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I thought I would post on what I hope will turn out to be an occasional series on sexuality here on Pallimed. We've covered sexuality some before. A post that leaps to mind is one by Christian in 2007 about the controversy that arose over a case where the staff at the world's first hospice designed specifically for young adults openly deliberated and decided to facilitate a 22-year-old patient's request to have sex before he died.

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Seattle and Vancouver Photo by Joan Robinson RN CHPN Seattle WA (from the Pallimed Photo Project)

I am not sure if Nick Genes (@blogborygmi) realized this when he approached me about a date to host, but this is the last edition of Grand Rounds for Volume 6.  A hospice blog as final chapter to a great year of medical blogging, there are things in life that are more serendipitous than this of course.  But of course here at Pallimed (@pallimed), we do cover things beyond just the last few days of life. So feel free to take a look at our 1,000 other posts.

On to the best of the medical blogosphere!  No themes here but I did ask (like GruntDoc) to include a post of  other than your submission to help broaden our reach this week.


Michelle Wood shares with us a realistic look at the medical uses of the iPad from FutureDocs (@FutureDocs) Vineet Arora "Attending Rounds with the iPad: Hype or Hinderance." I just don't know if I want to buy two iPad's one for isolation rooms and one for non-isolation rooms.

Tony Chen shares a post by Nick Jacobs from the very new American Board of Integrative Holistic Medicine blog "When Healing and Science Converge."  This blog has only been around for a couple of months, let's hope they stick with it.

MD from A Medical Resident's Journey writes about the recent WSJ piece on White Coat Ceremonies.  Is empathy teachable?  And bonus sharing with a post from Dr. Wes (@doctorwes) on the same topic, "On Humanizing Medicine."

Doctor Fizzy submits a post from next week's host Dr. Grumpy on the idiocy of e-prescribing. And probably the best new blog I have seen in recent months Doctor Fizzy's own 'A Cartoon Guide to Becoming a Doctor.'  I really did enjoy the cartoon descriptions of a headache.

Dr. Rich (@DrRich1) at The Covert Rationing Blog discussed the upcoming Guideline Wars with health reform with the cleverly titled but imaginary SYNTAX trial. Dr Rich also kindly introduced me to The Road to Hellth (by Dr. Perednia) with a post about when a doctor tells his patient how the medical system looks from a doctor's point of view.

Jill of All Trades shares three great blogs that should get more attention, while submitting none of her own.  She would be popular in my kids pre-school class with sharing skills like that! Here they are:

• Dr. Synonmous, a family practice doc, no relation to Dr. Anonymous that I can tell.
• Lockupdoc, (@lockupdoc) a psychiatrist in corrections
• And this was her blog post of note from WhiteCoat's Callroom: What's Fair? about writing prescriptions for OTC medicines in the ED.

How to Cope with Pain shares how some may find meaning in their pain with an Chinese tale. And just for a little light heartedness, a post from 1000 Awesome Things was shared.


Ken Covinsky writes at GeriPal about Humility in medicne, something that should be talked about more often.  By the way GeriPal (@GeriPalBlog) is an excellent team geriatrics/palliative care blog if you have not seen it already.

Maria Gifford at Better Health interviews Thomas Goetz about his recent book on personalized medicine and more importantly how to make good medical decisions.  Maria also wanted to share a guest blog post from Gary Schwitzer's blog Health News Review about the future of breast and ovarian cancer guidance for women with BRCA mutations.

Elaine Schattner blogs at Medical Lessons (@MedicalLessons) a classic post about how checklists (a la Gawande) may change the culture of medicine. If you ever wondered if you needed more 'poka-yoke' read this post.  Elaine also submitted a blog post from MD Whistleblower (@MDWhistleblower) (aka Dr. Michael Kirsch - he outed himself, I didn't blow any whistles!), titled Evidence-Based Medicine in Disguise: Beware the Surrogate because 'with so much emphasis and real need for greater EBM (evidence-based medicine), we should be aware of its limitations.'

John Schumann at the blog Glass Hospital (such creative names we bloggers have!) gives us a great glimpse into the skill of listening with this post Doctor Yenta. An excerpt:

As an internist, I’m trained to do things:

I listen.  I ask.

I examine, order, and test.

And then I assess.

I certainly try to treat.  All too often, this includesprescribing.

What frequently gets lost in this paradigm is that on many occasions, the listening part is often enough.

Laika (aka @laikas) shows how other blogs can inspire you to write.  After seeing Musings of a Dinosaur and  db's Medical Rants talk about why orthostatic vital signs should not always be considered scut work. This reminded Laika of a story about PCR and chromosome analysis.  Funny how our brains work sometimes!

