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(We hope you enjoyed our April Fool's jokes this year. Look for more of our past April Fool's posts here. - Ed.)

April 1, 2012

by Abe R Feaulx, Pallimed Special Reporter

On a cross-country plane flight, Dr. Arya Kidenmee finally admitted to her seatmate, an unabashedly handsome young shower curtain salesman, what the public has known all this time. "I finally had to tell him that hospice work is very sad. I'm not sure why people in hospice and palliative care always say it is rewarding.  We have meetings every week where we just sit and cry the entire time, it is absolutely emotionally paralyzing to try and help people with advanced illness."

When reached for comment, seatmate Brock Montgomery noted, "I knew it.  I run into people in health care all the time and people who work for hospice always appear so friendly and outgoing, but I knew there could not be anything rewarding in helping people who were in great pain feel better.  I'm glad she finally told the truth."

Dr. Kidenmee noted that she has struggled for years in talking at dinner parties and other social gatherings when asked about what she does for a living.  "If only I could take people with me and show them how utterly sad my everyday job is, then maybe they would understand that research that shows resilience and a strong purpose to work in palliative care was all a bunch of baloney. Yes I said it, baloney."

Update: It was later discovered after this story was published that Dr. Arya Kidenmee is not really a physician and clearly from her comments has no experience in hospice.  She was just trying to get Brock to feel bad for her and ask for her number.

Happy April Fools Day 2012 from Pallimed

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We welcome comments about any aspects of the questions or the answers/discussions.  The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.

Walking into a room at your hospice inpatient unit you see a tired appearing female patient lying in bed with soft moaning, holding her abdomen. She has end stage CHF and no history of cancer. Review of your notes show decreasing oral intake and increased time in bed. Her nurse reports she disimpacted her yesterday after suppositories and enemas were ineffective for worsening constipation.

Medications include: Fentanyl 50mcg patch (on for several weeks), Senna 2 tabs BID, Colace daily, Recent enema, and docusate suppository
Exam: Cachectic female, Scaphoid abdomen, hypoactive bowel sounds, formed (but not hard) stool on rectal exam.

What is the next best step?
a) Write an order for methylnaltrexone 8mg subcutaneously x1 now.
b) Switch her from a fentanyl patch to a morphine pump so you can better manage her abdominal pain.
c) Write an order for octreotide 200mcg subcutaneously twice daily for three days.
d) Place an NG and give her polyethylene glycol daily until she has a bowel movement or regains ability to swallow and you can remove the NG tube

Discussion:Show/hide Discussion

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For those who attended our blogs to boards session - here is the link to the PDF's posted on Slideshare (Questions + Answers; Questions Only)






If you didn't get the chance to attend, don't fret.  We plan to post a question a week on both GeriPal and Pallimed to get everyone ready of the 2012 palliative care boards.

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World Cancer Day is February 4th, and in honor of this day, I'm posting about a critical issue we have written about on Pallimed before... access to medications. There are three developments in the last few days I think are worth knowing about...

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I have a 1 in 542 chance of dying in the next year. In other words, for every 542 men who are the same age as me, one will die in 2012. For those of us who survive until 2017, the probability of death during that year will be 1 in 364. This probability will increase fairly predictably over the years. Gompertz Law of human mortality suggests that the rate doubles every eight years. Supposedly, this law stands the test of time and across populations.

Source: Meandering Through Mathematics

And if you live long enough, you'll likely develop a chronic disease. People are remarkably resilient and can adjust, so don't worry about this too much. With illness, you'll likely develop a greater awareness of your own mortality. Hopefully, you've prepared. If not, it's never too late.

But you'll go to your doctor with the expectation that he'll help improve your quality of life in the face of the chronic disease and also that he'll know what to do to help you avoid death. You've seen the ads on TV for such and such a pill which will improve your vigor. You'll look ten years younger than the average person with your condition, be able to win the stuffed animal for your grandkid, and the lights will go off in your bedroom a full 30-45 minutes before you plan on going to sleep. You imagine it to be so perfect that if a life-threatening condition arises and your doctor doesn't have a pill to fix the problem, you'll think, "This is the year 20XX, why don't they have a pill for this?"

This is the generic frame for the typical clinic visit for patients in the early 21st century. You know that doctors can't fix everything. Your doctor knows she can't fix everything. Both facts frequently go unspoken between the four walls of the clinic room as both sides labor to prevent a "premature" death. It's a noble and worthy goal but Gompertz Law remains. It occasionally crosses your mind: What would it be like to get sick, what type of interventions will you have to go through, what will happen if you become ill and don't have enough support to remain at home? It's crossed your doctor's mind, too. She's seen others go through it, but it's easier to talk about A1C's, LDL's, and holiday plans so concerns go unspoken. Advance care planning in the office remains challenging for multiple reasons, but the frame of the visit does not easily permit acknowledgement of death or other difficult outcomes.

