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1)
This past week has had two fairly prominent major media articles focusing on significant end of life issues. In Time Magazine, Dr. Scott Haig (an orthopedic surgeon) writes about the difficulties physicians encounter when contemplating the appropriateness of Do Not Resuscitate (DNR) orders. (Or more appropriately Do Not Attempt Resuscitation, since we cannot promise any guarantees.) Dr. Haig has written a few pieces for Time before, one of which we noticed here at Pallimed about the VAS for pain being inadequate.

In this recent Time article, Dr. Haig reviews the case of an elderly Italian woman (described as spooky, wacky, cute, and vivacious) who broke a hip and required a lot of medical care before she could undergo the procedure. His description of the tricky balance of caring for geriatric patients is very accurate:

"It took a few days, many medicines and quite a few units of packed red cells to get her blood counts up to the point where she could have the hip operation safely. This is a dicey business with the very old. The transfusions put them into heart failure (the heart can't keep up with the fluid overload, which backs up into the lungs), which has to be treated with diuretics, which drop their pressure, which ruins their kidneys, which makes the heart failure worse. Pneumonia, bed sores, blood clots and dementia nip at them too, along with the paralyzing pain of the broken hip, almost from the minute they fall. It's dangerous to let hip fractures go too long pre-op — and somewhat inhumane. Ask anyone who has had one; the operation relieves a terrible pain."

The family had requested a DNR for the patient, but there was no clear evidence that she lacked medical decision making capacity, but she was inferred to be 'high-functioning', so maybe it was a language barrier that precluded direct discussion with her. Anyway that is not the point of the article, but an important one for the public in reading this, because it implies doctors and families can make these important medical decisions for' cute old people who have difficulty communicating (for any reason). Not exactly the message that provides trust in the medical community.

A important fact that is skipped over is the conflicting issue of what to do with a DNR order during an operation. In the article it sounds like they did resuscitate her:

"As we worked on the hip, her ancient heart got balky. So they gave her the same drugs and used the same electrical devices they might have used in a code. And it worked."

So did they rescind the DNR during surgery and was this done with informed consent. I would be very interested to hear from other health care professionals on their opinion on DNR's in the OR.

If a DNR order is in place, and it will be rescinded during the time in the OR (and for that matter does it extend to the pre-op or PACU?) it is important to have that discussion with the patient/family before that happens. If someone has a cardiopulmonary arrest while undergoing a procedure does that condition change the underlying understanding of the DNR order? Most surgeons and proceduralists would say something to the effect:

"Yes, it does. If I am trying to 'fix something' and the patient arrests while I am fixing them, I have a moral imperative to do CPR, so that the patient does not die as a consequence of my actions."

But if the patient understand they may die on the OR table and is OK with that risk, could they still be DNR? Or would the surgeon/proceduralist refuse on moral grounds? Or statistical grounds since this may affect their mortality rate with surgery? Do bath aides get to rescind a DNR if a patient dies during a bath? That sounds absurd but you have to extend the ethical argument to the simplest form:

While operating on/bathing/touching/talking to a patient, they cannot arrest without an attempt to resuscitate them, otherwise I am culpable in their death, regardless of their preferences of resuscitation.

That ethical conundrum happens all the time in hospitals, but is rarely discussed in an academic or patient-centered fashion.

One of the more confusing or biased sentences was this one:

"How great it would be to send her off to rehab now, close the case and blast the DNR commies to hell." (emphasis mine)

Who are these "DNR commies" of which he speaks? Is it the family who advocated for the DNR in the first place? Or is it the dreaded Palliative Care Team with 'Dr. Greg Reaper', and Nurse Mel Anne Coley' who spent 90 minutes with the patient and family talking about what their goals are? If someone can point out the "DNR Commies", let me know who they are. You might be able to identify "DNR Commies" by their obvious use of symbols. Instead of a Hammer & Sickle they have a Defib Paddle and a ET tube.

After the surgery she had complications, and the family put limits on the amount of aggressive care to pursue and she ultimately died. Dr. Haig recounts the phone call from the night nurse and then reflects on the actions and events that before her death.

"A waste of effort, of time, money and blood is how many in my medical community would have described our dealings with Carmela over those three weeks."

The author is probably being a bit pessimistic about health care, as I think many in the medical community would actually say that he and the other doctors tried to do what they could given the goals set by the family (and presumably the patient). Aggressive but not too aggressive is an option, and shows good doctor-patient-family communication over goals. Compromise is not always a bad word.

The last paragraph left me flummoxed.

"But was it the DNR that killed her? Indirectly, maybe. I think it was realizing that her daughters planned to withhold care that made her give up."

Followed by:

"An old teacher of mine explained it this way: "I will neither give a deadly drug nor will I make a suggestion to this effect.""

Now he is mixing metaphors; Withholding, euthanasia, and physician-assisted suicide are all implied in this last paragraph, leaving the reader more confused. While I think this is an important topic, I am surprised it came out so ethically and emotionally confused. Maybe that was the point of the article, is that dealing with death in medicine is awkward and confusing for many.