Thanks so much for reading this week and thanks again to Nick Genes for organizing Grand Rounds.  Check out next week's host Dr. Grumpy and submit your posts early.

Keep In Touch With Grand Rounds:
Follow us on Twitter @grandrounds
Join our Facebook fan page
Subscribe to our RSS
See our Google Calendar for upcoming and past hosts.

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This is our 1000th post!  Christian posted an absolutely fantastic 5 year anniversary post, including a summary and history of Pallimed, back on June 7th:  highly recommended, and I'm not going to recapitulate his summary here.   I still have a hard time believing this thing I began noodling around with as a graduating internal medicine resident in 2005 has become what Pallimed is today.  I have my collaborators to thank for that, particularly Christian, who is absolutely responsible for keeping our blog alive, and evolving, and expanding.  Thank you my friend.

I've been toying around with an idea for a lighter post the last few months, particularly with the new fresh fellow season which is upon us, and thought our 1000th post was a good opportunity to do this.  I've been thinking about this lately with the new fellows, because I've been finding myself saying these things over and over, as I do every year, as I talk with trainees about this wonderful thing we do called palliative care.

So here they are - pearls for successful palliative care consultation (in no particular order).  I make no claims that any of these are original to me even if I've lost track of where they came from.  Feel free to claim them for yourself in the comments.  Few of these, particularly the ones I came up with, are aphoristic - if any of you can aphorize them please do so, in the comments.  If we get some good additions we may try to find a more permanent home to our collected wisdom.

1. Assume nothing, ever. 
2. Always talk to the team first.
3. Respond to emotion with emotion. 
4. 75% of what we do is showing up and shutting up.  
5. Tame the beast inside who just wants to talk, talk, talk.
6. Don't just do something, stand there.
7. Acute symptoms = acute meds.  (That is - don't jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.)  This is a variation of the idea behind:
8. NO DRIPS 'TITRATED FOR COMFORT.'
9. 'Good work' describes a process, not an outcome.
10. Palliative care is just good medicine.
11. And what is their bowel regimen?
12. What is their narrative?
13. Just because someone has less than 6 months to live doesn't mean hospice is right for them. 
14. You should worry more about your patients who want to die, and less about those who are desperate to live.
15. It's not about you.  (This is in reference to patients' and families' emotions.)

My absolute all time favorite, which was told to me I think by David Weissman, who was quoting a former oncology fellow of his:

    16.  You can't shine shit.

Please add your own. 

Thanks for reading, thanks for sharing Pallimed with your friends and colleagues, and thanks for commenting.

(Image from here, via Google image search.  Could not identify any copyright information.)

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On the eve of our 1,000th post (this is #999) Pallimed is very excited to be hosting Grand Rounds for the fourth time (find previous editions here: 2007, 2008, 2009).  There will be no particular theme assigned this week, but I will be adding a little wrinkle to the submission process: If you submit one of your own blog posts you also have to submit a recent blog post from another blogger.    Help me find the BEST in medical blogs out there!

I will be looking around myself and finding a few selections of my own as well.  Email your submissions to ctsinclair@gmail.com with "Grand Rounds" in the subject header. Deadline for submissions will be 5pm CT on Sunday September 19th.  Please be sure to include why you think your submissions should be included in the BEST of the blogosphere.  You could also tweet me any of your links this week to @ctsinclair with the tag #gr Fair warning: Not all submissions will be included in the final post.  I will be looking at your other blog posts too and if I find something better on your blog I might choose that one instead.

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Annals of Internal Medicine recently had a timely discussion of advance care planning, trying to focus the discussion away from helping patients specify what what they'd want, and more towards laying the groundwork for appropriate decision making by loved ones whenever that time comes.  Good one for the teaching file.

That is, instead of thinking of ACP as patients pre-specifying 'If X happens, then I want Y,' thinking about it more as helping patients and their loved ones prepare for the decisions they'll be faced when the time comes - e.g. helping them think about 'EOL' decision-making, about what are acceptable outcomes of therapy, etc.  My own drastic condensation of what they propose is focusing the planning on outcomes as opposed to specific individual therapies.  E.g. less 'No feeding tubes' and more helping prepare loved ones to think about the medical decisions they may be faced with in light of what an acceptable outcome, 'quality of life' would be, etc.

