by john cowper

• What percentage of the ED visits were preventable? What systems could be introduced to prevent the visits? (Urgent clinic availability, telemedicine, enhanced home health, etc)
• Would these system changes result in a more timely manner and would that result in reduced need for hospital admissions?
• As a palliative care clinician, it's not a surprise to see lung cancer disproportionately represented. One of the results of the Temel et al study regarding palliative care involvement from the time of metastatic NSCLC diagnosis was reduced hospital admissions/ED visits. It's not clear what the "mechanism of action" is, but improved access to a team that can help with the top symptoms certainly is one plausible hypothesis.
• What is the "right number" of appropriate ED visits/hospital admissions? Hard to say, but palliative care as a field should actively work to help our oncology colleagues to push the numbers as low as possible. As much as I like my ED colleagues, the ED is not a fun place to be.

NEJM published a perspective piece where the author briefly describes recent evolution of certain terms within medicine which may resonate with you.

"Patients are no longer patients, but rather “customers” or “consumers.” Doctors and nurses have been transmuted into “providers.” These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries."

"The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain."

NEJM presents a case of a man found to have a primary lung cancer and a solitary brain metastasis.  The discussion regarding management of the patient is noteworthy, especially the possible role of surgery and a brief discussion regarding the use of tyrosine kinase inhibitors.

The palliative care consultant should be aware of the available case series which suggest that a minority of patients might have a longer survival than what is usually expected in patients with brain mets.  (See Table 1 in the article.)  In the case series, patients received aggressive surgical intervention for the brain met and aggressive attempt at locoregional control of the primary cancer.

The article provides some guidance for selection of appropriate patients for aggressive disease-based management.  No particular quality of life outcomes are mentioned related to aggressive surgical management.

The bottom line dilemma: This is a scenario where multidisciplinary/multimodality management may give a small number of patients a chance at longer term survival.  The approach may be worthwhile to some, but talking about prognosis on multiple levels (survival, anticipated quality of life/burden of procedures) is essential.  I cannot remember encountering this scenario recently, but a palliative care consult would be appropriate in any patient with Stage IV lung cancer.  It's possible that the complexities of therapy and communication surrounding prognosis may only increase the usefulness of palliative care in this scenario.

The NPR show Tell Me More has a week long series on issues surrounding aging and end of life.

Today, the show highlighted the documentary Serving Life about care provided to inmates at Angola Penitentiary in Louisiana.  The documentary aired this summer on the Oprah Winfrey Network. 

Also, see this recent perspective piece from Annals of Internal Medicine which addresses the issue of compassionate release of prisoners near the end of life.

Pallimed has featured stories on palliative care in prisons previously (see search results for "prison" here).

by Lyle Fettig

The Journal of Clinical Oncology published a Swedish study which examines correlation between patients being informed of imminent death status and other palliative care quality outcome measures. In the study, 91% of patients were informed of their imminent death status.  How was this measured?  Sweden has a national palliative care registry which is described in the study text (click the little Union Jack at the top right of the page to view the front page in English) :

This online register was completed by the physician and/or nurse responsible for the patient's care during the last week of life, although HCPs were not aware of the research question of this study. The design of the SRPC Web questionnaire does not allow any missing data at submission. The Web questionnaire is based on the 11 principles constituting good death as defined by the British Geriatrics Society and was designed to be used in any care setting, independent of diagnosis, with the intent to look retrospectively at important aspects of care delivered during the last week of life. The 25 items on the SRPC include 14 questions that cover background data of patient and reporting unit and three questions that cover items not considered relevant to the aim of this study (ie, use of visual analog or numeric rating scales during last week of life, frequency of pressure ulcers, and staff reflection). The remaining eight questions covering, for example, degree of autonomy, information about imminent death, symptom control, parenteral as needed (ie, pro re nata or PRN) prescriptions, and preferred location at time of death, were included in the analysis in this study.

