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by Drew Rosielle (@drosielle)

A Series of Observations on Opioids By a Palliative Doc Who Prescribes A Lot of Opioids But Also Has Questions.

This is the 5th post in a series about opioids, with a focus on how my thinking about opioids has changed over the years. See also:
Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.

Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses

Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

Part 4 – Everything We Were Taught About High Doses Was Wrong, And The Same Hand-Crafted Graph

Part 5 – Why Do We Lump The Non-Cancer Pain Syndromes Together?

This is Part 6, which asks the sort of inverse question to Part 5 – Why Is Cancer Pain So Special?

Why is cancer pain, in so many guidelines and organizational/public policies ‘exempted’ from the dosing and safety guidelines. This is not a rhetorical question – I have not actually ever read a coherent explanation as to why.

One might reasonably assume there’s all this research demonstrating the safety and efficacy of long-term opioid use in cancer patients. In reality, that research is non-existent.

Guidelines like the CDC’s accurately point out that there are essentially no data demonstrating the long term efficacy of opioids for ‘chronic non-cancer pain’ (CNCP). True enough.

But where is the study proving the long-term safety and efficacy of opioids for cancer pain? Where are the well-designed, controlled (or at the very least prospectively designed and closely monitored) studies of opioids for cancer pain which follows patients for longer than 6 months? It’s possible I’ve missed some key studies, but don’t think I have (but correct me in the comments if I have!).

Notably, there are a collection of studies like this one, all involving 6 months or longer of open-label monitoring after a RCT of an opioid for cancer pain. It’s middling quality data involving highly selected patients, and, importantly, for every study like this in the cancer world there’s a similar one like this one in involving CNCP patients. In other words, I don’t see that we are in a situation where we can say we have more convincing, higher quality data for cancer patients than non-cancer patients overall.

And, what exactly do we mean by ‘cancer pain?’ A patient with metastatic breast cancer to bone who has bone pain? I think most of us would consider their pain ‘cancer pain’? What about someone with severely painful multiple myeloma who achieves a long-term remission but their bone pain only partially resolves? Their X-rays and scans continue to show widespread lytic bone lesions, but they don’t have active myeloma. And they may go 5-10 years before relapse. Is that cancer pain?

What about someone with severe, non-healing, osteoradionecrosis of the jaw but no evidence of active oral cancer anymore? Let me tell you, that patient will have severe pain, potentially for life. What about the patient with breast cancer – does it matter she may live over 5 years even with widespread, painful bone metastases? Is that still ‘cancer pain’ (obviously it is), but if so why do we collectively seem to make an important difference between her and the patient who may also live many years with painful, nonhealing osteoradionecrosis? None of this is to mention chemotherapy induced peripheral neuropathies – are those cancer pain? I’m not proposing that I know the answer to these questions – what I’m trying to do however is to make clear that I don’t think we are operating with a set of really fuzzy, imprecise, and ill-defined concepts even when we say something like ‘cancer pain.’

So, I think about all this a lot, and here’s where my current thinking is.

First off, I’ve been trying to find the answer to the question why is cancer pain treated so much differently in these guidelines? Like I intimated above, I don’t actually believe it’s due to there being significantly more/better research data out there establishing the safety and efficacy of opioids for cancer pain than the CNCP syndromes. As I’ve been writing this, I did some rooting around to try to see if I was wrong, and didn’t find anything to change my mind about this. If you want to, dig through this list of Cochrane reviews on the subject, and then try to convince yourself that, in important ways, we have better data for cancer than non-cancer pain syndromes.

Is it because we believe cancer generally hurts more than other pain syndromes? I hope not, that is stupid and wrong.

Is it because we believe patients with cancer are more morally deserving of pain relief than others? Christ, I hope not.

Is it history? That cancer pain has a deep history of decades of advocacy internationally to normalize chronic opioid use for it which has been successful? Maybe, but opioids for CNCP advocacy also has a pretty deep history of advocacy too, and I don’t think this is enough to explain the difference.

Is it because there is something unique about the cause of pain in cancer that makes it reasonably more likely to respond well to opioids long-term than other syndromes? While acknowledging this remains speculative for all of us, I do think this idea at least has some basis in reality, but it only goes so far, and does not justify broad lumping of all the CNCP syndromes together, or all pain-from-cancer syndromes together. That is to say, for at least some of the cancer pain syndromes we encounter, patients, in pretty straight-forward way, have space forming, inflammatory, and infiltrative tumors causing the pain. Ie, the cause of the pain is from clinically obvious, direct, inflammation-heavy, tissue damage and destruction, and, arguably, pain from this etiology (let me call it ‘tissue damage pain’ for short here) responds better long-term to opioids than pain from other causes.

While I don’t think I can cite you clear research data to prove this, I myself basically believe this/accept it to be true: tissue damage pain responds pretty well to opioids, long-term. Obviously, for many CNCP syndromes there is not this ‘tissue damage’ etiology. However, there are many syndromes, ones I’d note that you see a lot if you care for people with serious illness, that do involve tissue damage – sickle cell disease, some types of chronic wound pain, some types of osteonecrosis, ischemic limb pain, possibly pain from some of the inflammatory arthritidies, etc. (Referring to ‘cancer pain’ scenarios I mentioned above, I don’t myself know how to really categorize the chronic bone pain in patients who have achieved remission for multiple myeloma. Is that ‘tissue damage pain’ as I’ve defined it? I’m not sure.)

So, if this is the reason we treat cancer pain as special, my basic request to the world is that we actually say what we mean, and replace cancer pain with something like ‘pain from active tissue damage.’ It’s a godawful mouthful I know, undoubtedly there’s a more euphonious term one can use, but hopefully you get my point. Maybe we should coin a new term: “inflammalgia?”

Finally, is cancer pain treated special because patients with cancer are assumed to be terminally ill? At the end of the day, I think this is actually the predominant reason cancer pain is exempted from all these guidelines. It’s the same reason ‘palliative care’ patients are exempted – it’s because the people who write these guidelines think we’re only caring for patients near the end of life.

