience or I could use Waze, an app where I can select where I am leaving from, where I am going and what time I want to arrive by and it will tell me the best time to go based on a much bigger data set from drivers on the roads at that moment. Not only that, I could also use Waze to send an updated map to the clinic team to let them know when I will be there, so they can plan ahead as well.

But when it comes to medicine, we often deal with prognosis of many different outcomes, but we rarely use data and technology (evidence) and we rarely share this information clearly with others (documentation.) I recently finished the chapter on Prognostication for the new edition of the Oxford Textbook of Palliative Medicine, so prognosis has been on my mind a lot. One key article stuck with me and made me reflect on my practice of documenting evidence-based prognosis. Andrew Bruggeman and his colleagues at UC San Diego reviewed 412 inpatient palliative care notes for oncology patients and only 5 contained documentation of evidence-based prognostication. The validated tools used included the MELD score, the Walter Index, and the Lee Index. They looked for the Palliative Prognostic Score and the Palliative Prognostic Index as well but never found either of those documented.

First of all, I want to say kudos for publishing this research that basically says at their own institution a potentially critical part of a good palliative care note is missing. They are in good company thought because from my discussions with colleagues around the country I have not heard anyone else doing this on a consistent basis. At the organizations where I have and currently work, we do document prognosis but the note template and the EMR are not designed to easily include any particular evidence-based tool. This is consistent with other research of palliative care notes which showed 72% of notes contain survival estimates.

Secondly, we are entering a new age where machine learning and big data are crunching numbers and relationships with more power and speed then our simplistic point-based prognostic tools are capable of. But the output of these tools has not been widely tested, and how they construct their findings can be pretty enigmatic and not inherently logical to clinicians. These new black box prognostic machines may help us identify patients who may benefit most from palliative care, but I think we have not quite dealt with the ethical ramifications of what improved prognostic accuracy means for our clinical work and how it is delivered at scale.

We are barely starting to make evidence-based prognostication part of our clinical work and there are strong forces already at play using potentially more accurate tools that we don’t comprehend. This will be an important part of not only palliative care and hospice delivery, but health care delivery, health care reform, and even the overall insurance-based payment structure. We need clinician eyes, ears, and voices involved with the advances in prognostic science, and it begins with all of us being willing to use the tools we currently have and include them in our daily work.

If you are interested in this topic, I will be hosting a conversation about prognostication at the #hpm chat on Twitter Wednesday, August 29nd, 2018 at 9pET / 6p PT.

Christian Sinclair is the co-founder of #hpm chat and Editor-In-Chief of Pallimed. He leads the outpatient palliative care oncology clinics at the University of Kansas Health System. When he is not thinking about predicting the future, he can be found watching the Back to the Future trilogy looking for plot inconsistencies. You can find him on Twitter at @ctsinclair.

References

1: Bruggeman AR, Heavey SF, Ma JD, Revta C, Roeland EJ. Lack of documentation of evidence-based prognostication in cancer patients by inpatient palliative care consultants. J Palliat Med. 2015 Apr;18(4):382-5. doi: 10.1089/jpm.2014.0331. Epub 2015 Jan 21. PubMed PMID: 25608220.

2: Zibelman M, Xiang Q, Muchka S, Nickoloff S, Marks S. Assessing prognostic documentation and accuracy among palliative care clinicians. J Palliat Med. 2014 May;17(5):521-6. doi: 10.1089/jpm.2013.0454. Epub 2014 Apr 10. PubMed PMID:24720384.

Monday, August 27, 2018 by Christian Sinclair ·

Saturday, August 25, 2018

To Resuscitate or Not to Resuscitate

by Rebecca Omlor (@BeccaOm15)

The code bell goes off overhead calling for a rapid attempt to try to bring a patient back to life. Who is on the receiving end? Is it a frail older adult with dementia, a patient with multiple medical problems, or an otherwise healthy adult who recently underwent a cardiac catheterization for a myocardial infarction?

If this was the scenario in 2018, a team would rush to that patient and begin cardiopulmonary resuscitation (CPR) along with advanced cardiac life support (ACLS) including the use of medications and external defibrillation, if indicated, to attempt to revive the patient. While we put all this effort in, according to data from 2003, we have a little less than a 50/50 chance of getting that person’s heart beating again, and only 17% of these patients will survive to discharge1. There is no regard for how ill the patient is, what their pre-hospital functional ability was, or what might be the best-case scenario if they survive. If a patient states that he or she wants to be resuscitated, that is going to happen.

If this were the early 1960s, we would be looking at a very different scenario. According to the original group that published on the utilization of CPR, they had a very limited scope of when CPR was indicated.

Not all patients should have cardiopulmonary resuscitation attempted. Some evaluation should be made before proceeding. The cardiac arrest should be sudden and unexpected. The patient should not be in the terminal stages of a malignant or chronic disease, and there should be some possibility of a return to a functional existence. The rigid time limit of 3 to 5 minutes since the onset of arrest of cardiac output should not be exceeded. In regard to the latter when there is a genuine question of the duration of arrest, resuscitation should be attempted.2

In 1961, the understanding was that CPR would be used thoughtfully. It was viewed as a finite resource that would only be executed in cases where there would be known benefit. They hold to the understanding that if someone has been dead long enough to begin to develop brain injury, the benefit of CPR is significantly diminished and should not be attempted.

Today, we seem to disregard the limitations of CPR. Many people who work in healthcare can recount stories of resuscitation attempts on people who have been down longer than the 3-5 minute range only to have people remain in unresponsive states with minimal brainstem function only. We have stories about people we felt were knocking on death’s door where we tried multiple times to yank them back from the inevitable because that was their wish. We feel as if we are fighting nature, as if death is the ultimate enemy that we should somehow be able to overcome.

If we are to take the recommendations from 1961 to heart, then resuscitation should be viewed like any invasive procedure. As with surgery, if the medical team does not feel that there is meaningful benefit or that the harms outweigh the benefits, then resuscitation should not be recommended or attempted. Thoughtful discussions need to occur with patients about the ramifications and most likely outcomes, just as with any other informed consent. My hope is that more and more people will begin to realize that CPR seen on TV dramas is not reality and the potential harms that come from it can vastly outweigh the benefits in many cases.

This is the first Pallimed post by Rebecca Omlor, MD is a palliative care doctor at the Wake Forest Baptist Medical Center. She has over 500 pictures of her four fur-children on her phone and enjoys bragging about them to anyone willing to listen.

To see more Pallimed posts on resuscitation click here.