• Getting Timely Care, Appointments, and Information
• How Well Your Doctors Communicate
• Patients' Rating of Doctor
• Access to Specialists
• Health Promotion and Education
• Shared Decision Making
• Health Status/Functional Status
• Risk-Standardized, All Condition Readmission
• Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease
• Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure

by Holly Yang

On September 1st 2011, the Joint Commission started certifying hospital-based Palliative Care Programs!  It is open to all Joint Commission accredited hospitals including long-term acute care care and children's hospitals. The standards for certification were based on the National Consensus Project's Clinical Practice Guidelines for Palliative Care and A National Framework and Preferred Practices for Palliative and Hospice Care Quality from the National Quality Forum. For previous comments on the importance of this see Christian's post from spring when it was announced.

 It is "designed to recognize hospital inpatient programs that demonstrate exceptional patient and family-centered care in order to optimize the quality of life for patients with serious illness. Palliative care involves addressing physical, emotional, social and spiritual needs and facilitating patient autonomy, access to information and choice."

The full text is here, but some of the highlights of the requirements are (I'm paraphrasing, so please see the complete text for all the little words that make a big difference):

• 24/7 coverage - by phone on nights and weekends, with availability of someone to come in to see the patient if necessary, and "must be able to provide the same level of palliative care services during nights/weekends as during normal weekday hours."
• See patients - At least 10 in the past and at least one during the on-site review
• Use evidenced-based approach to guide care (and/or practice guidelines to deliver care using a standardized method)
• Have the ability to direct clinical management and coordinate care
• Have an IDT (interdisciplinary team) and follow an organized approach to deliver care
• QI  - Improve performance by collecting performance measurement data over time (at least 4 months' worth). No specific tools, but should be "evidenced-based, relevant, valid and reliable"

Eric Widera over at GeriPal posted in April about changes in the National Resident Matching Program (NRMP) timeline for medical subspecialty fellowships, and the implications for Hospice and Palliative Medicine (HPM) and Geriatrics.

I'd like to talk about our Match-less HPM fellowship application process, from one applicant's perspective.

Photography by Ken Goldberg. From “Tele-Twister” CC 2004. Some rights reserved.

Perhaps one might say, "I should be so lucky." My reaction is actually more like panic. The opportunity costs is high assuredly, but determining which I should choose and which I should forego is excruciatingly difficult. I still have 10 applications out (OK maybe too many applications. But, who knows at the outset how one is going to fare?). All of those programs are very interesting to me, for location, institution and program faculty, etc.

So, I ask for and get extensions of the offers. I interview at the program close to my wife's family. When I meet with the program director, I'm told their decision about my cohort of applicants will likely be made after my other offer extensions are up. I also get what is probably a generic invitation to contact the program if I needed an early decision to clarify matters. So, back to the offering programs to update them and ask for more time, which they graciously grant. I then ask for, but did not get, an early decision, which means I was still in the running. So, I am being pulled now in at least three ways, with irons still in the fire.

Interviewing is expensive, especially on a resident's salary, and doing this all during residency, with long hours while taking care of patients and collateral responsibilities, and having to use vacation time is all very stressful. As this is all going on interview offers continue to trickle in. I begin to turn down interview offers, even canceling interviews I already have scheduled, thinking I am likely to take one of these positions. At the same time, I am anxious about eliminating interviews out here in the Wild, Wild West because something could go wrong and my birds in the bush could fly the coop, and the whole thing could come down like a house of cards leaving me in the cold, and empty-handed.

The last few days start ticking down. Out of the blue, I get a contingent offer from a program that is very strong clinically and highly academic, in a culturally vibrant town, not too terribly far away from my family. They are working on getting approval for another Accreditation Council for Graduate Medical Education (ACGME) slot, versus perhaps another candidate may turn down an offer they have already made. At this point I make criteria for being "drawn and quartered," now being pulled in four different directions. The opportunity costs mount!

Illustrated by Jillian Gilliland © 2009. From “Tell Me A Story” © 2009 Universal Uclick. All rights reserved.

The way it felt, both as it was happening and in retrospect, was something like an uncertain, perilous and epic quest. It reminded me of my favorite epic, The Odyssey. Odysseus was struggling to get home after many long years away, but one problem after another cropped up to thwart him: the whim and malice of gods and goddesses, the threats of monsters, the thrall of enchantments, the lure of comfortable captivities, the sirens' call, tempestuous storms and even more monsters. It is at this point that imagery from the Odyssey wells up: Odysseus caught between the gorging and belching vortex of Charybdis on the one hand and the rapacious heads and voracious mouths of Scylla on the other, with no way out but through.