To an extent, I do think the poor prognosis-basis for the difference has some merit. If someone has a short prognosis (I’m not going to define what that means but I know it when I see it), I think it’s a pretty uncontroversial statement that having a short prognosis markedly changes the benefit:risk ratio when it comes to opioids. While preservation of function is typically a goal until a patient is really in the final stages of life, for patients with terminal illness and severe pain the simple goal of aggressively relieving suffering is often paramount, and opioids do a really good job of that, especially in the short term. Additionally, the risks to a patient of a lot of the long-term pernicious effects of opioids are less if time is short.

Makes sense to me, but I worry about an unexpected effect of exempting cancer pain from these guidelines and discussions: it gives some people the sense that opioids are unquestionably indicated for patients with cancer and we don’t really have to worry about pain. I’ve seen many situations in which a patient clearly has a dangerous OUD, who has pain and cancer, and people just keep on prescribing. Or, worse, a patient is clearly diverting and people just keep prescribing because 'they have cancer and we have to treat the pain, right?' You encounter the attitude also of 'well they’re dying so who really cares', which makes me want to vomit, as if addiction is a pleasurable thing for people and a great time for a family and not anything other than a tremendous source of total suffering, although I’m happy to say that lately it’s mostly been patients saying that to me ("I have cancer you have to give me meds. Who cares I’m dying anyway"), not my colleagues.

Fundamentally, I’m not really arguing that the policies or guidelines should be rewritten to lump cancer pain and CNCP together. Selfishly, we already waste a ton of time in my clinic begging to get opioids covered for my patients as it is, even for dying cancer patients, and I don’t want anything to happen to make that harder. Mostly I’m arguing the great split between cancer and noncancer pain is harmful because it encourages fuzzy thinking about risk in cancer patients, and lumps too many unrelated non-cancer pain syndromes together, in ways that are really harmful for people, and encourages clinicians and policy makers to think about, eg, a 60 year old patient with severe degenerative arthritis who can’t get out of bed due to pain with a 60 year old patient with depression, anxiety, a history of alcohol use disorder, and ill-defined chronic abdominal pain and headaches in the same category.

It encourages us to simplify what is complex, and our patients deserve better.

Thanks for listening,
--Drew.

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.
Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses
Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph
Part 4 – Everything We Were Taught About High Doses Was Wrong, And The Same Hand-Crafted Graph
Part 5 – Why Do We Lump The Non-Cancer Pain Syndromes Together?
Part 6 - Why Is Cancer Pain So Special?

For more Pallimed posts about opioids.
For more Pallimed posts by Dr. Rosielle click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.

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by Andrew Garcia (@ndyG83)

“We can focus on your comfort always means we’re giving up.” I can’t count how many times I’ve heard this sentiment from both patients and other healthcare providers, and to read it both frustrated and encouraged me at the same time. It’s frustrating because to know that what I do, as a palliative care physician, to help patients and their families during some of their darkest, scariest, heartbreaking and most painful moments, is seen as 'giving up' when it couldn’t be any more different. Yet, I also find it encouraging because it reminds me that there is much work left to be done on educating everyone on the importance of Hospice and Palliative Medicine (HPM).

“Everything Happens For A Reason and Other Lies I’ve Loved” is Duke Divinity history professor Kate Bowler’s personal perspective on how being diagnosed with cancer disrupted her "seemingly perfect life" and forced her to question what matters most when it comes down to the very real fact that she is dying. Her perspective is real and authentic, and at times unapologetic in its portrayal of her interactions with family, friends, and the medical community. For example, she writes, “She moves through the pleasantries with enough warmth to suggest that, at least on social occasions, she considers herself to be a nice person” describing an interaction during a post-op appointment with a PA. Stories of this nature are always a good reminder that what we do and how we are around patients has a larger impact on them than, we are able to anticipate, or even be aware of.

I find it’s always important to listen to a person’s story, especially when it comes to anything they consider “life-changing,” regardless if that is something we would also agree as being “life-changing.” Perspectives matter, and in healthcare, at times, we can get so caught up with our own perspectives we fail to realize other’s. This is something which doesn’t just affect healthcare providers and Kate is very aware of this as well when writing, “I keep having the same unkind thought – I am preparing for death and everyone else is on Instagram. I know that’s not fair – that life is hard for everyone – but I sometimes feel like I’m the only in the world who is dying”. In a sense she is right, our world is what we see and create with our own eyes and experiences, and Kate is the person “dying” in her world, so to see people who aren’t central to her story living as if nothing is wrong, well I can’t imagine just how frustrating that would be.

As an HPM clinician, empathy is central to what we do. We connect with patients on a different level than many other providers. We seek out - or better yet - we crave that personal connection with patients so we can know and understand what is important to them, who is important to them, and why. We can’t just know the who and what, we need the why, and Kate does an amazing job at sharing enough of her personal life story to allow us to understand why certain decisions in her care are made and also why she views certain interventions, or lack of, as “giving up”. It reminds us that people are a sum of their experiences, and the decisions they make when “push comes to shove” are largely based on those experiences.

I was a bit disappointed after finishing the book, since I assumed the book, given the title, would focus on what healthcare providers, and people in general, should avoid saying to patients dealing with any terminal illness. To my dismay, this was not the case. Sure there are interactions in the book that allow you to see just how “annoying” certain phrases can be, but the majority of the “pearls of wisdom” are left to an appendix at the end of the book. Like, why we should never say “Well, at least…” to any person (or patient) ever.

At the end of the day, if you are a person who is interested in reading the very personal journey of a person facing a very serious and life-changing cancer diagnosis, in an entertaining, heartbreaking yet reassuring and authentic manner, it is well worth the read.

Andrew Garcia MD completed a fellowship in Hospice and Palliative Care at the University of Minnesota in 2018. Interest in include health care disparities around end-of-life care. He likes to tweet at random and can be found on Twitter at @ndyG83

(You can see more of Kate Bowler's writing at her website and blog and podcast. You can also find her on Twitter (@KatecBowler). - Ed.)

(Note- Some links are Amazon Affiliate links which help support Pallimed. We also suggest for you to support your local bookstore. - Ed.)