References

1. Ramenofsky DH and Weissman DE. Fast facts and concepts #179: CPR survival in the hospital setting. Palliative Care Network of Wisconsin. . Updated July 2015. Accessed August 17, 2018.

2. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac Arrest; Report of Application of External Cardiac Massage on 118 Patients. JAMA. 1961;178(11):1063–1070.

Saturday, August 25, 2018 by Pallimed Editor ·

Friday, August 24, 2018

Death Notification as Behavior Modification: Let's think this through

by Ben Skoch (@skochb)

Opioid Problem. Opioid Epidemic. Opioid Crisis.

Call it what you will (as long as you don’t use the word narcotic, but that’s another article), but the United States has a real issue with opioids right now. It has been much talked about, publicized, criticized, politicized, has left some people ostracized, to a point where the concern has become supersized. Six years ago, a report stated enough opioid prescriptions were written for every adult in the US to have a bottle of pills, about 259 million. Couple that with the report from the CDC that over 42,000 people died from opioid (illicit and prescribed) overdoses in 2016, more than any year on record, and it’s easy to see why the topic has reached a fever pitch in our country.

Many efforts to curb potential causes have been suggested, including a list of “promising state strategies” set forth by the CDC. It is worrisome given the rising number of opioid-related deaths, along with nature of the problem including abuse of both prescribed and illicit opioids, that the current interventions have yet to tame this complex issue.

A recent study published in Science examined a novel approach to influence prescribing patterns of healthcare professionals (including MDs, DOs, NPs, PAs, and DDSs/DNDs) in San Diego County. Over the period of one year (June 2016 to July 2017), the researchers worked with the medical examiner to investigate deaths that were directly related to schedule II, III, or IV drugs. Utilizing CURES database (California's Prescription Drug Monitoring Program (PDMP)), the identified 220 people who died by overdose, with 170 of the 220 having filled at least one opioid prescription in the last calendar year before their untimely deaths. They could also identify each prescriber who wrote prescriptions to each decedent, and on average there were 5.5 prescribers per decedent.

The authors clarify they are not addressing, “appropriate or inappropriate prescribing at the patient level.” The intervention included sending a letter to each prescriber, who wrote an opioid prescription to a decedent in the months leading up to that person’s death, could influence their prescribing patterns. They note the letters were “supportive in tone,” and also identified by name the patient that had died, discussed the value of the state prescription drug monitoring program, and reviewed the CDC’s recommendations for safe prescribing strategies. They examined prescribing patterns three months before, and one to four months after each letter was written. There were 82 decedents (representing 388 prescribers) in the intervention group, and 85 decedents (representing 438 prescribers) in the control group.

What they found, as the authors describe, is that receiving such a letter mentioned above resulted in fewer subsequent opioids dispensed. There was no change in the control group over the observation period (71.6 milligram morphine equivalents (MME) to 71.7 MME), while the intervention arm decreased their prescriptions by almost 10%, from 72.5 MME to 65.7 MME per prescriber per day. In other words, prescribers who got the letter were writing one and a half tabs of 5/325 Norco fewer, or one 5 mg Oxycodone tablet fewer, per day after reading the letter. Among other reasons they propose for why the intervention showed a statistically significant reduction is that, “Clinicians may prescribe with greater care when they perceive that they are being watched, particularly by figures of authority,” citing a 2003 paper out of Current Directions in Psychological Science.

While I believe that the authors of this paper have the right intentions in wanting to help cure our national opioid sickness, I am worried this approach will have significant and long-lasting unintended negative consequences. Yes, I worry that on some level this will make it increasingly difficult for patients who genuinely need these medications to obtain them. Additionally, I wonder if guilting physicians into practice changes is the best way to pursue systemic changes, particularly in a system where physicians are already suffering increasing levels of burnout. Guilt has been well described as a symptom of burnout , so it’s no big leap to think that scaling this intervention to a national level as the authors suggest could severely complicate this issue.

The conclusion of this article correctly highlights several pieces of this picture, each important in viewing and solving the bigger puzzle. I am hopeful that PDMPs at the state level will be functional, easily accessible, and above all helpful to clinicians who are tasked with treating those with legitimate pain sources. I am encouraged by efforts being made to identify instances where we are likely overprescribing and the guidelines being put into place because of those studies. I am hopeful we can find a solution to this growing problem without adding unneeded suffering to both patients and prescribers. I have my doubts, however, that the letters mentioned in the above article are the best way to get there.

Ben Skoch, DO, MBA, a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family Medicine and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

More posts from Ben Skoch here. More Pallimed posts about opioids and pain control can be found here

Doctor et al., “Opioid prescribing decreases after learning of a patient’s fatal overdose.” Science 2018:361, 588-590.

Friday, August 24, 2018 by Pallimed Editor ·

Wednesday, August 22, 2018

Talking it Like it is: Advice from a HPM Fellow to all the New Interns

by Christine Bridges

The hallways are full again after a short June reprieve. Starched white coats, cleaner than it ever seemed possible bustle through the hallways, making up in speed what they lack in direction. They fill each space with eager anticipation. It is almost palpable. It is the scent of July. Each furtive glance at the clipboard in the elevator fills me with longing to tell them the advice I wish had been passed out with my first pager.

The biggest challenge ahead of you will be communication. Over the next 3-7 years more often than relieving tension pneumothoraxes, performing thoracenteses, or placing art lines, you will be you will be having difficult conversations. You will have to address substance abuse when you find cocaine on a routine urine drug screen in one of your favorite patients, the one who always brings cookies to her appointments. You will find yourself in the ED at 3am listening to radiology explain that the CT scan shows a large lung mass, not a pneumonia. Room 345’s son from California will arrive to the hospital at 4pm on Friday and need to talk about Dad’s pancreatitis urgently. You will have to tell people they are dying. You will have to tell families that their loved one is dying, that their loved one died, that they did not get to say good-bye.

You will be part of sacred moments in the lives of near strangers. You will hear the confessions, the deepest secrets that their own families may never know. You may hold their infant daughter before they do and be the first to tell them her gender. You will give a diagnosis that changes a life, you will be able to say: the scan is clear, the chemo worked, the surgery was successful, he came through. You will hold hands, wipe tears, and you will live in family stories for years.

It will not go well sometimes. It won’t be the first difficult conversation you had that day, it will be the fifth. Maybe you didn’t sleep well, maybe you missed lunch. Perhaps the person with unkempt hair sitting across from you wearing pajamas to their 3pm appointment will question your medical credentials because you look ‘too young to be a doctor’. Maybe this patient has spent more time in the hospital as a patient than you have as a physician, they have more experience with difficult conversations than you do. Your feelings will get hurt. You may stand in a room tightly clenching a stethoscope like a lifeline as you discuss a discharge plan while a fragile patient cries and says you just don’t care about her. You may be sent by your attending to explain to an undocumented immigrant that there are no options for outpatient dialysis for her renal failure. You will be the recipient of gratitude you did not earn and anger that you cannot understand.