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The 'palliative care extends life in NSCLCA trial' has made its way to broadcast nightly news (see embed below).    It's an interesting couple minutes, and while very positive about palliative care, I'm curious as to others' reactions to this.  Watch it - you'll see what I mean.   The patient, a middle-aged man with advanced lung cancer who is clearly living with his cancer with as much dignity and vitality as could be imagined, is also the healthiest appearing advanced lung cancer patient I've seen in a while; much of the stock footage seems to take place on a pulmonary rehab unit (e.g. on the treadmill) (?);  the palliative care clinician is called a 'guide'; and alternative medicine interventions are given as much airtime as anything else.  It sorta de-medicalizes what we do, and if I had no clue what palliative care was I'd think it was some sort of friendly person who stuck you on a treadmill and referred you for qigong.   It's kind of like watching one of those Zyprexa ads where you see that attractive middle-aged woman leading this meaning-filled, poignant life full of family and work and you say to yourself 'Gee I wish I felt like that & I don't even have bipolar disorder.'  Such are the growing pains of fame for our field, I guess.

That aside - the piece focuses as much, or more, on quality of life and symptom improvement than the mortality benefit, and, per my post about the paper, I can't see how this is anything but a net boon to our patients and access to us.

Our blog contributor Brian McMichael alerted us to this - thanks Brian!

(Late edit - read Brian's comments for links to related interviews.)

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Drawing of a nasal cannula from Wikimedia Commons

It's a common assumption amongst both the general population as well as medical professionals that breathlessness equals some problem with oxygen delivery, and therefore, every patient with dyspnea should have at least a little bit of oxygen delivered through a nasal cannula regardless of their oxygen saturation (sometimes endlessly).  Because of the ubiquitous nature of oxygen therapy, why not?  It helps many patients, and it makes sense that the higher concentration of O2 molecules represents the critical component of the therapy.  It's been shown to palliate dyspnea, improve functional status, and prolong life in patients with COPD with hypoxemia. 
Hypoxia isn't always the cause of dyspnea, however, and Abernethy et al. set out to test the hypothesis that room air delivered by a concentrator at 2 liters per minute might rival the efficacy of oxygen delivered at the same rate for patients with advanced disease, refractory dyspnea, and normal blood oxygen concentrations (Pa02 >55 mmHg).  The results of the double-blind, randomized control trial were published in Lancet recently. 

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In case you were missing the latest edition of the best writing in the Hospice and Palliative Care blogosphere, you can hop on over to the AAHPM blog and find a smorgasbord of links to keep your brain satiated until the Fall TV premieres begin.  I know Drew can't wait for Glee to start. (That is not true I just made that up. Or maybe it is true. I doubt it. End internal conversation.)

Check it out and go give some comment love to all the writers out there giving their all.  Don't forget to spread the good stuff to your IDT, as well as on Facebook, Twitter or LinkedIn if you find something you really enjoyed.

And if you get to the end and click on the Geripal link, I guarantee you will laugh and anyone who doesn't live and breathe palliation and communication will not get the joke.  Everyone loves an inside joke; unless they don't get it.



Cartoon by Dave Walker. Find more cartoons you can freely re-use on your blog at We Blog Cartoons.

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(Note for our email subscribers you may want to go to the actual post to see all the embedded media best.)
For those of you who missed the announcement back in July, hospice and palliative medicine has enough people on Twitter that we started having a weekly Tweetchat every Wednesday night at 9p ET/6p PT.  We have had good turnout and support from a lot of people who think what we do is very important.  If you that last sentence confused you just watch this for a quick tutorial (over 1200 views on Slideshare so far):

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(Editor's note:  I discovered last night that Blogger doesn't allow really long comments, so I have taken the liberty of posting my comments about Lyle's post on the NEJM early palliative care trial and the subsequent comment discussion as a full post.)


Well it's been one of those weeks-after-vacation in which it takes you an entire week of madness just to catch up with what you didn't do the week you were gone.  Along those lines, I finally read the full paper today, and had the following reflections:

1. I think the core, talking-point message from the paper is that early palliative care specialist consultation for 'high risk' cancer patients helps our patients: it improves their symptoms and quality of life.  These were consistent and moderate effects across the board for this intervention.  When it comes to HRQOL improvement for incurable cancer - moderate improvements are a very very positive and gratifying outcome.  
2. Along these lines, the big 'selling point' of this to our friends in oncology who don't particularly object to us but aren't sure what we add is that we are needed/helpful, we improve their patients' lives which is our mutual goal.
3. I think the real limitation of this study, as others have mentioned as do the authors, is one of generalizability - one center, one patient population, pre-screened (in essence) by their oncologists, and it's unclear what the pall care team did.  That said, reading the appendices, what they outline sounds very much like routine palliative care assessment/interventions, nothing fancy: whole person symptoms, disease understanding, coping, communication preference, goals.  I don't know how you pre-specify further what it is we do in real life.  
4. Survival:  I disagree with those who suggest that the survival finding was some sort of fluke - there's nothing in the study design to suggest this is an error *within the constraints of this protocol*. The fact that it's a secondary outcome doesn't mean it's not a real phenonomenon: it's a basically unbiasable outcome - you're dead or not - and the effect here is huge - 3 months median.  Not subtle at all for this patient population.  Yes, there could be a flaw in the study design, or this is a statistical mishap, but I don't see anything in particular which would lead me to that conclusion.   If this was a RCT of a hypertension drug in which a drop in mean SBP greater than 10mmHg at 3mo was the primary outcome, and a secondary outcome was all-cause mortality at 3 months, and it so happened that there 30% more drug patients died than placebo, you wouldn't dismiss it.  In addition, if median survival in the palliative care group was 3 months shorter than non-PC I hope people wouldn't dismiss it outright, b/c they shouldn't.  It'd be 'bad press' I guess, but if you believe that patients should have expert asssistance in maintaining 'quality' of life regardless 'quantity' then you should be comfortable with that quantity being shorter.  Cf. the recent study looking at abx for pneumonia in advanced dementia that we blogged about (to be sure this was observational not a trial, I'm just using this to illustrate my point) in which those without antibiotics had no worse/and maybe better symptoms and died sooner: that should be ok with all of us.  Anyway, I seriously doubt for cancer there'll ever be an association for palliative care specialist interventions with increased mortality for a lot of reasons (patients, generally, want to live and want treatment; anticancer treatments for those near the end are generally ineffective and not life prolonging anyway so even if palliative group patients didn't get them they'd still live as long, etc.).  Anyway, for this study, the big question in my mind about survival has to do with the fact that 30% of patients were still alive at the time of censuring - enough to substantially alter the survival outcomes at, say, 5 years.  That concern doesn't invalidate the findings within the scope of their protocol.
5. All of this is to say that I think this study really does raise the question of whether certain palliative interventions in certain patient populations really do help people live longer.  Why not, after all?  Is there any reason to think expert symptom control, anticipatory guidance/planning, etc. are any more likely to alter survival than, say Tarceva for NSCLCA patients with ECOGs of 3?  Nonetheless touting improved survival outside of the specifics of this study are - generalizing it - to be sure, premature.  
6. One of the probably starry-eyed ideas going through my head after reading this is that the real impact of this study should be to, as others have argued in the past (I can't remember who exactly at the moment, maybe Abernathy and Currow et al), do away with the nebulous 'routine care' or 'routine supportive care' as a control intervention for cancer therapy trials.  It should be replaced with, instead, specialist palliative care.  I know that's practically impossible - there's not enough people to do this etc. - but I think this study, if it does nothing else, should be the beginning of the end of that practice. Routine supportive care, whatever that means, is not a standard.
7. The media will be the media, but I agree with those who think some in the HPM community mis-fired in playing up the survival benefit (the authors of the paper did not play it up).  This is not because the benefit, within the confines of this study, was bogus, but because as others have said the focus on survival shifts focus from our core values and creates unrealistic expectations. 
8. I don't think all the heat generated however is really warranted, and part of me felt like 'Gee, so it's come to this, a skirmish about whether we should be touting or cringing from findings showing we prolong life.'  Part of the lack of sobriety in reacting to the survival results, I wonder, is from a tacit recognition of how young we are as a field, how misunderstood many of us feel sometimes, and how sick we are of people outside our field assuming things about us that aren't true (we are the death doctors, we casually hasten death, we don't support our patients' will to live despite the odds, etc.) - such that there is a little triumphant 'See! We don't kill people!' aspect to this.... 
9. That aside - the cult of mortality (as a meaningful outcome divorced from other considerations, particularly in patients with chronic, life-limiting, morbid conditions) is pernicious to medicine, research, society, and our patients.   And, I think as a community we don't want to lose site of the larger war, just to celebrate this single battle.  *Forgive  the martial metaphor -  I can't come up with anything more appropriate at the moment.
10. What we do improves the lives of our patients and their families, it helps them get the medical care that they actually want and helps them meet their goals.  If it improves mortality, great; if not, no problem because adding a few months of life is not what all our patients want given the consequences.  
11. One doesn't want to be too naive, however.  "You had me at 'palliative care improves HRQOL'..." is what you hope oncologists, other referrers, and payers will say, but I know data about mortality and cost savings are taken seriously by many of our key constituents, so it should be discussed, and goddammit we should be proud of what we do, and this study gives us good reason to be, and I cannot imagine how long term this trial will be nothing other than a boon to our field and to our patients (by improving access to our services).

I hope David Weissman will forgive me for paraphrasing his response to the discussion about this trial:  "If I'm a life-prolonging intervention, does that mean I'll have to discontinue myself when a patient is ready to die?"  Funniest thing I've heard all week.