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By Christian Sinclair (@ctsinclair)

The growth of palliative care in the community and outpatient settings has been one of the more popular stories in our field in the past few years. No longer is palliative care only available to serve in the intensive care units, but the demand for person-centered, family-oriented, symptom-based care with an emphasis on communication and decision-making is being heard in the earlier stages of illness. Serving patients and families in clinics and in their home is unleashing the true potential of palliative care. Even in my own work leading our outpatient efforts in an academic cancer center, we are very excited about our upstream involvement setting the stage for the 2016 ASCO Clinical Practice Guidelines on implementing palliative care into oncology practices. I have seen the positive impact of being involved early and it gets me excited to hear from my peers across the country doing the same thing.

But we have learned in the delivery of palliative care, to be wary of the overpromise of new medications and new technologies. We see the patient impact due to the hype around a new treatment lead to a widening of “eligible” patients which is often followed by a lack of impact compared to original trials. We hear the stories of medical bankruptcy because of expensive new treatments that never panned out for patients. And knowing this I have begun to worry about the Goldilocks principle as applied to palliative care; not too late while also being not too early. Unfortunately, not all the research is helping us define the right time to initiate palliative care, which is a crucial question because we still do not have the workforce to be undisciplined in what populations are served.

The Danish Palliative Care Trial (DanPaCT), published in Palliative Medicine this May by Groenvold et al, is just the kind of study which may help us begin to focus our efforts on this important question of timing. It is the first major European trial of SPC compared to all the other studies which have been based on North America. DanPaCT researchers looked at early referral to a specialist palliative care (SPC) team versus standard care. I came across this study because it was covered in the December Hospice and Palliative Medicine Journal Club (#hpmJC, @hpmJC on Twitter). The study population involved nearly 300 people with stage IV (metastatic) cancer at 5 Danish oncology centers. The SPC intervention took place over eight weeks and included in-person and telephone visits. The outcome studied was the change the single most distressing need for a patient using the EORTC QLQ-C30. And the results showed that early specialist palliative care made no difference in the most distressing issue. That is not heartening.

(Sidebar - Patient Selection - They looked at 1146 patients with metastatic cancer and after completing a palliative care screen (showing multiple high scores on EORTC QLQ-C30), they found 464 (40%) patients that they thought would benefit from SPC. That is a helpful metric to emphasize not everyone with metastatic cancer may have needs to be met by your palliative care team. Also, 30 of the 297 patients died during the eight-week study period, which is a pretty high mortality if this was designed to be a trial of EARLY palliative care.)

The study was well-designed and the publication is a must-read for anyone looking to make a case for upstream palliative care. I expect it will be featured in the state of the science at The Annual Assembly of Hospice and Palliative Care in 2018 even though it is a negative study There are some caveats to be made before you change course and tell your Stem Cell Transplant Team that you can’t see the patient BEFORE they get their transplant because you won’t make a difference.

The researchers looked at primary need, which was based on patient-reported outcomes (Good!) but picked because it was the highest score on the severity scale, not because the patient said it was the most important thing (Bad.) We all can imagine a patient who rates their anxiety a 7 and their pain a 5, but states that they would really be less anxious if they felt some control over their pain, so they feel pain control is the most important issue. Also picking one issue is a narrow view of the whole-person approach that defines palliative care, but to be fair when they looked at the improvement in other areas in the secondary outcomes analysis, there really was no major impact by SPC either. While not the focus of this first major DanPaCT publication, I hope to see other key areas of impact published like health care utilization (days at home, hospitalizations, ER visits, cost of care) and patient satisfaction with care.

It was not clear what professional disciplines were involved in delivering SPC, which is one of the most important factors in helping other clinicians decide how they can design their palliative care program. Many of the studies featured in the ASCO CPG were quite explicit in how their palliative care intervention was delivered, which helps program leaders decide what staff they need to hire.

My conclusions are:
1. This was a fantastic and well run trial
2. But they probably chose the wrong primary outcome
3. And underpowered given pragmatic approach#hpmJC

— Katherine Sleeman (@kesleeman) December 13, 2017

So this gets me back to the Goldilocks Principle. If we are going to properly balance our small but growing palliative care workforce and meet the needs of patients who would benefit most from our interventions, is there a problem with being involved with being too far upstream? We all know the problems involved with being called too late, now we might start developing a vocabulary around the challenge of being called too early.

We will be talking about this Wednesday, December 27th at 6p PT/9p ET on Twitter at #hpm chat. We hope you will join us!
Additional Info:

• Good short review by the Cicely Saunders Institute on PubMed Commons (PS would love to see more HPM Fellowship Programs make use of this for Journal Club Reviews. Steal this idea!)
• Nice detailed statistical analysis plan for this study published to help prevent bias during the analysis phase. I learned a lot about trial design in reading this.

Christian Sinclair, MD, FAAHPM, is an assistant professor at the University of Kansas Health System, editor-in-chief of Pallimed, and immediate past-president of the American Academy of Hospice and Palliative Medicine. You can find him on Twitter at @ctsinclair. 

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by Drew Rosielle


The Annual Meeting of the American Society of Clinical Oncology was last week. It’s been my observation over the years that much of the best palliative-oncology and supportive-oncology research is presented at ASCO each year, before it’s actually published (if it ever gets published).  So I always dig through the palliative/EOL/supportive/psychooncology abstracts each year to see what's happening. Below is a gently annotated list of the abstracts that caught my eye the most, for your perusal and edification. Undoubtedly, these are my idiosyncratic choices, and if you want to dig through all of them you can browse the abstracts by category here. A couple additional comments first.

One of the big headline trials was a supportive oncology trial showing that regular tablet-based symptom assessment in cancer patients prolongs survival.  Christian promises me he's going to do a deep dive into the symptom tablet trial so I won't really talk about it here.

It’s interesting however to compare it to one of the other major headlines which was about abiraterone for advanced prostate cancer. People went nuts for this study, although if you dig into the results they’re pretty modest (3 year survival 83% in the abiraterone vs 76% in the placebo group), but in cancer trials that’s typical. I’m not knocking the study, they are good results, I’d undoubtedly do abiraterone myself, but there’s often a big disconnect in the headline findings in cancer research and the actual, real, patient-relevant results. Lots of money to be made and spent on abiraterone, which is why it’s gotten so much press. Full paper here:http://www.nejm.org/doi/full/10.1056/NEJMoa1702900#t=abstract

Here are the other abstracts which caught my eye, loosely organized, and mildly annotated. (I should note that my annotations are summaries of the findings - keep in mind these are abstracts, not full publications that have been through peer review, we can't really look at the methods, so when I say that the abstract shows that X is effective for Y, that's me summarizing the abstract, not endorsing the veracity of the findings.) Also, if you're an author, and I misrepresented your findings, shame me in the comments and I'll append edits in the permanent post. 