I remember the way my own stiff white coat chaffed at my neck, fitting too long in the sleeve as I rounded my first July as an intern. Long sweaty months running to the ER followed, life blurred, lessons became habits and I became a fellow. And now today I want to place one hand on each intern’s shoulder and tell them: It will all be OK. You are not alone. Neither is your patient. There are skills as real as sterile technique. Skills that will carry you through difficult moments. We are not born ‘good with patients’ or skilled with microscopes. The upper level who glides into the room, smiles gently, and leads a goals-of-care discussion acquired those skills because it matters to her patients. She fought for this capability with education and hard work, not with genius or luck.

You can learn the same skills now on your first days, you can practice them in every interaction from the clinic to the OR. You have palliative care professionals who want to join you in your work, to be your ally, to be your patient’s champion. If we can’t be in your hospital we want to be your educators at workshops and conferences. We’ll see you in the halls and elevators. We want to talk and listen.

Christine Bridges, MD is a hospice and palliative medicine fellow at the University of Louisville Health Science Center. She enjoys baking and watching zombie movies with her husband.

Wednesday, August 22, 2018 by Pallimed Editor ·

Monday, August 20, 2018

Does Colace (docusate) Work For Constipation? No!

by Bob Arnold (@rabob)

(This is the first post from the Pallimed Writers Group, a growing group of nearly 20 clinicians who are reviewing landmark studies and important current research. This study was highlighted in the GeriPal Top 25 articles in HPM.- Ed.)

Randomized, Double-Blind, Placebo-Controlled Trial of Oral Docusate in the Management of Constipation in Hospice Patients. Tarumi et al. Journal of Pain and Symptom Management, 2013: 45(1), 2-13.

Palliative care fellows may wonder about their attendings fixation on bowel movements. It may be because we do not ask medical students to disimpact patients any more or because, given the lack of ambulatory care many residents do, they do not see it as a big deal (Constipation a GREAT topic for those of us who like puns and dad jokes).

For patients, however, constipation is a topic they think about many times a day. It is very common (39-70% prevalence) in patients with cancer or other serious illness, particularly in elderly patients. The prevalence goes up to 80% in patients on opiates and for many of my patients, the bloating, nausea and discomfort associated with opiates are worse than the pain we are treating.

At the hospital where I work, Colace (docusate) is often used as the first treatment of constipation and/or as the drug of choice to prevent constipation. This has been despite a lack of evidence (JPSM 2000:19:130-6). I was thrilled to see this RCT of docusate and sennosides vs placebo and sennosides looking at whether docusate improved stool frequency, volume, and consistency. They found no difference in any of these variables.

Let's take a closer look using the JAMA Users' Guides to the Medical Literature:

1) Are the results valid?
     a. Was the assignment of patients to treatment randomized? Yes
     b. Were all patients who entered the trial properly accounted for and attributed for at the conclusion? Yes (and I wish I would have gotten more information.) Of the 1426 patients who were screened, only 305 met the study criteria and 80 consented. More data about why so many patients did not meet the study criteria or how the 26% who consented differed from non-consenters would be nice. Once we got to the 80 patients, the information and follow up is great (although only 73% completed the ten-day study.)
     c. Were patients, clinicians and study personnel ‘blind’ to treatment? Yes (although I would like it better if they asked patients if they got the placebo or the active drug to make sure the blinding worked.)
     d. Were the groups similar at the start of the trial? Yes; moreover, their OME, and use of other drugs were similar enough to be comfortable with the groups equivalency. It might have been nice to know how physically active both groups were and if they were from the same hospices, but now I am being a pain in the ass.
     e. Aside from the Experimental Intervention, Were the Groups Treated Equally? Yes.

2) What Are the Results?
     a. How Large Was the Treatment Effect? This was impressive. They looked at bowel movements every which way and found NO DIFFERENCE. They looked at frequency, volume, difficulty of defecation, and symptoms of constipation. There were differences in consistency (thankfully no pictures) but this was not consistent.
     b. How Precise Was the Estimate of the Treatment Effect? I have no worries about this. I might have chosen constipation symptoms as the primary outcome (and this would have required a different sample size). Given the consistency (UGH) of the findings, this does not seem to be a problem.

3) Will the Results Help Me in Caring for My Patients?
     a. Can the Results Be Applied to My Patient Care? This patient population is sicker and has more cancer than my patients. The patients were all recruited from an in-patient hospice unit where the median LOS was 16 days and 97% died during their stay. Moreover, the study population changed in the middle of the project (from requiring the patient be on opiates and have cancer) which should always make a reviewer nervous. This is going to be biggest question for many of you (although there is no reason to think that non-cancer, less sick patients will have different findings).
     b. Were All Clinically Important Outcomes Considered? Yes. I think this is a strength of the study.
     c. Are the Likely Treatment Benefits Worth the Potential Harm and Costs? Someone might say – who gives a shit? Docusate is cheap as stink (in my hospital taking it off the formulary would save less than 1000 dollars a year). And the pill does not taste as nasty as the liquid formulation (see GeriPal’s excellent laxative taste test) and is just one pill (not even that if it is given as a combination with senna).
      I still hate docusate because clinicians think they are doing something when they are not. In my hospitals, the house staff think when they are giving docusate for patients on opiates they are doing something and thus DO NOT USE ANOTHER (EFFECTIVE) LAXATIVE. This study is worth reading and quoting so people start off using the right drugs rather than letting patients get constipating and then chasing their tail.

Let’s get things moving!

Robert Arnold MD is a palliative care doctor at the University of Pittsburgh and a co-founder of VitalTalk. He loves both high and low brow comedy (The Good Place and Nanette), pop culture (the National Enquirer and Pop Culture Happy hour) and music of all kinds (not opera tho!)

Monday, August 20, 2018 by Pallimed Editor ·

Introducing the Pallimed Writers' Group

by Christian Sinclair (@ctsinclair)

We used to publish a lot more article reviews here on Pallimed. Sometimes the analysis would be quite deep and sometimes we would just lump together a while bunch of snippets from key articles. I have been keeping an ever-growing list of articles I would love to write up for the site*, but never seemed to have the time to get to them, and then new ones would come out, that I would want to write about, but they too would just get added to the list. At the end of the year, I would look back on key articles for our field and be pretty bummed out that I never got anything published here about them. A few weeks ago, I ignored my self-deprecation and put out a plea on Twitter for any interested clinicians to join a group and write together and encourage each other, and give feedback to one another.