By luck and craftiness Odysseus barely averts disaster again and again, and by holding to the course, he finally achieves his quest and arrives home, travel-weary, older, perhaps wiser… but also with an unnecessary case of PTSD. To reason that since the hero survives and achieves the quest, the arduous and circuitous course he was made to take is justified is, in my opinion, a rationalization.


In the end, I secured a position and I am very happy with my outcome. I am however very unhappy with the process. Thank goodness for the Electronic Resident Application System (ERAS) where one's application, CV, personal statement, letters of recommendation, are uploaded into the electronic ERAS cloud once, and then are electronically submitted to one's desired programs (except for the programs that don't participate in ERAS and require old-fashioned paper applications, thus duplicating work for interested applicants and their recommenders). Having ERAS in place prevented the process from being even more labor-intensive and chaotic.

The diversity among programs in their respective timelines for application review, interviewing, and how and when to do what about making offers is frankly stunning. My process was cut short by a spoils-to-the-swift ethic. Because of the asynchronous timelines, I had to decline interview offers from programs I was very interested in. Given the inherent power disparity in the roles and the dynamics involved, I did not believe I had the latitude to walk away from offers from great programs in order to "explore my options" further. Perhaps my issue, but I doubt mine alone.

If there wasn't already an existing, simple, validated, large-scale, low-cost system to regulate and standardize behavior and decision-making among applicants and programs then one would be pragmatically stuck with the status quo. Luckily for us the kinks and bugs have already been worked out and a process is readily available for us to plug into. I'm speaking of course of the NRMP, or more simply "the Match."

Having been through an NRMP Match, and now this Matchless Meet Market, I find the latter is wholly unsavory and unsatisfactory. Rather than feeling like I've come through a fair process conducted on an even playing field to arrive at an optimized placement to advance my learning and professional development and to staff the houses of programs with the best they can attract, instead I feel like I just bought a house in today's market; I've closed the best deal I could, but I really would not want to do that over again.

Furthermore, I believe I was extremely lucky; my timelines were generous and fluid. I just think about those souls out there who are waiting for an interview in their preferred program, near their family, but get an acceptance from another program with a one week deadline to accept the offer (not an uncommon demand). Yes, I feel lucky for how it turned out in the end, but I also feel like I've been through the wringer unnecessarily, and I resent that.

My conclusion is that for the sake of learners (and I actually believe in the interests of most programs) HPM needs to align with the leaders in GME and participate in The Match on the same timeline as the other medical specialties. Incidentally, moving the process into applicants' final year of specialty training would bring it in line with the fellowship application process in other specialties, at least with Physical Medicine & Rehabilitation and Emergency Medicine.

If you have a war story, please feel free to add it. I would suggest de-identifying the data for the sake of human subjects protection, if you get my drift.

[Ed. Note: In the vast palliative care social media echo chamber, Eric Widera over at the GeriPal has provided the 2 to a 1-2 post combination on the problems of applicant/learners in the current state-of-the-fellowships. Please be sure to pop on over and check it out. - McMichael

And after you read that, you can see Christian Sinclair's alternate take on the Geripal post. - Sinclair]

If you are a med ed geek like me, you L-O-V-E the Interactive Educational Exchange which has been a fun and exciting part of the Americal Academy of Hospice and Palliative Medicine (AAHPM) Annual Assembly for the past two years. It's not your ordinary concurrent session. No! Instead, you listen to a quick overview of the different presentations and then you zip around to learn more about the ones that you find most intriguing. I have always come away with at least one interesting idea to try or tweek to fit my teaching style and audience. So... if you're students are yawning, you can A) buy them coffee or B) go to the Interactive Educational Exchange on March 9th, 2012 from 3:30 to 5:00 pm. 


If you've got an exciting way to teach palliative medicine to any discipline, please do share!  Submit it for the 2012 Interactive Educational Exchange at the AAHPM Annual Assembly in Denver! Hurry! Submissions are due by 5 pm PST August 2, 2011! Heck! They make it easy by even giving you previous year's submission examples.

Photo by Elizabeth Thomsen via Flickr