1. A RCT of pretty high doses of lorazepam vs placebo, plus haloperidol for EOL agitation, showing that the addition of lorazepam helped. This got a lot of chatter on Twitter, especially about how it compared to the RCT of low dose haloperidol/risperidol for delirium.  I think it’s validation of the idea that it’s imperative to keep in mind the therapeutic goals with regard to delirium and agitation. Ie are we trying to sedate someone (=suppress the agitation behavior) or are we trying to improve the delirium? The first we can do, as this abstract shows, quite easily with a good dose of a benzodiazepine; the second we still lack any convincing data about any effective strategy in our late-stage patients, despite the widespread observation (belief?) that haloperidol & similar agents help.  Good stuff and I hope it's published in full soon:  http://abstracts.asco.org/199/AbstView_199_181607.html
  
2. A study looking at chemotherapy and palliative consultation in ICUs:  http://abstracts.asco.org/199/AbstView_199_192587.html 

3. Another study showing helpful effects of early palliative consultation in hospitalized cancer patients:   http://abstracts.asco.org/199/AbstView_199_190938.html 

4. A study looking at the relative stability of treatment preferences in advanced cancer patients over time:  http://abstracts.asco.org/199/AbstView_199_192725.html 

5. A study looking at Latinos & EOL preferences, including the generational effects after immigration: http://abstracts.asco.org/199/AbstView_199_193461.html 

6. A study about patient-caregiver agreement about goals: http://abstracts.asco.org/199/AbstView_199_192587.html 

6. A study looking at the natural history of fatigue in breast cancer survivors for 6 months. I wished they followed for even longer and hope they come out with data at years 1, 2, 3 and beyond: http://abstracts.asco.org/199/AbstView_199_182648.html 

7. A mobile CBT app for anxiety in cancer patients does very little: http://abstracts.asco.org/199/AbstView_199_194370.html 

8. A study looking at what healthy people say about whether they'd want 'palliative' vs curative chemo for AML, hypothetically speaking. Interestingly, responses seemed to be more fixed (fixed beliefs about whether chemo is worth it or not) than based on the information provided about different levels of side effects. This sort of research is fascinating, but I always worry that what healthy people say in a survey about a hypothetical question is very different from what they do when actually facing a life-threatening disease. The same problem with statements people make when they are healthy, and even put into health care directives. "Uncle Joe would never want to go to a nursing home." That sort of stuff - ie does it actually mean Uncle Joe would rather choose to die this month than go to a nursing home - how do we actually interpret the prior statements, etc. Anyway:  http://abstracts.asco.org/199/AbstView_199_192439.html 

9. A fascinating study about potential interactions between depression, and depression treatment, and length of stay in  hospitalized cancer patients:  http://abstracts.asco.org/199/AbstView_199_188306.html 

10. A cocoa-based balm for onycholysis in chemo patients. There were 2 onycholysis abstracts this year. Why not?  http://abstracts.asco.org/199/AbstView_199_186790.html 

11. A mildly promising pilot study lactoferrin for chemo dysgeusia:  http://abstracts.asco.org/199/AbstView_199_191178.html 

12. Several studies of olanzapine for chemo nausea/vomiting (CINV). One showing it's more effective for emesis than nausea?:  http://abstracts.asco.org/199/AbstView_199_185558.html. More data for olanzapine: http://abstracts.asco.org/199/AbstView_199_181353.html. And in case there was any doubt, here's a metaanalysis of olanzapine for CINV demonstrating its effectiveness:  http://abstracts.asco.org/199/AbstView_199_187470.html 

13. A follow-up, with longer term data, from the RCT of palliative care for stem cell transplant patients showing improvements in depression and PTSD, but not other outcomes, at 6 mo: http://abstracts.asco.org/199/AbstView_199_188285.html. Earlier publication here: https://www.ncbi.nlm.nih.gov/pubmed/27893130 

14. Predictors of aberrant drug behavior in a cancer center population (helpful, and it’s exactly what you’d expect it to be, because they are the same predictors in the healthy population): http://abstracts.asco.org/199/AbstView_199_192505.html  

15. Yes, transbuccal fentanyl helps for dyspnea: http://abstracts.asco.org/199/AbstView_199_181614.html 

16. A RCT of minocycline for chronic myeloma pain (!) which showed promising results (phase II, better trials are needed). I vaguely had a sense minocycline had antiinflammatory effects, but apparently it could have analgesic effects too. Really looking forward to a study which hopefully looks at long-term safety and efficacy: http://abstracts.asco.org/199/AbstView_199_186197.html 

17. I hadn’t known this but there is actually a RCT showing that l-carnitine WORSENS taxane CIPN. Ugh. I have never used it due to lack of data showing efficacy, but hadn't realized it was probably toxic and still see patients on it sometimes. If one needed reminding that all these herbs, supplements, and so-called alternative treatments aren't these bland, safe, anodynes this is a good reminder. Science-based medicine is what our patients need and deserve. This abstract is a follow-up to the study showing it was poison:  http://abstracts.asco.org/199/AbstView_199_184547.html 

18. A deeper look at the truly nasty neurotoxicities of anti-PDL1 drugs (the major class of cancer immunotherapies). Little is known about this (I've now seen one case) and we will see more and more of this as these drugs are more widely used:  http://abstracts.asco.org/199/AbstView_199_191534.html 

19. Finally, and whoa -- single fraction is as good as multi-fraction radiation for cord compression. At least in patients with poor long-term survival (median survival was 12 weeks in this cohort). I look forward discussing this with my rad onc colleagues, as it would be a very welcome option for patients with less than 3 months to live so they didn't have to spend 2+ weeks of that time getting radiation: http://abstracts.asco.o/199/AbstView_199_186591.html

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By Lori Ruder

He moves over and she snuggles in close to her fiancé. She pulls their blanket over them. A special blanket made just for this moment. “I love you” she murmurs, soaking in his face and his warmth. “Goodnight lovebirds,” his mother teases as she turns out the lights.