And boom! Just like that nearly 20 people answered the call. We have our first list of articles to be published with a mix of new and old.

You can help us find good articles to cover by commenting here, or tagging @Pallimed in a tweet with your suggestions. If you are interested in joining this group we are already collecting names to join the second wave sometime this Fall. Email christian@pallimed.org or ping @Pallimed on Twtter and we will add you to the list. We have a lot of attending physicians, but only one social worker, one medical student, one fellow, and one nurse practitioner, so we are definately looking for a little diversity of professional experience.

If you have written for Pallimed before, you are not being left out. You will be getting invitations soon to join the Pallimed Writers' Group. If you know me and you are waiting for me to ask you, please do not wait. Write! It is good for your mind and body. Submit something and let's see if we can get it published.

The first review from our Pallimed Writers' Group is published today is from physician Bob Arnold on the 2013 Tarumi article on Docusate vs Placebo for constipation in the Journal of Pain and Symptom Management.

As we get more people published I will add them to alist here to make sure that this group gets credit for the work that they do for all of us.

Also, you may see an increase in emails if you subscribe, so you may want to consider changing to the MWF or weekly email options. You can find them at the bottom of your email from Pallimed.

* along with lists of books and films! Calling any humanities nerds.

List of published Pallimed Writing Group authors:
Robert Arnold
Rebecca Omlor
Drew Rosielle
Ben Skoch
Christian Sinclair

by Christian Sinclair ·

Saturday, August 18, 2018

Professional Development for the Whole Team

by Karla Washington (@comokarwash)

I entered graduate social work education in 1998. St. Louis Cardinals first baseman Mark McGwire broke the single-season home run record that year. Hearings were held regarding the impeachment of President Bill Clinton, and Céline Dion released a duet with R. Kelly, forming a collaboration that probably sounds preposterous to most people younger than 25. On the technology front, social media as we know it today was years away (Mark Zuckerberg was only 14). Google itself was less than a year old. Its corporate headquarters were in a garage.

Fast forward to 2018. I used Google to obtain 100% of the facts I presented in the paragraph above; the search engine is now so ubiquitous that the term itself is used as a verb. And just this morning, I read a Twitter update supposedly posted by a celebrity cat. Professionally, in my work as a palliative care researcher, I recently completed a pilot study of a problem-solving intervention delivered entirely via technology, and I’m developing a mHealth (mobile health) tool to support rural family caregivers of hospice patients with cancer.

I asked you to join me in that walk down memory lane to make the following point: Like me, virtually everyone on every healthcare team in every health system everywhere needs continuing education. On my first day of graduate school, Google did not exist. This afternoon, I’ll be reviewing data analytics from a Facebook support group for family caregivers of people with advanced cancer. And unless it’s possible to win the lottery without actually playing, I’ll be working for at least 20 more years. I need periodic tune-ups, and so do your colleagues from all disciplines and professions represented on palliative care teams.

Below I’ve provided a few questions to consider when thinking about the professional development needs of palliative care professionals. Because I’m trained as a social worker, many of the examples I provide are discipline-specific, but the underlying concepts are more broadly applicable. If you’re in a leadership position on your team, I encourage you to give the questions below some thought. If you’re not, feel free to use this list to facilitate a conversation with those who are.

Which individuals on your team have access to professional development opportunities?

I learned long ago that worrying too much about who is getting paid what, who gets credit for what, and who is getting free lunch is a recipe for resentment, burnout, and bad patient care. At the same time, consider the message leaders send when they allocate virtually zero resources for some employees’ professional development while sending their colleagues to week-long conferences in some of the most expensive cities on the planet. There will likely always be inequities in how resources are allocated, but there may be ways that existing resources could be reallocated (or additional resources identified) to improve access to professional development for members of the team who tend to be less tangibly supported in their growth. In graduate school in the 1990’s, I learned that grief occurred in five predictable stages and that stressed out caregivers should punch pillows to relax. We now know that grief is much messier than previously thought, and research has shown that it’s a fairly terrible idea for people to rehearse violence when they are angry or frustrated. I’m sure pharmacists, chaplains, nutritionists, and others would be able to weigh in with examples of how the knowledge that informs their practice has expanded and evolved since their formal education. Patients and families receive better care from well-trained teams. We need to support all team members in access to professional development.

What are the continuing education requirements of the members of your palliative care team? How can you help?

In Missouri, where I work, it’s expensive to get licensed as a clinical social worker. I won’t bore you with the details, but the cost for someone starting out with no financial support from their employer is at least $5,000, which is a very low estimate if they pay out-of-pocket for weekly meetings with a qualified supervisor. That’s a lot. The good news is there are tons of ways to support these new professionals. Is someone on the team already licensed? (Possibly.) Can that person get trained and credentialed to provide supervision as an employment benefit for licensure candidates? (Pretty easily.) Would leadership allow them to receive licensure supervision during regular working hours? (Lots of leaders do.) Can training approved for continuing medical or nursing education also be approved for social work contact hours? (This is probably easier than you think.) The list goes on. I’m sure there are similar lists for other professionals on the team or for social workers in later stages of their careers. Palliative care professionals tend to be great problem solvers. Get them involved in brainstorming low-cost ways to support their acquisition of new knowledge, skills, and credentials.

Can you more meaningfully engage team members in shaping their own professional development?

I love conferences. I go early and/or stay late. I find conferences intellectually stimulating and return from them energized with lots of new ideas. Some people prefer to get their professional development needs met with less face-to-face socialization involved. They might prefer online trainings or access to books or journals. There are sometimes valid reasons to nudge team members toward an educational experience others know to be excellent, but often a more effective strategy is to engage team members in crafting their own professional development plan. This very importantly includes planning the logistics of how their plan will be executed. If you attend a conference, there’s a good chance you’ll need to stay in a hotel. Do I have colleagues I’d be happy to share a hotel room with? Sure. Bodies do weird things in the middle of the night, and we all look different when we first wake up, but I can name a dozen people I’d be willing to navigate that with. Is that true of everyone? Absolutely not. And the list of colleagues I’d even consider sharing a bed with is in the low single digits. I’m guessing most people would just pass on that entirely. We can’t always know what people will want, and we should avoid making blanket policies when it’s not necessary to do so. It’s probably an all-around better idea to just be transparent about available resources and let people make decisions like the professionals they are. And if they have to miss work for a professional growth opportunity – no matter how terrible it actually was while they were gone – they should not have to endure a guilt trip upon their return.