It's always appropriate to prepare for multiple scenarios. Explicit discussion of prognosis, while not an absolute prerequisite, can serve as an entree to discuss the possible scenarios. The healthy young man looks at his probability of death and buys life insurance but prepares at the same time for life as a 50, 60, and 70 year old. In old age, it's still appropriate to prepare for multiple scenarios. If you are an 80 year old with a Mazzaglia Index score is 3, then you have an 8% chance of dying in the next 15 months and a 30% risk of being hospitalized, it makes sense to do some preparation for those events. However, you also have a 92% chance of NOT dying in the next 15 months. What then? What will it take for you to age in place? What happens if frailty or other circumstances make this impossible? Prepare for the most likely and worst case scenarios. It should be your expectation that your healthcare team can help you prepare.

In the JAMA article, the authors suggest using the indices to guide discussions about preventative care (such as whether to pursue a screening colonoscopy in a woman with advanced COPD and comorbidities). This use of the indices makes sense. Colonoscopy, while generally safe, is not without risk of complications, especially in older adults with comorbidities. It's appropriate for physicians to use the indices along with their clinical judgment to guide their recommendations. This has brought about accusations of bedside rationing, which is really a separate discussion. Medicare covers screening colonoscopy once every ten years. I wouldn't anticipate physicians refusing to order a colonoscopy for a non-terminally ill elderly patient based on a prognostic score.

It remains to be seen whether ePrognosis will increase awareness of prognosis in non-terminal, older adults or whether this will impact clinical decisions. I think it will. Time will tell.

(See also this recent NEJM perspective piece and related Geripal commentary.)

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Image credit: Wikipedia

Christopher Hitchens, noted author and philosopher died December 15, 2011 leaving behind many essays, books, and other writings as well as contributing to several lectures, ethics/religion debates, and TV talk shows.  His acerbic style often ruffled feathers as he attacked religious dogmatism.

As one of the most famous outspoken atheists of this era, his thoughts on being diagnosed with an incurable disease would be a powerful insight into how atheists might approach illness and death.  Where others might retreat from the public spotlight, Hitchens attacked his cancer through writing.

As a doctor caring for patients facing their own mortality, understanding their spirituality becomes an important part of caring for the whole person.  I have seen many caring family members and friends inquire to me if their was enough time to get the appropriate clergy to help a patient convert or be saved.  A person dying as an agnostic/atheist or even not the right religion becomes a very important focus for some people.  Some have asked me or chaplains if we have ever seen any 'deathbed conversions' or someone who died without being saved.  I never really expected this before I became a palliative medicine fellow.

What surprises me about the inside peek that Hitchens gives us with his writings is that many of his feelings, thoughts and experiences are really about the human condition and I have seen and heard similar things from religious patients as well.  In reading his articles it helps me understand that despite all our differences we are all human and as we die our experience is both unique and universal.

I wanted to share a few choice quotes from his articles here.  Any one of them would be a good review for your team or learners on discussing the different approaches to dying that our patients experience.

The quotes come from the following Vanity Fair articles:
Unanswerable Prayers - Oct 2010
Miss Manners and the Big C - Dec 2010
Unspoken Truths - June 2011
Trial of the Will - January 2012 (published posthumously)

On stories about any possible deathbed conversions:

In which case, why not cancer of the brain? As a terrified, half-aware imbecile, I might even scream for a priest at the close of business, though I hereby state while I am still lucid that the entity thus humiliating itself would not in fact be “me.” (Bear this in mind, in case of any later rumors or fabrications.) 

On holding hope and realism:

The absorbing fact about being mortally sick is that you spend a good deal of time preparing yourself to die with some modicum of stoicism (and provision for loved ones), while being simultaneously and highly interested in the business of survival. 

On losing his voice:

Now, if I want to enter a conversation, I have to attract attention in some other way, and live with the awful fact that people are then listening “sympathetically.” At least they don’t have to pay attention for long: I can’t keep it up and anyway can’t stand to.

On sharing stories about other people's cancer:

...your narrative may fail to grip if you haven’t taken any care to find out how well or badly your audience member is faring (or feeling).

On a false cliche (What doesn't kill you makes you stronger.):

After all, if it were otherwise, then each attack, each stroke, each vile hiccup, each slime assault, would collectively build one up and strengthen resistance. And this is plainly absurd. So we are left with something quite unusual in the annals of unsentimental approaches to extinction: not the wish to die with dignity but the desire to have died. 

On pain:

It’s probably a merciful thing that pain is impossible to describe from memory. It’s also impossible to warn against. If my proton doctors had tried to tell me up front, they might perhaps have spoken of “grave discomfort” or perhaps of a burning sensation. I only know that nothing at all could have readied or steadied me for this thing that seemed to scorn painkillers and to attack me in my core.

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There was a time when I heard about chemo shortages, and I thought that must really force some tough choices for patients and physicians.  But thankfully (I thought) drug shortages for generic non cutting edge medications that have been around for a long time like the ones commonly used for symptom control would probably be relatively immune.

• Bedford discontinued lorazepam in May, 2011 to concentrate on the manufacturing of other products.
• West-Ward acquired Baxter’s lorazepam injection products in May, 2011. The company cannot provide a reason for the shortage.
• Hospira states lorazepam vials are on shortage due to increased demand. The 1 mL iSecure syringes were discontinued in September 2011.