This moment is both tender and tragic: tender because they are demonstrating their love for each other, tragic because this is happening in the ICU.  Her fiancé is on life support and he is dying. He moved over because I moved him over to make room for her in his narrow hospital bed. I repositioned his ventilator tubing and central lines out of her way, closed the side rail behind her for support, and helped her pull their blanket over them. This blanket was made by ICU nurses for moments like this: to have something to offer when medicine doesn’t.

Using our own time and money, we gather together to make blankets. We make them in many colors and patterns, to match the many styles that come from all walks of life. They are simple fleece tie blankets, the kind a Girl Scout might make, but they are soft and warm. They are something soft amidst the harsh reality of critical illness and death, and something to provide warmth and comfort--to touch a loved one during last moments as if to capture their essence before they are gone. The blankets are a memento of touch to take with them when they leave this place and their loved one behind.

We give our blankets when we know the end is coming, after
the “I wish we had better news” has been said. And sometimes we give our blankets when it hasn’t been said yet. We know when it’s time usually before anyone else, before the family realizes or the physicians are ready to admit. We give them at our discretion; we do not need an order.

We have blanketed older patients so that husbands or wives of many years will have something that remains. We have covered a young mother dying from cancer with two, one for each of her preschool-aged children, so when they don’t have memories of their mother’s arms around them they will have her blanket and know it came from her. We provide markers so that those coming to say goodbye can write a message of love. When the patient dies we leave it to the family to decide where it goes. Some choose to leave it behind. Some choose to keep it with the patient after death. Many take it home with them. It is our gift of love in a time of sorrow, and how they choose to accept it is honored. Our hope is that these blankets will warm their hearts and cloak their grief.

“Blanket” defined as a verb means “to cover completely with a thick layer of something.”  Synonyms include “cover,” “shroud,” “swathe,” “envelop,” and “cloak.” By using the term “cloak” my intention is not to cover or obscure grief, to pretend it isn’t there. By using the term “cloak,” I am referring to the Latin origins of the word, “pallium,” now in its current English form as “palliate.”  To palliate means to make something less severe, to ease and soothe, without removing the cause. Our intention is to hopefully make grief less severe, to ease it in some small way through a simple gesture of cloaking the dying with a blanket created from caring.

On this particular night my patient already had a blanket, one that had been autographed with messages of love, one that had covered him and his mother earlier when she moved in close to say tender goodbyes. But I realized he had two important women in his life who needed comfort. His mother, who loved him before his birth and never left his side, and his devoted fiancée who dreamed of a future with his own children that would never come to be.

I took her out to our supply of blankets to choose the one just right for them. She instantly liked a light green one with polka dots.  Although she was hoping for purple, his favorite color,our selection didn’t offer a purple one that was masculine enough for the strong man she knew. I told her, “He loves you. He’d be happy if you chose the one you really like.” And so it was the light green one that she snuggled under close to him, sleeping peacefully while his heart took its last beat. It was the green one that she clutched to her chest after he died, her face a blank slate of shock and disbelief. It is the green one that I pray she still holds tight in her time of grief, feeling the same sense of closeness and tenderness she felt on their last night together.

It was a simple fleece blanket, tied together by ICU nurses who bear witness to much suffering, sadness, and loss. It was something to offer that didn’t cause pain and only provided warmth and comfort. These blankets are tied together by our sincere desire to palliate the heartbreak of our patients’ families and, selfishly, our own.

Lori Ruder MSN RN is a Certified Hospice and Palliative ICU nurse in the Medical Intensive Care Unit at University Hospitals Cleveland Medical Center.  Many times spoken words can’t give her heartfelt and heartbreaking experiences justice, so she writes them to remain resilient.  If you’d like to summon your inner Girl Scout and help the cause you can find her on Twitter @LoriRuder.

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by Emily Riegel

Clinical question:
Your patient* is a 60 y/o male with refractory AML, admitted with pneumonia. He is on broad spectrum anti-microbial therapy, including anti-fungal therapy, and has been stable since admission. Your team have been consulted to assist with pain management. His pain is pleuritic in nature, exacerbated by “twisting” or movements that involve change in position of his chest wall. It is not constant, and he has periods of time with no pain whatsoever, as long as he remains fairly still in his upper body. He has no other chronic or long-lasting pain issues. His primary team has written for him to have oxycodone immediate-release 10mg by mouth, which he is using 5-7 times a day, as well as hydromorphone 1 mg IV, which he is using 5-7 time daily in addition to the oxycodone.

Your plan:
You round on the patient over the weekend. As he does not have continuous or chronic pain, you decide not to add a long acting agent. You transition him to a single-opioid regimen of hydromorphone IV or PO as he felt the hydromorphone was more effective than the oxycodone. You also opt to add dexamethasone 4mg by mouth daily, starting on Saturday morning, as an adjuvant for pain control. The primary team agrees with your plan for a brief, 2 day course of dexamethasone. By Sunday afternoon, your patient reports he had little to no pain, was able to now walk 10 laps around the unit, and required only 2 doses of PO hydromorphone in the past 24 hours.

The dilemma:
In discussion with your colleagues at Monday morning handoff, one of your partners raises a concern about the use of a steroid in a patient with an active infection and an immune system already compromised by AML. Although you have frequently utilized steroids as an adjuvant for pain control as well as in the management of a multitude of other symptoms, and have done so with the blessing of the primary physicians, you find yourself now wondering if the concern over immunosuppression ought to be of greater concern to you.

To the literature we go!

Literature review:
Not surprisingly, upon research of this topic there is no literature that directly addresses this clinical question. Let’s look at what we can find, though. Use of glucocorticoids (we will henceforth simply use the term “steroids”) in the management of severe infections has been well documented in literature. It continues to be recommended for patients with severe septic shock, especially when hypotension is refractory to adequate fluid resuscitation and vasopressor treatment¹.
There are also several studies, including multiple meta-analyses² and a fairly recent randomized control trial that actually show an advantage in the concomitant use of steroids in managing community acquired pneumonia³.