If our friend Google can be trusted, someone named Harvey S. Firestone once wrote, “The growth and development of people is the highest calling of leadership.” Even if that’s not a real person, that’s still a great quote. I am fully convinced that professional development is a vital ingredient in high-quality palliative care, and I’m so grateful to get to be a part of this vibrant, innovative, and growth-minded community. To thank you for reading this post to the very end, I looked up Harvey S. Firestone. He founded the Firestone Tire and Rubber Company in 1900. He is also the author of Men and Rubber: The Story of Business, which I hope we can all agree is a horrible name for a book, even if it is focused on professional growth.

Karla Washington, PhD, LCSW is an Assistant Professor of Family and Community Medicine at the University of Missouri where she researches interventions to support patients and families receiving hospice and palliative care. When not working or spending time with family and friends, Karla enjoys several British television shows including The IT Crowd (her all-time favorite) and, more recently, The Great British Baking Show (or, as they refer to it across the pond, The Great British Bake Off).

Photo composite created by Christian Sinclair and includes photos from Jonas Jacobsson and Tyler Callahan on Unsplash

Saturday, August 18, 2018 by Pallimed Editor ·

Wednesday, August 15, 2018

Book Review: “The Four Things That Matter Most” by Ira Byock

by Ben Skoch (@skochb)

As someone new to the field of hospice and palliative medicine, I recognize that “The Four Things That Matter Most” by Ira Byock has been around for some time. As I sit down to write this review, I’m reminded of a joke from comedian Jim Gaffigan when he referenced people who want to talk about movies many years after they are released. That being said, the book was new to me as I picked through the 10th Anniversary Edition, and it’s easy to see why this book could easily have many more anniversary editions in the coming years. I was indirectly nudged to read this work while on my inpatient hospice rotation as I counseled a patient’s loved one along with one of my attending physicians. While the specifics escape me, I recall this person having a hard time finding the right words to say to her dying spouse. My attending plucked this book off the shelf, gently held it out for this loving wife, and said, “This should help.”

Byock highlights an important premise in his opening lines when he writes, “We live each day just a heartbeat away from eternity” (xvii). I think most people in the hospice and palliative care world readily accept this. For others, it is easy to hide these thoughts in the dark recesses of the mind, which can often lead to postponement of important conversations and decisions. “It’s never too soon” to have the most important conversations with the ones you love, and as you make your way through these beautiful and sometimes heart wrenching stories, you will see why.

I’ve learned most effectively through stories during my training, when I can tie a concept to a person who I have encountered along the way, so clearly this is one reason I enjoyed this book so much. Byock drives home each of his “Four Things” with touching stories from families across the country. It’s helpful to see how different families are able to say “‘I forgive you,’ ‘Please forgive me,’ ‘Thank you,’ and ‘I love you’” in the face of some terrible emotional wounds. While these stories alone will make the book absolutely worth your time, there are a few other salient points that resonated with me, which I will share here.

A recurring theme seems basic, but it’s critical to remember: We are all human. While we live in a society that strives for perfection, none of us ever will be, and we share many of these imperfections. One such imperfection in our culture is that we are largely death-denying. We would rather do just about anything than contemplate our own mortality. This happens daily. It becomes routine. Therefore, when someone shares difficult news or negative thoughts, our immediate response is too often, “Oh don’t talk like that” or “think positive…it will get better!” As Byock notes, perhaps offhand comments from people could be best viewed as, “an invitation to listen” (15). That is, if someone shares difficult information, help explore the thoughts with something like, “tell me more about that.” There is no telling the depth of what people will share when given a chance.

Another imperfection we share is that, “as we grow up and age, each of us is emotionally scarred to some extent” (39). As part of the human condition, we will love, those we love we will hurt, and they will hurt us. All of this may initially be unintentional, but the scars can be long-lasting. Some of those cicatrices will be more readily recognizable in some people, just as it will be easier for some to share about their difficult past. In others, we may have to be discerning. “People who are nasty, mean-spirited, or greedy are often acting out their own pain” (59). Putting this another way, remember that we are all a product of our past experiences. I find that keeping this at the forefront of my mind during those “difficult patient” encounters can help get to the heart of many issues.

One concept that was entirely new to me was that of “emotional economics.” Byock shares a full chapter on this relating to forgiveness, and it is important to highlight. Consider the emotional scars mentioned previously. The longer those sit unattended to, they accrue “years of compounded emotional pain” (63). I love the analogy of using forgiveness as “a onetime cost” that can help repair all those years of hurt. This can obviously be difficult depending on what the initial insult was, and to some maybe even seem impossible. But, as is pointed out in the book, forgiveness is not absolution. Granting forgiveness to someone does not mean forget and move on. But forgiveness is a huge step toward healing. Refusing to forgive is also a decision to remain in “emotional debt.” If I think about this when talking with someone who may not have long to live, it seems like it could be extremely helpful. Encouraging family members to say “I forgive you” before a loved one dies could be helpful for the days, months, or years that the person granting forgiveness still has left to live.

I regularly hear from patients a phrase that Byock tackles head-on: “I don’t want to be a burden.” Basically, that’s not a thing. Because you are human, and because you are loved by other humans, you will be a burden. Being human will mean at some point things won't go according to plan, your body will fail, and others will have to care for you. The important point is that we can all do our best to minimize this burden on our loved ones by accepting when it is our time to be cared for by others. I have witnessed this become an extremely difficult task for people, especially when it feels like a loss of identity for that individual. Here again, patience and listening will be crucial to coming to a common ground.

Perhaps some of that identity can be maintained by practicing “authentic loving care” as described on page 158. I was struck as this was described as a process that “involves touching people tenderly.” It may seem natural and reflexive to some, but I assure you this does not happen with uniform regularity in a hospital setting. And it’s sad. I was lucky to have this modeled to me during my residency, and as I move into an attending physician role I will make it a point to pass that on to my trainees as well. Don’t be afraid to hold a patient’s hand, touch their shoulder, or one of many other things which can help someone experience human interaction. A small gesture can help a patient in a time of great confusion to remember that they are human and that they are loved.

Lastly, I can’t get enough of the following from Byock which describes why many people might choose to work in the field of hospice and palliative medicine. “It is not within my capacity to discern the ultimate meaning of life in the universe. I can only honor the mystery and hope to be of some service to others” (212). If I could go back in time and put that on my medical school resume, I’d bold and underline it because I like it so much, and it’s the very essence of what I want to do for people. What an awesome gift to be able to live in the service of others during their most critical moments. I am confident that after reading this book I will be able to help others enrich their lives, nourish their relationships, and hopefully mend old wounds even if their time may be short. I simply need to help them see The Four Things That Matter Most.