Luckily for Pallimed Readers we have an upcoming interview with Dr. Pauline Chen, the author of FINAL EXAM: A Surgeon's Reflection on Mortality (now out in paperback). So look for that in the next few posts, and if you have read the book (or not) and have any questions for her, feel free to email me at ctsinclair @t g.m.a.i.l d0t c0m.

2)
Jane Brody, health columnist in the New York Times, made a personal appeal to encourage readers to look closer at the underlying issues of requests for hastened death in dying patients. She presents personal anecdotes and is fairly balanced on the issue, but leans more towards considering legalizing PAS. She does highlight Dr. Timothy Quill's 2004 NEJM article on helping his own father die (subscription req'd). For newer people to palliative care, Quills article is an important one to read if you have not yet already. As palliative care practitioners we are asked about hastened death by patients and families all the time, and given that it is only legal in Oregon (PAS only), we must understand how to respond compassionately to these requests, understand their root causes, and practice within the full scope of our legal guidelines.

Medicare Hospice Cut?
Hospice Guy at Hospice Blog has a good review post about the "cut" in the expected hospice reimbursement for the Medicare Hospice Benefit in the President's proposed budget. His final take is don't get too riled up about it.

ECMO Prognosis
ECMO survival is hard to predict, but do note the high 30-day mortality rate of 37.5% in this study which looked at possible prognostic factors for survival on ECMO. The researchers did not find any, but they did get 80 patients. Unfortunately it took 16 years to get that many, so I don't expect to hear much about prognosis in ECMO for some time given the difficult accrual numbers.

Nude Hospice Calendar
Some hospice patients are so dedicated to raising money for their hospice in the UK that they are planning a "tastefully done" nude calendar. (via mental floss and Wigan Today) Wigan and Leigh Hospice seems to be a pretty progressive hospice seeing as how they also have a Hospice Real Ale made for them by a local brewer, and are the charity of choice for a local Starbucks. Good development department there!

"DNR Commie" Image Created by Christian Sinclair

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1)
2 from Journal of Medical Ethics:

• First is one on terminal sedation and the 'imminence condition'. It's a difficult-to-summarize paper whose main point seems to be that the 'imminence condition' (continuous sedation to unconsciousness without fluids/artificial nutrition is OK as long as the patient is imminently dying and so withholding sustenance is unlikely to hasten death by much), which is endorsed by some proponents of TS, has not been fully explored in the literature and is full of holes (ethical analytical holes, you know the type). Never one to avoid whacking my clinician's head over an ethical analysis, the major issue I had with this is that the author repeatedly states that the imminence condition is not supported/explained by ideas of autonomy, proportionality, or double effect. However he never explains how proportionality fails to support the 'imminence condition.' I mention this because when I lead discussions on this I make the argument that it does (all of this is my opinion of course):
• Imminently dying (likely prognosis less than ~~few weeks) & intractable symptoms; potentially hastening death by providing deep sedation without artificial nutrition/hydration is proportionate to the alleviation of intractable suffering and the loss of several days of life. Vs.
  
• Not-imminently dying (prognosis of months) and intractable symptoms (existential or otherwise) --> here I think one can make a good argument for lack of proportionality between shortening life by months and alleviating the suffering. (Lord knows not all would agree with this, or with my first point above; my point however is that the concept of proportionality informs this discussion.)

• Second is a study on physicians' confidence in discussing DNR orders. In case you have any any doubts about its results, it indeed did find that we are far less confident in discussing 'code status' than other medical procedures, and that housestaff are less comfortable than attendings.
  

2)
Journal of Pain recently had a supplement on all things post-herpetic neuralgia. It has articles on the diagnosis, natural history, prevention (vaccination), etc. of PHN. The supplement is industry funded. A couple things to note:

1. The treatment article lists (in its summative drug treatment table) levorphanol as one of the opioid treatments (and not hydromorphone, fentanyl, or oxymorphone). This seems to be an idiosyncratic choice by the authors (i.e. not because levorphanol has been particularly studied for PHN). When was the last time you saw levorphanol mentioned in an article like this (except in an article suggesting it should make a comeback)? Anyway it's a good review article and mentions numbers-needed-to-treat as much as possible (although frustratingly fails to define what the NNT was for: e.g. 50% pain reduction?). One for the teaching file.
2. The mechanisms of pain and itch in PHN article is very readable, and morbidly fascinating (read the itch part). It has a lot of history and in some ways traces the history of thinking about chronic pain via examining the evolving understanding of PHN.
   

3)
Journal of General Internal Medicine has a series of articles on discontinuing implantable cardioverters/defibrillators (all full-free text). One on the ethics of doing so; one on patient attitudes about it (an incredibly depressing but thankfully small qualitative study in which none of the patients had discussed ICD deactivation or knew it was an option and seemed freaked out by even discussing it); and one on clinician attitudes about discussing ICD deactivation. Quote of the year:

"That’s like an act of suicide. It’s a threat to your life. That’s like cardiac arrest. That’s insane."