In what may be the most similar scenario to your patient in terms of anticipated duration of steroid use, a literature review of use of single dose steroid to prevent post-op nausea and vomiting and risk of infection/delayed wound healing did not find increased occurrence of infection across multiple included studies⁴.

Conclusion:
Although there is no definitive, absolute proof that use of dexamethasone as an adjuvant agent for symptom management does not confer a potential increased risk of infection, we do have literature indicating that steroids are used to help manage and treat certain infections, and that there has not been evidence of increased new infections when used in a single dose post-operatively. The clinical take away here is that it okay to consider the use of a steroid, especially in a low dose for a short period of time, in managing pain of an inflammatory etiology (such as pleurisy), and when compared to the potential risks of other pain management strategies such as systemic opioids.

Emily Riegel, MD, is a Med/Peds Palliative Care Physician at the University of Kansas Health System.
References:

1. Casserly B, Gerlach H, Phillips GS, et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Medicine. 2012;38(12):1946-1954. doi:10.1007/s00134-012-2720-z.
2. Nie W, Zhang Y, Cheng J, Xiu Q. Corticosteroids in the Treatment of Community-Acquired Pneumonia in Adults: A Meta-Analysis. PLoS ONE. 2012;7(10). doi:10.1371/journal.pone.0047926.
3. Torres A, Ferrer M. What’s new in severe community-acquired pneumonia? Corticosteroids as adjunctive treatment to antibiotics. Intensive Care Med Intensive Care Medicine. 2015;42(8):1276-1278. doi:10.1007/s00134-015-4042-4.
4. Assante J, Collins S, Hewer I. Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. Accessed October 4, 2016. (Open Access PDF)

*Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. The case and discussion is published as a means to illustrate important teaching points in healthcare. Patient details may have been changed by Pallimed editors to ensnure anonymity. Links and minor edits are made for clarity and Pallimed editorial standards.

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by Sujin Ann-Yi

According to the Caregiving in the US 2015 research report (PDF) conducted by the National Alliance for Caregiving (NAC) and American Association of Retired Persons (AARP), 43.5 million adults in the US have provided uncompensated care to an adult or a child in the past year. The same report found caregivers provide on average 24.4 hours per week of support to their family member. Spouses were found to provide on average 44.6 hours per week and almost 25% of caregivers provide 41 hours per week.

Caregivers refers to family members who provide ongoing continuous care, typically without any compensation, for those with serious health issues such as cancer. Family caregivers provide significant support to patients which includes but is not limited to physical, psychological, spiritual, and emotional support as well as communicating with health providers, treatment monitoring, administering drugs and medical treatments, and advocating for their loved ones (Caregiving in the U.S., 2015).

Caregiver distress results when caregivers have overwhelming demands and unmet needs, coupled with other stressors such as feeling isolated, feeling burdened, financial strains, negative emotions, and work loss. A positive correlation has been reported between cancer patients’ and their respective caregivers’ distress (Hodges, Humphries, Macfarlane, 2005). Caregivers are at risk in developing both depression and anxiety as well as consequences to their own health (Nipp, El-Jawahri, Fishbein, et al., 2016; Palos, Mendoza, Liao, et al., 2011). Caregiver distress is associated with: being female, younger age, being the spouse of patients, lower social economic status, employed, and lacking personal and social support (Kim, Given, 2008).

In the spirit of family centered care, recent attention has focused on directly identifying and providing support for caregivers in addition to patients as part of standard care. Palliative care professionals have improved symptom management and quality of life for patients and have intuitively included patient’s families and caregivers. Palliative care has been associated with improved caregiver well-being, family satisfaction, and physical and psychological symptom management for patients and caregivers. Early palliative care with newly diagnosed lung and GI cancers showed improved depression and quality of life in caregivers (El-Jawahri, Jackson, Greer, et. al., 2016).

Please join me @sujinannyi for our #hpm tweetchat to further discuss how palliative care professionals can play an instrumental role in identifying and addressing caregiver distress.

T1: Do your respective organizations currently either formally or informally assess for caregiver distress? If so, what is the process and what tools do you use if any?
T2: What services or resources are offered for caregivers at your respective organizations?
T3: What are some barriers for providing intervention and support for caregivers in your respective organizations?

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 10/26/2016 - 9p ET/ 6p PT
Host: Sujin Ann-Yi, PhD @sujinannyi

Follow @hpmchat and go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org

For more on past tweetchats, see our archive here.

Sujin Ann-Yi, LMFT, PhD is a palliative clinical psychologist from MD Anderson Cancer Center and is hosting her first #hpm chat.

References

Caregiving in the U.S. 2015 (2015). Retrieved from The National Alliance for Caregiving and the AARP Public Policy Institute websites
http://www.caregiving.org/caregiving2015/
http://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf

El-Jawahri, A., Jackson, V.A., Greer, J.A., Pirl, W.F., Park, E.R., Back, A., Muzikansky,A., Kamdar, M., Rinadldi, S., Jacobson, J., Fishbein, J., Eusebio, J., VanDusen, H., Nipp, R.D., Ryan, D.P., Temel, J.S. (2016). Effect of early integrated palliative care on family caregivers outcomes for patients with gastrointestinal and lung cancer. Journal of Clinical Oncology, 2016 Palliative Care in Oncology Symposium, 34, 234.

Hodges, L. J., Humphris, G.M., Macfarlane, G. (2005). A meta-analytic investigation of the relationship between the psychological distress of cancer patients and their carers. Social Science & Medicine, 60, 1-12.

Kim, Y. and Given, B.A. (2008). Quality of life of family caregivers of cancer survivors. Cancer, 112, 2556-2568.

Nipp, R.D., El-Jawahri, A., Fishbein, J.N., Gallagher, E.R., Stagl, J.M., Park, E.R., Jackson, V.A., Pirl, W.F., Greer, J.A.,Temel, J.S. (2016). Factors associated with depression and anxiety symptoms in family caregivers of patients with incurable cancer. Annals of Oncology, 27, 1607-1612.