This is the first Pallimed post by Ben Skoch, DO, MBA, a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

(Links are Amazon Affiliate links which support Pallimed. Also, please shop at your local bookstore.)

Wednesday, August 15, 2018 by Pallimed Editor ·

Sunday, August 12, 2018

Pallimed Calendar of Conferences and Events



Most of the items on this calendar are focused on significant national or international conferences, but also include some historical events related to our field. Occassionally regional or local conferences may be included. You can sync this calendar with many dfferent software platforms and apps or just pick certain events to add to your calendar. This list of palliative care and hospice related events and conferences is maintained by Ishwaria Subbiah (@IshwariaMD), Allison Jordan (@doctorjordan), and Christian Sinclar (@ctsinclair).

If you would like to help, have feedback or see an error, please contact us via Twitter.

Sunday, August 12, 2018 by Christian Sinclair ·

Friday, August 10, 2018

Grief and the Healing Property of Time

by Abigail Latimer (@abbie_lcsw)

The recent article about the orca carrying her dead calf sparked a flurry of media conversation about grief. [1] As the only palliative clinical social worker in an 800-bed hospital (and former bereavement counselor), I am frequently asked by clinicians to help when family is struggling with grief. Requests also come directly from family members seeking help talking to children and understanding their own grief. Regardless of the situation, the underlying desire is the same. Everyone wants to know the “right way” to grieve and ease suffering.

Some years ago, Elisabeth Kübler-Ross published her book on death and dying based on her work with terminally ill patients.[2] Despite the wealth of information presented, people mostly remember the stages of grief. And why not? Stages help us to think of grief as a nice and tidy, forward moving process. It is comforting to think that this stage will be over and the next one will take place, hoping the “end” of this hurt will come soon. The book cautioned us that grief is not actual stages and that point has been emphasized since then.[3] Yet, the belief persists that following a death we will go through denial, anger, bargaining, depression, and acceptance, and hopefully in that order. Unfortunately, this assumption can be harmful.[4] So if grief doesn’t come in stages, what does it look like? To quote the youth of today, a “hot mess”.

It’s worth mentioning the clinical difference between “normal” and complicated grief. Complicated grief is also called: unresolved grief, traumatic grief, pathological grief, prolonged intensified grief, and abnormal bereavement.[5] About one out of ten bereaved adults will experience prolonged grief disorder.[6] In fact, the DSM-5 included “Persistent Complex Bereavement Disorder” in its proposed criteria for conditions for further study (p.789)[7]. Palliative clinicians should be trained to recognize risk factors and symptoms of complicated grief in order to not over-pathologize normal grief responses.[8][9] Although the effectiveness of preventative interventions is debated, there is some evidence symptom severity can be lessened in the short and long-term.[10] (This article will not begin to address the complexities presented in suicidal, homicidal, child or antepartum, perinatal, or postpartum bereavement.)



For most adults who experience the death of a loved one, they will move through normal grief reactions without any pathology.[11] What I try to reframe are the expectations we have regarding what’s “appropriate coping”. Sometimes I get called to a family because the patient or family is crying too much; other times it’s because they aren’t crying at all. What I want everyone to know is either response is acceptable. Grief can cause you to withdraw from people and activities, sleep too much or not enough, feel empty, guilty, depressed, and/or lost.[12] Even anticipatory grief (grief occurring before death) has been linked with these symptoms as well as worsened problem solving skills.[13] Contrary to stage theories, these symptoms can occur all at once or in loops. The low part of the loop can be intense negative feelings and then gradually lessen over time. Soon after loss or right before, these loops can be very low, occur frequently, and last for a long time. We hope as time goes on, the upswings lengthen and last longer as those intense painful feelings lessen. It can be confusing for the grieving because just when they think they’re getting better…down goes another loop. Although distressing, these feelings are all very natural and normal and it’s absurd to suggest there is some “right way” to endure it.

As hospice and palliative care providers, the goal is to alleviate suffering; but often with grief, some suffering is inevitable. Ongoing grief work is often treated by a balance between avoiding and confronting loss through various activities and tasks.[14] Mental health professionals can employ a variety of interventions through cognitive behavioral therapy, family focused, and meaning making approaches.[15] Although the treatment for normal grief reactions is debated in efficacy, it hasn’t demonstrated any harm.[16],[17],[18] Nevertheless, an undisputed and effective treatment for both complicated and normal grief is time.

There is no stage or emotion that “should” be felt and there is no timeline. By means of radical acceptance, I encourage patients and their loved ones to acknowledge what is and sit with whatever feeling they’re experiencing. I advise them to stop “should-ing” themselves, as it only worsens the guilt. Sitting with this intensity of distress is hard for those suffering and for those witnessing the suffering. But like the orca reminds us, there are no quick or easy solutions to ease the pain and suffering caused by death.

Abbie Latimer, LCSW, ACHP-SW is the Palliative Care Clinical Social Worker with University of Kentucky HealthCare and is also a second year doctoral student with the University of Kentucky College of Social Work. When she's not studying, writing, working, or doing CrossFit, she's likely binge watching old episodes of Breaking Bad and the Office. You can find here on Twitter at @abbie_lcsw