4)
A provocative little letter in CMAJ (free full-text here) about decision-making in impaired adults:

"Our colleagues in pediatrics, who face an equally limited decision-making capacity among their patients, have taken a more nuanced approach based on the following principles: children have dignity, intrinsic value and a right to medical treatment that serves their best interests; children should be involved in decisions that affect them; information should be presented truthfully and with sensitivity; decision-making should be interdisciplinary and collaborative; and the best interests of individual children should be of primary concern. We at CMAJ are surprised that such principles are not considered for adults with diminished decision-making capacity."

Their argument is that decision making capacity is not an all-or-nothing thing, and we should stop treating it as such. My feeling is that in real-life the above-mentioned principles are often considered for impaired adults, even if not explicitly stated (at times my group discusses the need for assent from our impaired adult patients even if we cannot obtain 'informed consent'). It's nice however to see these ideas in print.

5)
On the EBM front....

NEJM recently published a piece looking at publication bias in antidepressant trials (it looked at all trials of antidepressants which were registered with the FDA and compared those which were published in the literature and those that weren't). They found that the unpublished trials were much more likely to be negative ones, and that even several trials which the FDA deemed negative (not supporting the efficacy of antidepressants) were published with positive sounding results. This is not to say they aren't effective but that the magnitude of benefit may be over-estimated, and also sounds a (general) cautionary alarm when interpreting systemic reviews or meta-analyses which rely only on published research (particularly in areas in which there is a lot of industry-sponsored research and thus perhaps a lot of research which is never published).

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Too many items noted too briefly:

1)
A few from the Journal of the American Geriatrics Society:

• First is a paper looking at the symptom experience of dying long-term care residents. This was a multi-institutional study involving interviews of family and staff caregivers of deceased LTC residents (~670 patients, mean age 85 years, most cognitively impaired). Pain and dyspnea were significant in about half the patients prior to death: and significantly while almost all patients had meds for pain about a third had none for dyspnea. The most commonly reported symptoms were issues surrounding cleanliness. From a research perspective, this paper found pretty good agreement between staff and family caregivers about symptoms (in fact, they found generally better agreement between these groups than other research has found between patients themselves and family caregivers). (Thanks to Dr. Robert Arnold for alerting us to this article.)
  
• A related article (same data set as above) is a brief report on pain, dyspnea, and perceived quality of dying in LTC residents. Caregiver related quality of dying was compared between patients with and without pain and with and without dyspnea. Presence of pain had no bearing on caregiver rated quality of dying; increasing dyspnea actually was associated with better quality. Weirdly, low dyspnea and severe dyspnea were related to better quality of dying; 'medium' dyspnea wasn't, which makes one wonder whether these results are picking up a lot of noise. One also wonders what the severely dyspneic patients themselves would say about the 'quality of their dying.' Authors' conclusion: "These findings suggest the need to look beyond physical symptoms to understand the quality of dying," which seems pretty reasonable. I still haven't figured out what QOL actually means (besides whatever a patient says it is) and don't know how to begin to conceive what the bereaved's reporting of 'QOD' actually signifies.
  
• Third is another mortality follow-back study looking at the impact of palliative care consultation on many care outcomes/family satisfaction. This one involved interviewing caregivers of deceased veterans who had received care at a VA; after multiple adjustments family satisfaction/perceptions of care quality were compared between those vets who received palliative care consultation and those who didn't. PC consultation was associated with better outcomes in most domains (satisfaction with communication, pain, well-being/dignity, etc.). They also looked at the role of earlier consultation and didn't find that that seemed to make much difference in satisfaction.
• Finally is a small but intriguing study of methylphenidate to prevent falls. It's actually a small, placebo controlled trial looking at the effect of a single dose of methylphenidate or placebo on certain fall-risk tests (e.g. the timed up and go test) in 26 elderly subjects. Methylphenidate significantly improved one (out of 4) of the 'fall-risk tests' (by a small amount) and not much else. Despite the positive spin on this in the abstract this modest finding does not seem promising that methylphenidate will have any salutary effects on fall risk in this population.
  

2)
BMJ has a study providing some generic prognostic information about dementia. The data come from a large, population based study in the UK in which ~13,000 patients were interviewed every 2 years for 14 years and, among other things, were given dementia screens (mini mental state exam among others; they note that a 'validated algorithm' was used to diagnose dementia). The relative novelty of this study was that they could pick up on incident dementia (they identified 438 cases of incident dementia), in real time so to speak, and thus hopefully get a more accurate assessment of survival. Median age of onset of dementia was 84 years and survival was 4.6 years for women & 4.1 for men. As expected, age predicted survival: women less than 70 years had a median survival of 7.5 years; men over 90 had a median survival of 3.4 years. Male sex and functional status were also predictive of survival. Of note these findings probably overestimate survival (a little) as those patients who developed dementia and then died before their next interview were not counted.