Palos, G.R., Mendoza, T.R., Liao, K.P., Anderson, K.O., Garcia-Gonzalez, A., Hahn, K., Nazario, A., Ramondetta, L.M., Valero, V., Lynch, G.R., Jibaja-Weiss, M.L., Cleeland, C.S. (2011).Caregiver symptom burden: the risk of caring for an underserviced patient with advanced cancer. Cancer, 117, 1070-1079.

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by Amy Clarkson

(Margaret Edson, author of Wit, will be speaking at the 2016 Palliative Care in Oncology Symposium, so we are sharing this review from our Arts and Humanities site, originally published in 2009. - Ed.)

There are many movies out there with palliative themes, as we can attest to with our top 10 movie post, which garnered much comments. One of my all time favorites, also made number 1 on our top 10 palliative-themed movies list; Wit.

I first saw this movie in medical school. In fact, according to the IMDb, this movie is known for being shown at medical schools as an example of how not to practice medicine. Also, the plot deals with dying, so it's all the more relevant to those of us who care for dying patients.

The plot is this: An English lit professor, known for her high expectations and little compassion in the classroom is diagnosed with ovarian cancer. The movie shows her experiences from diagnosis to death. Her last weeks are spent in the hospital, undergoing rigorous treatment. She is alone, except for the nurses, attending and fellow who treat her. Through her reflections and memories there is a definite parallel between her heartless days teaching and the heartless medical system she is now in.

The movie is based on a play by Margaret Edson and this monologue, play-like background is the inspiration for the screenplay, making it unique. The soundtrack is simple with only 4 pieces listed. My favorite piece is "Speigel im speigel" or 'Mirror in a mirror' by Arvo Part. It is played often in the movie, the simplicity of the cello and piano is also melancholy, leaving the viewer with the feeling of being alone, just as the main character is.

I love this movie not just for it's ability to pierce me with its sad realities of the medical world, but also for it's subtle sub theme about death. All through out the movie we are bombarded with a certain text from a John Donne's Holy Sonnet 10. The main character was a John Donne expert and specifically recalls the punctuation differences pointed out at the end of this poem by her mentor.

The last line of the sonnet entitled "Death be not proud" is "And death shall be no more, Death thou shalt die." The version our main character had found was different "And Death shall be no more; Death thou shalt die!"

Here is the discussion with her mentor on the punctuation differences, talking about the version with the comma: "Nothing but a breath, a comma separates life from life everlasting. Very simple, really. With the original punctuation restored Death is no longer something to act out on a stage with exclamation marks. It is a comma. A pause. In this way, the uncompromising way one learns something from the poem, wouldn't you say? Life, death, soul, God, past present. Not insuperable barriers. Not semi-colons. Just a comma. "

If only the main character's death could have been so simple. Yet of the many ways death is portrayed in films, her portrayal is haunting. No one should have to die like this, without dignity and respect (ignoring her DNR)...alone in a hospital. Yet it is haunting, because of how real this type of death is. It is the antitheses of a palliative care death.

I've included a clip of our main character (Emma Thompson) thinking out loud. It's a lovely introspection of what's she's dealing with. Another clip has been taken down from YouTube, but when originally posted, it is a beautiful moment when our character actually gets her one and only visitor, her old hard-nosed mentor. The simplicity of human connection in the clip, with the Arvo Part soundtrack accompanying, makes me tear up every time.
I'd also suggest reading John Donne's Holy Sonnet 10 "Death be not proud" (This version uses a semi-colon and no exclamation!)

Dr. Amy Clarkson is a hospice and palliative care doctor in Pratt, KS, and former co-editor of the Pallimed: Arts and Humanities Site.

Image Credit: Still Image from Wit

If you are interested in writing reviews for old or new books and films, please check out our Pallimed Opportunities page. - Ed.

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by Ross Albert

I'm surprised that I’m not hearing more about the recent ‘Guidance Statement’ put out by the collaboration of ASCO and AAHPM on “Defining High-Quality Palliative Care in Oncology Practice.” (OPEN ACCESS PDF) It’s a report that provides some very interesting insight into what pieces of primary palliative care should be part of general medical oncologists’ practice.

When I read it the report, I was pleased to see that it was published in ASCO’s journal, and I noted the impressive list of authors. My eyes briefly glazed over as the discussion moved to Delphi methodology, but a few quick Wikipedia searches on study-design later, I was back on track, diving into the data. I am, of course speaking about that in jest—these statements and guidelines need to be rigorous and they need to be done with well-defined methodology.

The group essentially did the following:

1. Gather a bunch of very smart oncologists and palliative care professionals.
2. Give them a list of nearly 1000 statements of specific actions that might be part of high-quality primary palliative care practice in oncology.
3. Have them decide if those items are definitely/maybe/not part of primary palliative care that oncologists should regularly be doing.

The panel also grouped these practices into “Domains” for organization: End-of-Life Care, Communication and Shared Decision Making, Advance Care Planning, Appropriate Palliative Care and Hospice Referral, Symptom Assessment and Management, Carer Support, Coordination and Continuity of Care, Psychosocial Assessment and Management, and Spiritual and Cultural Assessment and Management.

The panel’s views on the different domains were informative. The highest percentage of items which the panel endorsed as “Included” in primary palliative practice by oncologists were in the realms of End-of-Life Care, Communication and Shared Decision Making, Advance Care Planning—more than 75% of items assessed were deemed to be part of standard practice. The lowest percentage was in Coordination and Continuity of Care, Psychosocial Assessment and Management, and Spiritual and Cultural Assessment and Management—with less than 50% of the items assessed deemed part of standard primary palliative practice by oncologists.

These numbers don’t mean that oncologists aren’t interested in any Coordination of Care though—It means, for example, that while the item “Communicating current prognosis to primary care [provider]” was thought to be included within their regular scope, that “Obtaining family/surrogate feedback regarding clinic practice of coordination and continuity” was thought not to be—again, they looked at nearly 1000 specific actions.