For more Pallimed articles on grief and bereavement, click here. For more articles from Abbie Latimer, click here. For more articles from social workers, click here.
References:
[1] Raphelson, S. (2018, July 31). Grieving mother orca carries dead calf for more than a week, over hundreds of miles.
[2] Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
[3] Elisabeth Kübler Ross Foundation. (n.d.). Excerpt from Dr. Allan Kellehear’s foreward: “On death and dying”- 40th anniversary edition.
[4] Stroebe, M., Schut, H., Boerner, K. (2017). Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief. OMEGA Journal of Death and Dying, 74(4), 455-473. Doi: 10.1177 0030222817691870
[5] Dodd, A., Guerin, S., Delaney, S., Dodd, P. (2017). Complicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review. Journal of Patient Education and Counseling, 100, 1447-1458.
[6] Lundorff, M., Holmgren, H., Zachariae, R., Farver-Vestergaard, I., O’Connor, M. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138-149.
[7] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
[8] Solomon, C. G., Shear, M. K. (2015). Complicated grief. The New England Journal of Medicine, 372(2), 153-160
[9] Nielsen, M.K, Neergaard, M.A, Jensen, A.B, Vedsted, P., Bro, F., Guldin, Mai-Britt. (2017). Predictors of complicated grief and depression in bereaved caregivers: A nationwide prospective cohort study. Journal of Pain and Symptom Management, 53(3), 540-550.
[10] Wittouck, C., Van Autreve, S., De Jaegere, E., Portzky, G., van Heeringen, K. (2011). The prevention and treatment of complicated grief: A meta-analysis. Clinical Psychology Review, 31, 69-78.
[11] Jordan, A., Litz, B. (2014). Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice, 45(3), 180-187.
[12] Clayton, P.J., Herjanic, M., Murphey, G.E., Woodruff, R Jr. (1974). Mourning and depression: Their similarities and differences. Journal of the Canadian Psychiatric Association, 19(3), 309-312.
[13] Glick, D., Motta, M., Wiegand, D., et al. (2018). Anticipatory grief and impaired problem solving among surrogate decision makers of critically ill patients: A cross-sectional study. Journal of Intensive and Critical Care Nursing, https://doi.org/10.1016/j.iccn.2018.07.006
[14] Stroebe, M. and Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Journal of Death Studies, 23(3), 197-224.
[15] Neimeyer, R. (2014). The changing face of grief: Contemporary directions in theory, research, and practice. [Special Issue]. Progress in Palliative Care, 22(3), 125-130.
[16] Larson, D. G., and Hoyt, W. T. (2007). What has become of grief counseling? An evaluation of the empirical foundations of the new pessimism. Professional Psychology: Research and Practice, 38(4), 347.
[17] Currier, J. M., Neimeyer, R. A., and Berman, J. S. (2008). The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review. Psychological Bulletin, 134(5), 648.
[18] Jordan, A. H., and Litz, B. T. (2014). Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice, 45(3), 180.

Friday, August 10, 2018 by Pallimed Editor ·

Friday, August 3, 2018

Little Legacies: The Solace and Connectedness of Ellie’s Boxes

by Kristina Newport (@kbnewport)

In 2016, the palliative care community lost a dedicated advocate and compassionate caregiver when Eloise “Ellie” Coyne died. She was well-known to the Virginia Commonwealth University (VCU) Community where she held the position of Volunteer Coordinator but her colleagues knew the all different roles she played for patients and staff on the 11 bed unit: mother, advocate, healer, listener, comforter and mother. Of all the many things Ellie provided to her patients and colleagues, perhaps the most important was here complete acceptance of all people, with an uncanny ability to meet people exactly where they were and see value in each person.

Ellie regularly provided opportunities to create legacy through story telling, artwork, photos and mementos. It was rare for a patient to leave the Thomas Palliative Care unit without a pillow case of signatures or a plaster caste with a handprint. One of the legacy projects that now lives on in her absence has been lovingly named “Ellie’s Box”.

While Ellie was still living, she worked with Palliative Care RN Dawn Quinn to create small glass stones backed by pictures or words that are meaningful to patients and their family members. On the back of the pictures, families could have the fingerprint of their loved one done in archival ink. It was just another one of the ways this caring team helped families and loved ones to make a meaningful connect in they could carry with them. “This is so much about the importance of connection,” states Quinn. “When I see someone find the "perfect stone", I feel touched with privilege to help create a new way for them to remain connected to their loved one.”

Quinn recalls a time when a family was struggling with the timing of removing their loved on from life-prolonging artificial support. After they had the opportunity to choose stones that reflected their loved one and had her finger prints placed on them, it was as if the memento they received had ensured their connection would not be lost. The family held tightly to the stones in their hands and allowed extubation and a peaceful death to proceed.

At VCU, the stones are kept in boxes that families can look through and choose from, on the palliative care unit. The idea has spread, however, throughout the hospital, to the point that the palliative team tubes the stones throughout the hospital to other units where patients are in their last hours or days.

So now, families leave VCU with a memento and memory of their loved one, due in part to Ellie’s work and influence on the providers in that system. If it had been up to Ellie, all suffering patients and families would have a hand to hold, a comforting blanket and a memento to take home with them that can continue on. It is only fitting that Ellie’s Boxes be made and offered to people in other health systems as well. It is just the way Ellie would have wanted.

Kristina Newport, MD, FAAHPM, is a palliative medicine physician in Central pennsylvania who will soon join the Palliative Care team at Penn State Health as Section Chief and Assistant Professor in the College of Medicine. You can find her on Twitter at @kbnewport. You can read her other Pallimed posts here.



Friday, August 3, 2018 by Pallimed Editor ·

Wednesday, August 1, 2018

How Proposed Changes to Medicare Documentation Regs Can Impact Palliative Care

by Amy Davis (@MaximizeQOL)

(CMS open to comments until Sep 10, 2018. See end of post for details. - Ed.)

Centers for Medicare and Medicaid Services (CMS) has proposed sweeping reforms to documentation requirements, clinician reimbursement, and the Quality Payment Program (QPP), to begin in 2019. (1)  If approved in their current form, the changes are likely to have dramatic net negative effects on outpatient palliative care reimbursement. A detailed review and analysis of all 1,473 pages of the Proposed Rule, plus its addenda, would not be practical here. The reader is referred to the complete text (1) and others’ assessments (2) reviewing its discussions of specific codes, telemedicine, unrelated Relative Value Units (RVUs), the QPP (3), and other issues less directly related to general specialty outpatient palliative care. The sections involving the new documentation and reimbursement paradigm seem poised to have the biggest impacts.

Numerous professional organizations have been persistently calling for CMS and other similar stakeholders to eliminate the ever-growing administrative tasks burdening clinicians today that are not meaningfully helping patients. For example, the American College of Physicians’ initiative (4) has avidly encouraged, among other things, the elimination of duplicative and clinically irrelevant documentation and a focus on those administrative elements demonstrated to have clinically meaningful impact.

CMS has listened to this universal outcry and is making strong efforts to adjust requirements accordingly through its Patients Over Paperwork campaign. The 2019 Proposed Rule would consolidate the complicated 1995/1997 Evaluation and Management documentation guidelines currently used to support billing for the various levels of outpatient care provided in medical offices (CPT codes 99201-99205 and 99211-99215 for new and established patient visits, respectively). Clinicians would continue to bill for the appropriate level of care provided (levels 1 through 5; see also below). However, levels 2 through 5 would only require documentation corresponding to a level 2 visit; that required for 99201 and 99211 visits would remain unchanged.

The Proposed Rule further suggests documentation of straightforward medical decision-making (5) would alternatively be acceptable, as long as medical necessity was established. Clinicians would still retain the options of adhering to current documentation guidelines or to bill based on time. Further, billing for a home visit (CPT codes 99341-99350) would no longer require explaining the medical reason the person could not be seen in the office. CMS indicates reforms pertaining to additional sites of care will be proposed in future years using a step-wise transformation model. The Proposed Rule also suggests ways to eliminate the unnecessary duplication of documentation, such as an unchanged family history, between visits and among clinicians using a shared electronic medical record. While of course other insurers and third-party companies managing the prior authorization system are not obligated to follow CMS’s lead in changing documentation requirements, CMS encourages other stakeholders to similarly reform.