3)
A couple from the Clinical Journal of Pain:

• A pre-clinical, proof-of-principle, trial of mirtazapine for pain. Pre-clinical insofar as it involved inflicting pain on healthy volunteers (given 30mg of mirtazapine or placebo) and then seeing if there was any difference in those who received the active drug. There was, with increased tolerance to painful stimuli in the mirtazapine group, although maybe they were just experiencing a deep sense of contentment and peace... We'll see where this leads: most of the neuropathic pain I treat is cancer-related and I'll just throw out the observation that I haven't found antidepressants (of any subclass) to be routinely or convincingly effective for most patients.
• The second is one on geographic variations in opioid availability. It is based on a survey (60% response rate) of opioid availability in outpatient pharmacies in Washington state. Notable findings: 1) more pharmacies stocked meperidine than hydromorphone, 2) most pharmacies stocked most available opioids (unlike in similar studies in other areas), 3) however in multivariate analysis not stocking opioids was associated with being in a zip code with a higher non-white resident percentage (this was a small, but statistically significant association).

4)
Health and Quality of Life Outcomes has a study on changes in quality of life as death approaches (free full-text here). It uses data taken from a study done in the Seattle area using complementary therapies in those with short prognoses (most in hospice) and uses some of the most maddeningly complex data manipulations I've seen for a long time. Ok, it's not the most complex, but it struck me as unnecessarily complex; this may be frank ignorance on my part and if someone smarter than me reads the article and can tell me why they did the data manipulations they did I would genuinely appreciate it. (To be fair, this was one of those articles which was as much about demonstrating the feasibility of its methods as it was about its actual results: i.e. it's written as much for biostatisticians as anyone). Anyway, their major finding, looking at QOL in the 10 weeks prior to death, is that most people rated their's good for most of those weeks, but with a rapid drop off in the last 3 prior to death, which fits my gestalt about what happens with many people. (Their QOL measure was a simple, one-item, "rate your quality of life on a 10 point scale" measure).

5)
Supportive Care in Cancer has a systematic review on the treatment of dyspnea in cancer patients. Good one for the teaching file and a nice reference list for every trial imaginable on the topic. It downplays the results of this trial, which actually changed my practice a bit (I have begun adding benzodiazepines as adjuncts for dyspnea not immediately responding to opioids), which I found interesting (the abstract implies that there's no support for using benzos for dyspnea; my reading of this trial is that they are effective adjuncts to opioids).

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Drew and I appreciate all of the wonderful feedback we received while in Tampa at the AAHPM/HPNA Annual Assembly last week. Thanks to all the readers who proudly wore the "P" sticker and who came to Backjack's to meet with other Pallimed readers. It was good to match faces to names. If I missed you there or didn't have much time to chat, I apologize. For being there less then 24 hours it was quite an exhausting pace.

We heard a lot of interesting comments about the conference as well. I wished I could have made it to more than just the Case Conferences on Saturday (which were great BTW). So to make up for all of my lengthy posts about what I thought were interesting talks, I would like to turn the rest of the post over to the readers.

Please comment on the talks that you thought were remarkable or avoidable or what would you like to see next year, etc. Remember we are not an official part of AAHPM/HPNA, but just wanted to open some discussion about what Pallimed readers thought was important. (And if this is your first time to Pallimed, welcome!)

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This is my first post for a couple weeks and I have amassed a large backlog so my next few ones will likely focus on a single article and then mention others only in passing.

Thanks for everyone who said Hi in Tampa, or who came to the happy hour (M. sorry about the loud music - it's too bad Wham! is not your cup of tea). Tom Q - we missed you.

A quick note about the Blogging on Peer-Reviewed Research and Research Blogging system that we have alluded to before. The Research Blogging website is now officially up and running. It is, among other things, an aggregator of all blog posts by bloggers who use the BPR3 standards - it's an organized attempt to promote 'serious' academic blogging & we are hopeful it will be successful.

1)
Archives of Internal Medicine has published a fascinating article about race and hospice revocation to pursue 'aggressive' care. It is a retrospective analysis of data from a multi-state hospice group and compares characteristics of white patients who revoked their hospice enrollment to pursue aggressive care (the hospice agency prospectively gathered data on reason for hospice revocation at the time of discharge).

In some ways, simply the epidemiologic data are interesting: over 5 years 167,000 patients were discharged alive and only 2.8% of these were to pursue aggressive care, a median of 22 days after enrollment. This is, then, a rare event. African-American patients were more likely to disenroll to pursue life prolonging care (4.5% vs. 2.5% of whites), and this difference survived controlling for age, income, diagnosis, and other demographic variables. Length of stay, age under 65 years, non-cancer diagnosis, and not having an identified caregiver were also associated with revocation to pursue life-prolonging care.