As a palliative care physician, I found the data included on symptom management most interesting. The report showed a figure with 23 symptoms ranked in order of whether items related to them were thought to be “Included” or “Uncertain” to be part of oncologists’ general practice (also remember that there was a third “Not Included” category, to put this data into perspective). Chemotherapy-related toxicity, nausea and vomiting, dyspnea, fatigue—over 90% of the items were thought to be “Included” as part of standard practice. Pain—66% of the items evaluated were deemed part of standard practice, and 33% “Uncertain.” Depression and anxiety—only 27% and 20% of these items were thought to be “Included” as part of primary palliative care activities for oncologists.

So how do we use this data? Again, the report doesn’t show that oncologists aren’t interested in treating depression, or aren’t interested in psychosocial aspects of their patients. But, it does show that there were pieces of the care of depression, and pieces of psychosocial care that might fall outside of what oncologists might be doing in their practices. This tells me that while I, the palliative care specialist, might be able to help control a patient’s nausea or fatigue, this panel notes that the general oncologist might feel that they’ve got those symptoms mostly covered. But instead, as the collaborating consultant, it sounds like extra support with pain, anxiety and depression, and extra psychosocial and spiritual care would be welcome. It also seems that while a physician or APRN might have value being placed in an oncology clinic, we really need to pull in our social workers, psychologists, and chaplain colleagues to care for patients in aspects that oncologists are likely least comfortable performing as part of their standard practice.

Dr. Ross Albert is the chief of the division of palliative medicine at Hartford Hospital, and the medical director for the Hartford HealthCare at Home Hospice teams, in Hartford CT.


Reference:
Bickel KE, McNiff K, Buss MK, Kamal A, Lupu D, Abernethy AP, Broder MS, Shapiro CL, Acheson AK, Malin J, Evans T, Krzyzanowska MK. “Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement.” Journal of Oncology Practice. Published online August 16, 2016.

Image Credit: From the article cited above. 

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by Christian Sinclair

August 2016 has left the building along with a lot of heat, rain and wildfires.

Here is a recap of all of our posts from August 2016. We know there are some you may have already bookmarked, but forgot to read, or maybe you liked it so much you want to share it again.

Make sure to follow, engage, like and comment with us on Facebook, Twitter, Google+, Pinterest, Tumblr, Instagram and LinkedIN.  We always appreciate it when you recommend us to your peers and social media makes it very easy!

Communication

• Palliative Chemotherapy: An Oxymoron by Rebecca Gagne Henderson

Humanities/Media Reviews

• Redefining "Death in Dignity": Sherwin Nuland's 'How We Die' by Vivian Lam

Interview/News

• Behind the Scenes: Media Watch by Barry Ashpole

Narrative/Opinion

• What happens when it is you? by Michael Fratkin

Research/Education

• August 2016 Journal Review by Christian Sinclair
• Trisomy 13 and 18: When a lethal condition is no longer lethal by Jenni Linebarger
• Worse than Death? ...Dependence by Ross Albert
• FOUR Score: Coma scales and prognosis in the ICU by Drew Rosielle

Comment Shout-out's for July (in no particular order):
Clay Anderson, Drew Rosielle, Lyle Fettig, Anthony Back, Lizzy Miles, Gerg Gifford, Kyle Edmonds, Kathy Kastner, Karl Steinberg, Lynne Kallenbach, Emilie Clark, Robin Kleronomos, Anthony Herbert, Tom Quinn, Karen Kaplan, Lisa LaMagna, Sidnee Weiss-Domis, Daniel Miller, Robin Youlten, Rebecca Gagne Henderson, Linda Dolan, Andy Probolus, Amy Getter, Alex Smith, Gerald Tevrow, Elizabeth Lindenberger, Vikranta Sharma, Elaine Glass, Matt Rhodes, Vickie Leff, Paul Rousseau, Emily Riegel, Will Grinstead, Jeanne Phillips, Staci Mandrola, Julie Koch, Michael Pottash, Thomas Reid, Pippa Hawley, Kat Collett, Michael Fratkin, Julie Christenson and a few anonymous people.

Highlighted Comment for August 2016
Frustrations with words not living up to their promise continue to be a theme this month. Thomas LeBlanc had a great comment on the challenges with the term palliative chemotherapy.

Let’s not throw the baby out with the bathwater; the best way to palliate cancer-related symptoms is to actually treat the cancer (if it’s treatable, and if the patient is not too frail to tolerate the treatment). The enemy here isn’t the chemotherapy, it’s the inappropriate use of it in patients who are too ill, or who have resistant disease, or whose goals can’t be met by the treatment. The enemy isn’t the chemotherapy, it’s the notion that patients should be forced to choose either cancer treatment or good palliative care. Instead, I believe they should be able to get both, and we should all work together as a team, oncologist and palliative care clinicians alike, to do what’s best for each patient at each step along the way.

Social Media Highlights

• Most popular Pallimed Facebook post: Condoloneces to Amedisys hospice on the death of Bill Borne - Reached 15k+ people
• Most popular Pallimed Twitter post: We need to be frank about death with terminal patients via @newsweek - 91 Engagements
• Most popular Pallimed Instagram Post: "That's all I wanted: for someone to look at me and listen to me, but in some beautiful and artisitc way." - Gene Wilder - 453 impressions

"That's all I wanted; for someone to look at me and listen to me, but in some beautiful or artistic way." - Gene Wilder #genewilder #willywonka #quotation #quote #hpm #hapc #palliativecare #listening

A photo posted by Pallimed (@pallimedblog) on Aug 30, 2016 at 1:11pm PDT

Passionate Volunteers and Writers Wanted
Do you love hospice and palliative medicine? Got something to say or find interesting things to share? Want to reach nearly 40,000 people with your ideas? We do this with a volunteer staff of ten, but we could use more regular volunteers.

If you are interested in writing for or working with us at Pallimed please check out the Pallimed Opportunities page and complete the form at the bottom. If you want to help we have something you could do! Like write this simple monthly review post (this would be really easy to hand off)! Or join our team of social media ambassadors to help run one of our social media accounts (especially with Facebook, Pinterest, LinkedIn, Instagram and Tumblr) - we do on the job training!

Christian Sinclair, MD, FAAHPM is a palliative care doctor at the University of Kansas Medical Center and editor of Pallimed. When not advocating for health care professionals to use social media you can find him playing board games.

Image Credit: Lionello DelPiccolo via Unsplash CC0 1.0

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by Christian Sinclair