CMS’s corollary to these meaningful and appreciated improvements involves uncoupling reimbursement from documentation, providing a single payment amount for level 2 through 5 visits. The Proposed Rule suggests a new, single RVU for the different levels of outpatient care provided during new and established patient visits done in medical offices, regardless of the visit level submitted. The payment amount was determined based on the weighted general frequencies visit levels 2 through 5 were submitted on all 2012 through 2017 claims. CMS accordingly proposes a RVU of 1.90 and 1.22 for new and established visits, respectively. Direct practice expense inputs were similarly established ($24.98 and $20.70). CMS applied these calculations to the available 2018 claims data and suggest the corresponding reimbursement would have been $135 for new and $93 for established level 2 through 5 visits, respectively. The complex data and calculations provided in the Proposed Rule and its Addenda suggest these amounts would generally be similar in 20196 if instituted unchanged in the Final Rule.

CMS further proposes the creation of HCPCS G-code “add-ons.” One is designed to account for the increased overall care complexity tackled by clinicians practicing certain areas of medicine, such as oncology, endocrinology, and interventional pain management, reflected in higher frequencies of level 4 and 5 visits in their claim submissions (GCG0X). Another is an attempt to counterbalance the increased practice expenditures primary care clinicians face “…coordinating patient care, collaborating with other physicians, and communicating with patients” more than other clinicians, as described on page 355 (GPC1X). Most clinicians providing outpatient palliative care appropriately almost exclusively submit visit levels 4 and 5 due to the high medical complexity of the patients involved. Further, they are generally highly involved with the same costly services also provided by primary care specialists. While the chronic care management, advanced care planning, and prolonged face-to-face service codes will remain available to all clinicians, palliative care specialists ironically do not seem to be eligible for either of these add-on G-codes. However, the overall financial impact of these G-codes is expected to be small. The proposed significantly decreased reimbursement, coupled with the G-code inclusion oversight, is likely to result in a major, if not prohibitive, deficit in our ability to provide much-needed outpatient subspecialty palliative care services. Worse, it may result in palliative medicine specialists intentionally re-classifying themselves as primary care or other alternate covered specialties in order to try to mitigate this potentially devastating financial loss.

Many in palliative care more often code visits based solely on the time spent with the patient than those practicing other specialties, primarily due to the nature of our role in helping patients and teams match provided care to the patient’s goals. CMS proposes eliminating the current policy that requires more than 50% of the time-based visit involve counseling and/or care coordination, suggesting the time spent is often a valid surrogate to the visit’s complexity. The face-to-face requirement remains unchanged. CMS also proposes to eliminate the current policy preventing two clinicians with the same Medicare enrollment specialty from receiving reimbursement for care provided on the same day. This will hopefully eliminate patients having to return to the office on a subsequent day or clinicians foregoing reimbursement for the care they provide. CMS’s formal recognition that a clinician enrolled with Medicare as an internist, for example, may also have additional training in another specialty, such as palliative care or geriatrics, is appreciated but will likely benefit a rather limited number of patients and clinicians.

The CMS paradigm transformation proposed for 2019 implementation offers a number of very positive reforms. CMS is clearly listening to the global outcry from clinician stakeholders across the healthcare spectrum, and their efforts are sincerely appreciated. However, taken in its entirety, the proposed changes as they stand are likely to result in potentially profound net negative consequences on the provision of outpatient palliative care. It is imperative that palliative care organizations, clinicians, and other stakeholders offer comments (7) to CMS before the comment period ends on September 10th to sustain and support outpatient palliative care.

(Primer on how to make comments to CMS here by lawyer Matthew Cortland (@mattbc). CMS open to comments until Sep 10, 2018.- Ed.)

Amy Davis (@MaximizeQOL) is a private palliative care physician in the Philly area. She sometimes thinks about overlapping serious illness & SUD and about quality improvement while gardening and enjoying her turtle

References and Resources
1 - Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program. (Prepared by the Center for Medicare and Medicaid Services, 42 CFR Parts 405, 410, 411, 414, 415, and 495 [CMS-1693-P]) Baltimore, MD: Department of Health and Human Services; July, 2018. Accessed 07/17/2018.

2 - Pear, Robert. “Sniffles? Cancer? Under Medicare plan, payments for office visits would be same for both.” NY Times 2018 July 22. Accessed 07/23/2018. Doherty, Bob. ACP Advocate Blog 2018 July 13. Accessed 07/13/2018. Young, Kerry Dooley. Medscape: Medical News 2018 July 18. Accessed 07/22/2018. CMS, Fact Sheet: Proposed policy, payment, and quality provisions changes to the medicare physician fee schedule for calendar year 2019. 2018 July 12. Accessed 07/22/2018. Patients Over Paperwork: CMS.gov

3 - Fact sheet: Proposed rule for the Quality Payment Program year 3. (Prepared by the Center for Medicare and Medicaid Services, 42 CFR Parts 405, 410, 411, 414, 415, and 495 [CMS-1693-P]) Baltimore, MD: Department of Health and Human Services; July, 2018. Accessed 07/17/2018.

4 - Erickson SM, Rockwern B, Koltov M, McLean RM, for the Medical Practice and Quality Committee of the American College of Physicians. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017; 166: 659–661.

5 - The current guidelines for a 99202 visit include an expanded problem-focused history (chief complaint and one history of present illness element), an examination with at least two (1995) or six (1997) elements, and straightforward medical decision-making (minimal diagnosis and minimal risk, with or without data). The current guidelines for a 99212 visit include two of the three: a history containing the chief complaint and one history of present illness element, one examination element, and/or straightforward medical decision-making (minimal diagnosis, one stable problem, and minimal risk, with or without data).

6 - The lack of specificity in the Proposed Rule, and anticipated changes when finalized, make conclusive detailed amount determinations impossible. Sincerest thanks to Dr. Christopher Jones and to those who wish to remain anonymous for discussing this complex topic with me.

7 - All comments received through Sept. 10 will be reviewed. Send comments via: (1) http://www.regulations.gov and follow the “submit a comment” instructions, (2) (regular mail) Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, P.O. Box 8016, Baltimore, MD 21244-8016, or (3) (express mail only) Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Wednesday, August 1, 2018 by Pallimed Editor ·

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