What I found most notable was the 1 year survival amongst those who revoked hospice to pursue life-prolonging care: 48% (for both African-American and white patients). Those who died after revocation did so relatively quickly (~40 days), but almost half were alive at the end of a year. The authors note that those 40 days of survival are only a couple weeks longer than median survival in hospice, suggesting that those who died probably didn't have their lives prolonged much by revoking hospice. The relatively long survival of the others suggest that the decision to enroll in hospice was wrong (at least from a prognostic perspective). This data may be out there, but I know of no other good study looking at long-term outcomes for those who voluntarily revoke their hospice benefit. Of course, there are other important outcomes than 1 year survival, and we don't know what those years looked like, but that's for another study.

The authors discussed possibilities as to why African-Americans may revoke hospice care more than whites (and thankfully avoid pathologizing these decisions as due to 'mistrust' which implies a sort of irrationality). They do propose this explanation, which is pure speculation, but quite novel I thought:

"However, because African American patients are less likely to participate in advance care planning, they may spend less time thinking about or discussing their preferences for end-of-life care before enrolling in hospice. Because hospice care facilitates advance care planning, hospice enrollment may provide African American patients with the opportunity to solidify and discuss their treatment preferences. When these preferences conflict with the hospice philosophy of care, they may withdraw from hospice."

Johnson, K.S. (2008). Racial Differences in Hospice Revocation to Pursue Aggressive Care. Archives of Internal Medicine, 168(2), 218-224.

2)
Clinics in Chest Medicine recently had a review on 'end of life considerations' for chronic lung disease (mostly COPD). It's a general overview, well written, and notable for its very practical, straight-forward discussion of end of life communication towards its end. It is quite matter of fact about things, and directly addresses physicians' own discomfort in discussing death and dying (something that is often missing from such discussions; it's great to see this in a journal like this). This paragraph was also appreciated:

"Frequently, part of the decision for patients with lung disease is whether they want to receive CPR in the event of cardiac arrest. In our opinion, in helping patients make this decision, it is important that advanced cardiac life support not be broken into components but rather presented as a package. Breaking advanced cardiac life support into components (chest compressions, antiarrhythmic drugs, vasopressor agents, intubation) makes these decisions unnecessarily complex and can lead to an absurd resuscitation status, such as compressions and all drugs but no intubation."

3)
BMJ has a trial of a cannabinoid vs. an opioid for chronic neuropathic pain. It is a randomized, blinded, placebo controlled cross-over trial which compares nabilone (a synthetic cannabinoid) with dihydrocodeine (an opioid unavailable in the US about which I know little). Each patient was randomized to 6 weeks of the study drug and then crossed over to the other drug after a 2 week washout; patients could go through a dose titration protocol for each drug as needed for pain control. Both groups had lots of drop outs and the authors present per protocol analyses mostly. Dihidrocodeine did a little better than nabilone, although frankly both come off as crummy analgesics (few in either group achieved a 1 point drop in their pain on a 0-10 scale). Not a great endorsement of either cannabinoids or weak opioids for neuropathic pain.

4)
Very briefly:

• Social Science & Medicine has a recent article about hospice & Medicare cost savings (it's a case control study and tries to establish what is the ideal length of time for someone to stay in hospice, from a Medicare cost savings standpoint - the answer, thankfully, is much longer than the median hospice stay).
  
• JAMA recently had a commentary about definitions of disability. It was placed in the context of an 'impending wave' of population disability. There was something in the way the authors discussed how disability is conceptualized and medicalized which seemed, to me, consonant with how death is medicalized. I'm not suggesting this is a perfect analogy, at all, but thought I'd throw it out for the more anthropologically minded reader. See here:
  
• "By the late 19th century, the medical model of disability was firmly entrenched. "The medical model views disability as a problem of the person, directly caused by disease, trauma or other health condition. . . . Management of the disability is aimed at cure or the individual's adjustment and behaviour change. Medical care is viewed as the main issue." The medical model thus built upon 2 assumptions: first, that individuals should strive, largely through their own efforts guided by physicians, to overcome disabilities; and second, that physicians know what is best for patients. Both assumptions often made disability a lonely state—defined and frequently stigmatized by others, with individuals required to "cheerfully and unselfconsciously" make their own "good adjustment."
• Radio Lab, a public radio show which is usually about science, thought, and Big Ideas, recently put out a podcast about music written for a morgue of sorts (a viewing chamber at a hospital for the family to see the recently deceased). You can listen/download here.
  

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Well there is less then 24 hours left in the chance to do the survey. It closes at midnight Tuesday PM.

So far we have 82 responses but we want some more to make this a representative sample. We especially need more RSS reader input since only 8 of over 400 RSS readers have submitted surveys.
And since this is the last post before many readers take off for AAHPM, please don't forget about the Pallimed Party at Backjack's
just 0.3 mi south of the Conference Center. The bar is inside Jackson's Bistro. Here is a map:

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Here is a picture of Drew (Tue-Sat)








and Christian (Fri-Sat) so you can spot us at the AAHPM conference.







After the Annual Assembly, we may post a recap or two, and then back to our regular scheduled programming, including the survey results. Take it if you have not already! Less then 5 minutes, honest. And thanks for hanging in there for those of you who don't care about this conference.

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OK, I know I said that the last post was the last one about the conference, but this one is about conferences in general.

I compiled this list of helpful hints from my own experiences and from peers input over the past few years. I think it may be helpful to first timers but also to veterans of national/regional meetings like the American Academy of Hospice and Palliative Medicine (AAHPM) Annual Assembly. I have reorganized the list into with some prioritizing/categorizing and added more content on presenting. I have also made the language more neutral to apply to any conference, besides Palliative Medicine.

This was originally posted to the AAHPM Professionals-in-Training Special Interest Group email list.

Any comments are appreciated. Feel free to agree/disagree or add hints.

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* If you are bringing family or a significant other, make sure to spend some time with them.
* Bring business cards, lots of them. Make sure they have your email on them. If they do not write your email a number of the cards so when you hand them out, you are not trying to find a pen right then to add it.
* When you get a business card from someone else, immediately write down what you were talking to that person about. If the time isn't right, then do it soon afterwards. When you get home, you will have met so many people, you won't remember who that person was, as throw out their business card.
* If you get someone's business card, and you don't care if you ever interact with them again, make a special symbol that only you know on it, so you know to throw it out when you start going through all the business cards. Not everyone you meet is going to be a hub of a network you need.
* Bring your CV (multiple copies, and UPDATED), regardless of whether you are looking for a job. Many people may want to know more about you for networking reasons, not just job offers.
* Turn in your session evaluations in a timely manner.
* Find someone who is organizing the event and let them know they are doing a excellent job. They don't hear that enough, and are probably pretty exhausted from putting out everybody's "EMERGENCY!" They have put a lot of hard work and seldom get recognized.
* Also find the conference chairs and thank them. While likely celebrities in the field, they don't always get personal recognition for the months of work put into coordinating the activity.
* Reconnect with old friends.
* Try and get out and see the city you are in, since you never know when you will be back there or if it will be devastated by a major hurricane.
* Ask other attendees what talks they are planning on going to or avoiding. You may find something interesting to you that did not strike you at first. Kind of like a "If you like X, then try Y."


* Talk to people.
* Don't sit by yourself unless you are the first person in the room. Sit next to someone and then introduce yourself.
* Don't stay in your room too much, you'll miss too many opportunities
* Stay in your room sometimes. Take some time to unwind and be yourself.
* There is usually a bulletin board in a central place where people post messages: Look there for any messages regarding you or get-togethers you are interested in.
* When you go out with other people, you do not HAVE to talk about your field. (The people at the table next to you may appreciate that).
* You should make lunch/dinner plans with people outside the group you came with, but invite your group along too, if appropriate.


* Try to ask a question in at least one session that strongly interests you.
* When you ask a question, introduce who you are, and where you are from (quickly). This helps calm you down if you are nervous to ask your question. It also lets the audience know if they want to talk to YOU after the session if they have similar interests.
* Ask your question succinctly. Other people have questions too.
* When you come back to work, schedule an educational session with interested parties to share everything you learned there.
* Don't just depend on your notes during each session; chances are you will never look at them again. Write down key facts you have learned towards the end of the day.
* Go to the poster sessions and talk to the people who made the posters. A lot of hard work went into most of these, and everyone likes to hear when they have done a job well.
* Go to at least one paper session. The concurrent sessions are great but you can find out some interesting up and coming things in the paper sessions.
* Don't be afraid to introduce yourself to any of the 'celebrities' in the field. Most of the well-known people are very friendly and willing to talk, just make sure they are not in a rush for somewhere else. If you don't read the situation right, they will cut the interaction short, and you will think they are a big jerk. Remember, a lot of people would like to have their attention.
* After a session, if you talk with a speaker, make your point or ask your question, and then allow others to interact. Nothing is worse, than trying to make a quick point after a session, then the know-it-all who wants to take up all the time of the presenter without regards to other people's interest.
* If you don't like a session, leave. Make the most of your time there.

Presenting

* Start on time. Respect the people who got there to hear you speak.
* End on time. Respect the people who are still there at the end of your talk.
* Don't read your slides. Your slides should never be able to give your talk without you.
* Repeat every question you are asked, because the whole audience likely missed some/all of it.
* Thank people who asked the question. Even if it was a dumb/condescending/off-topic question. Your audience will admire your graciousness and know the questioner is an imbecile without you implying so.
* Don't take too long to answer the question. If you are covering it later, say so. If the answer will take a lot of time, give a short answer and ask those who are interested in the long answer to meet after the talk.
* If you are presenting and after the talk is over you encounter the know-it-all who wants all of your time (see above), make sure to set limits, and let others ask you questions.
* Bring your power cord.
* Email your talk. Have it on a jump drive. And on your hard drive. Never too cautious.
* Don't change your slides from the handout whenever possible.
* If the slides presented are different from the slides in the handout, mark the title of the slide with an asterisk to remind you to inform your audience.
* Turn off all unneeded programs. IM, Website alerts, Weather alerts, CITRIX prompts, etc.
* Give credit to others who helped prepare your talk, especially if they are there.
* Put your contact information on the last slide if you would like people to contact you about your topic.
* If you are a presenter at this meeting or anywhere, take note of how other presenters are effective or ineffective. Think of how you may incorporate/avoid their style in any of your future talks.

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Since there is so much going on at the American Academy of Hospice & Palliative Medicine and the Hospice and Palliative Nurses Association Annual Assembly I will just cover some of the highlights of each day. This is the last one covering the conference sessions. You can find the previous ones at the links below...or get the whole series in one document for easy printing.

Previous posts for 2008 Annual Assembly:
AAHPM Pre-Conferences Wed Jan 30th
HPNA Pre-Conferences Wed Jan 30th
AAHPM/HPNA Annual Assembly Thu Jan 31st
AAHPM/HPNA Annual Assembly Fri Feb 1st

7:30-8:15am

AAHPM and HPNA SIG Meetings
Never been to a Special Interest Group (SIG) meeting? You should find one that interests you and get there to #1) Network with like minded individuals, and #2) Make some change for our profession and support the AAHPM and HPNA. The SIG's are split up over this AM and Thursday PM. You can see the barely active Professionals-in-Training Special Interest Group at http://pitsig.blogspot.com

8:30-9:30am

While many sessions this AM may cover topics that interest you, I highly recommend the Case Conference's during this session, 9:45-10:45a, and 11am-Noon (last one not listed in mailed program). Each case conference session has 3 cases presented by students, residents, fellows of various disciplines with plenty of time for Q&A afterwards. This is the 4th year of the Case Conferences and if you have not been to one yet, make time to go. Here is a list of the cases to be presented at the PIT-SIG Blog. I am grateful to the AAHPM/HPNA for expanding this session to three sessions this year. It is a real pleasure for me to work with the submissions and see how much the response to this opportunity for Professionals-in-Training to present at a national conference.

Another great topic is Hypodermoclysis by Gomez (Woodlands), Robb and Voiles (MD Anderson) and working with patients who cannot speak and another session on substance abuse. For those interested in hypodermoclysis (subcutaneous administration of fluids), I highly recommend the free article from American Family Physician which includes practical tips.

9:45-10:45am

Besides the second of the Case Conferences, I am most intrigued by the talk by Baker and Berger (NIH) titled Being There: Extrapolating the Meaning of Support. "Being present" along with "dignity therapy" are two areas that palliativists practice all of the time, but rarely have a structured framework for understanding or giving credit for all that they do. To highlight this topic there is a recent blog post by an Emergency Physician who acted well by "being there" for a dying patient in his ED.

Although the proportion of HIV patients in hospice has dropped in the last decade, understanding the place for HAART in Hospice by Norris (Lifepath) would be good for the practitioner who works closely with this population. Also there is another "State of the Science" lecture this time on Supportive Care for Pulmonary Disease by Rocker (Dalhousie University). I am guessing these are labeled State of The Science since they are invited lectures? Is there some sort of trademark on "State of the Science?" If not I need to cash in on that.

11am-Noon

Last of the Case Conferences this session. Along with the previous talk on Medical Errors, the theme of Palliative Care Consults Gone Wrong is great to see at a conference. Our field cannot improve if we are not quick to point out our failings, or missteps. I wonder how many palliative care teams or hospices have some version of M&M conferences? Small I would imagine. Many thanks to Galanos and Gentry (Duke) for presenting this. For those who have not worked with Dr. Galanos, he is a very good palliative care clinician, I am sorry I will be missing his talk since I will be at the Case Conferences. Ritchie (UAB), Kvale (UAB), and Bruera (MD Anderson) cover Cachexia, probably presenting some info gathered from the recent Cachexia conference. A group of Florida Hospices present how to approach hospice patients about much needed research. Filling out the rest of the session are Depression, Radiation Oncology, Nausea/Vomiting and Geriatric Palliative Care

1:45-2:45p

Debility Unspecified and Failure to Thrive as Appropriate Hospice Diagnoses are presented by Rozynes and Beroldi (Vitas) which would be of great interest to those working with many LTC facilities. I wonder if they might have any inside scoop as to CMS possibly planning to change reimbursement mechanisms for LTC patients? Eric Prommer (Mayo) presents on Spinal Cord Compression. If anyone wants any hints about how to get accepted to AAHPM for a talk, talk to Dr. Prommer. He is presenting three topics this year, and I recall him presenting at least 2-3 sessions for each of the last few years. Tell him Pallimed sent you. And further encouraging the role of research at hospices, Melissa Carlson (Mount Sinai) helps us in Designing and Analyzing Observational Studies.

3-4:15p

Always a great lecture to end with, as has been tradition for the last few years at least. Entertaining and informative these two do a classy job in giving us the key research articles that can help us provide quality care and inform our non-palliative peers on how our field can help. I hypothesize that their talk is going to be very similar to the Annals of Internal Medicine Update in Palliative Medicine article (free after July 2008). Here is a link to the table that summarizes the highlights. AAHPM usually publishes their slides on the front page after the conference as well for those who miss the talk.

Phew. Done. No more posts about the conference.

Please take the survey as there are only a few more days left.

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Since there is so much going on at the American Academy of Hospice & Palliative Medicine and the Hospice and Palliative Nurses Association Annual Assembly I will just cover some of the highlights of each day.

Previous posts for 2008 Annual Assembly:
AAHPM Pre-Conferences Wed Jan 30th
HPNA Pre-Conferences Wed Jan 30th
AAHPM/HPNA Annual Assembly Thu Jan 31st

8-9:45a

The speaker is from the Palmetto GBA and will be speaking on a new approach to verifying appropriateness for hospice. What is Palmetto GBA you ask? It is a Regional Hospice and Home Care Intermediary that helps verify Medicare claims for hospices mostly in the Southeast, although I am not sure of their entire coverage area. Apparently they have developed a new system with the WHO's International Classification of Functioning Disability and Health. While this talk is likely to be oriented to policy makers and organizational/administrative levels, it is probably good for many clinicians to begin to understand new ways we may have to justify appropriateness for hospice Medicare benefits. I would be really interested if anyone who attends this would be willing to write up a review for Pallimed after the conference.

10:15-11:15a

There are a lot of FAAHPM speakers in this next session, with the three novel topics presented. Intravenous Methadone by Dr. Bridges (Alive Hospice) should give some comfort and caution to hospice clinicians working with this effective medication for pain relief in the IV(subcutaneous is also available) form. I am very glad for my palliative medicine fellowship with Dick Stephenson and Hospice and Palliative CareCenter in Winston-Salem, NC for allowing me to become familiar with prescribing it in the hospice population. Palliative Care for Patients with Developmental Disabilities by Ellison & Shabanowitz (Geisenger) is a great topic for an underserved population with unique challenges. The difficulty is probably in taking such a broad range of disabilities and applying general principles, but they should have some good insight. Filling out the session is Ira Byock (Dartmouth) covering responding to Requests for Hastened Death, as well as some more administrative issues, specifically Long Term Care, Research, and Legislation.

12:45-2p

Wyeth sponsors the luncheon covering Opioid Bowel Dysfunction (hint: methylnaltrexone). I usually like the lunch time to meet with colleagues and network, and you usually have to preregister for this anyway.

2:15-3:15p

The Program Planning Cmte (Christine Ritchie and MaryJo Prince-Paul) did a good job of splitting up the areas covered with each section. Evidence Based Ventilator Withdrawal with Campbell (Wayne State), Full-Time Palliative Care in a Rural Area with Pile (Hospice of Southwest Virginia) and Smusz (Carilion New River Valley), Physician Order for Life-Sustaining Treatment (POLST) implementation with Briggs (Gundersen Lutheran), and PTSD in Veterans at End of Life with Cutson and Sease (Duke). All great topics. (Do you think the AAHPM should have a POLST full-day pre-con next year? Might be good synergy?)

The one session I would highlight here is What's New in Analgesic Pharmacotherapy because 1) it is presented by pharmacists, which is nice because pharmacy is more involved with palliative training, and 2) it is presented by a University of Maryland School of Pharmacy faculty member, Dr. McPherson. I have to commend the University of Maryland School of Pharmacy for being so active at the AAHPM these last several years I have been. They always have several posters and one or two presenters. More palliative pharmacists please.

3:30-4:30p

There is a lot of talks in this time slot not including the two paper sessions. And you have a lot of competing well-known speakers: Quill, Crossno, Casarett, Cleary, Arnold, Tulsky. Where to go? The most interesting topic but likely the one with the smallest proximal clinical impact is the session on the Patients' Rights and Public Policy in the Wake of the Abigail Alliance. For some reason this did not seem to hit the news cycle very long, but this is an important issue for the medical field. The Assembly is also experimenting with some limited registration workshops during this time which include Pain Management and Breaking Bad News, highly suggested for the new palliative care clinician without access to a lot of formal training resources.

4:45-5:45p

Following the other workshops is a Symptom Management Skill Building session with Twaddle (Midwest PHCC). Two great topics during this time are Sarah Freibert (Akron Children's) instructing us how to Create a Palette of Care: Implementing a Full Service Pediatric Palliative Care Program. Hopefully we will have enough pediatric palliative care programs in the next few years to sustain more training programs in this needed area. Cuyegkeng and Scott (Kaiser Permanente) review a possibly overlooked area for hospice and palliative care: Medical Error and Patient Safety. A recent Fast Facts just came out about medical errors and I think there are a number of reasons this issue has not come up in hospice much before so this should provide a good framework. And congratulations to Irene Higginson from King's College London on her AAHPM Award for Excellence in Scientific Research.

And don't forget the 6-7pm Service of Remembrance and Celebration. No other meeting has something like this so if you have not participated before I highly encourage it.

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