Monday, April 9, 2012
This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
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.You visit a patient at home receiving hospice care for cancer. Her pain has been well controlled with long acting morphine 60mg BID and occasional PRN doses of short acting liquid morphine (10mg) over the past few weeks: she had been tolerating this well. She has had recent progressive functional decline and is currently at a PPS of 20%. In the last 24 hours the patient has vomited and has been more lethargic and having difficulty swallowing pills. She appears uncomfortable. In your examination you see a very thin patient who appears to be dying with a prognosis in the few days to a week range.
The patient’s son is a respiratory therapist at a hospital and is insisting you change the patient’s opioid to a fentanyl patch because “it is less sedating than morphine.”
The best response is:
a) Because the patient is cachectic, you tell the family that fentanyl transdermal patches are not indicated because the medication will not be absorbed.
b) Agree with the son and convert the patient to a 37.5mcg/hr fentanyl patch with oral morphine liquid 10mg q1 hour PRN
c) Because the fentanyl will not be effective for over 24 hours, continue the long acting morphine sulfate 60mg BID but give it rectally instead of by mouth
d) Suggest starting a morphine infusion via her port at 1.7mg/hr basal with a 3mg q30min bolus PRN after talking with the son about his concerns about sedation.
Discussion:
Monday, April 9, 2012
Monday, April 2, 2012
This is the fourth in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
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.Mrs Dole, a 68 year old with 20 year history of Diabetes Mellitus Type II is referred to Palliative Care from Oncology with Stage III Nasopharyngeal carcinoma. Nausea is the key concern. For last 3 years she has had early satiety but maintained weight. Since initiating chemotherapy, she has had nausea for the first 2 days of her chemotherapy cycle, which then resolves.
1 week after the last round of chemotherapy she required intravenous fluids for dehydration. Now 2 weeks later is having intermittent severe nausea. It can be provoked by sudden changes in body position. She fell once because she lost her balance. Usually she does not vomit, but occasionally does. She describes a feeling of the room spinning associated with the nausea.
Of the following options, which drug is most targeted to this patient’s specific nausea type:
a) Ondansetron
b) Prochlorperazine
c) Metoclopramide
d) Diazepam
e) Meclizine
Discussion:
Monday, April 2, 2012
Sunday, April 1, 2012
(We hope you enjoyed our April Fool's jokes this year. Look for more of our past April Fool's posts here. - Ed.)
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| Leaders of the APRIL-FUL showing good bedside manner |
Chicago, April 1, 2012.
by Abe R Feaulx, Pallimed Special Reporter
In a joint news conference, representatives of the Accreditation Council for Graduate Medical Comedy (ACGMC) and the Alaskan Veterinary Medical Association Accreditation Council on Comedy (AVMA COC) outlined new requirements for accreditation of fellowships in Hospice, Palliative Care and Pupplies (HPCP). As many of you will recall last April 2011, the Association of Palliative Realists Interested in Looking For Unified Language (APRIL-FUL) declared the new name for the field "Hospice, Palliative Care and Puppies."
Explaining the historic cooperation between ACGMC and AVMA COC, ACGMC board chairman Dr. Moe Howard said "the recent change in the specialty's name presented an opportunity for strategic cooperation between our two organizations that we couldn't pass by. Working together, we can fulfill our mission to assure the public that graduates of HPMP training programs are fully competent to carry out all the duties of an HPCP specialist, including finding the right type of puppy to meet a patient and families needs."
Explaining the historic cooperation between ACGMC and AVMA COC, ACGMC board chairman Dr. Moe Howard said "the recent change in the specialty's name presented an opportunity for strategic cooperation between our two organizations that we couldn't pass by. Working together, we can fulfill our mission to assure the public that graduates of HPMP training programs are fully competent to carry out all the duties of an HPCP specialist, including finding the right type of puppy to meet a patient and families needs."
The new requirements include:
- one month rotation at a veterinary hospital accredited by AVMA COC
- six month continuity clinic at a PetSmart or other similar community-based pet training center
- inclusion of a pet therapist (the pet, not the person) at all IDT team meetings that the trainee attends
- a scholarly project documenting impact of puppies on palliative care patients or staff or volunteers
In a coordinated announcement, the National Alliance of Hospice, Palliative Care and Puppies,(NAHPCP) pledged to quickly adapt the competency statements, measurable outcomes, and competency toolkit to these new requirements. "We'll be integrating evidence-based competencies that are applicable to the new training requirements into the competency toolkit. For instance, it will be very important for graduating fellows to be able to train the pet therapists on hospice IDT's in prognostication skills, such as those exemplified by Oscar the Cat," said Dr. Sitt Phydo, chair of the AAHPCP task force to promote evidence based palliative pets. (PEPP)
When asked for comment, the National Association for Cats in Hospice issued a statement declaring, "We would rather work on our own and not be dependent on any other organizations like some sniveling canine."
Happy April Fools Day 2012 from Pallimed
When asked for comment, the National Association for Cats in Hospice issued a statement declaring, "We would rather work on our own and not be dependent on any other organizations like some sniveling canine."
Happy April Fools Day 2012 from Pallimed
Sunday, April 1, 2012
To the cheers of supporters, aides to Generalissimo Francisco Franco announced that the Generalissimo has received a left ventricular assist device, also known by the abbreviation, LVAD. The procedure was performed at an undisclosed location. At this time, it is uncertain how this development will ultimately affect the Generalissimo's fate. Aides declined to comment on whether the Generalissimo would be placed on a heart transplant list.
At this time Generalissimo Francisco Franco is not dead.
Stay tuned for further updates.
(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
Monday, March 26, 2012
This is the first in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).
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:
Monday, March 26, 2012
Thursday, March 8, 2012
Pallimed/GeriPal Blogs to Boards - Hospice/Palliative Medicine Board Review 2012 (Q and A + Discussion) from Christian Sinclair, MD
Pallimed/GeriPal Blogs to Boards - Hospice/Palliative Medicine Board Review 2012 (Questions only) from Christian Sinclair, MD
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.
Thursday, March 8, 2012
Wednesday, March 7, 2012
As seen on GeriPal...It is on - the 3rd annual Pallimed/GeriPal Meet-and-Greet during the AAHPM / HPNA Annual Assembly!
Tarantula Billiards Bar and Grill is one block away from the convention center. The address is 1520 Stout St. Denver, CO.
The party is open to all, so drop on by.
Wednesday, March 7, 2012
Wednesday, February 8, 2012
This week the American Society of Clinical Oncology (ASCO) published a new Provisional Clinical Opinion (PCO) as an early release article online, The Integration of Palliative Care into Standard Oncology Care. Seven published RCTs formed the basis of the "Panel’s expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden."
The Oncology Report published a background piece on this PCO, which highlights the impetus of this paradigmatic shift in comprehensive cancer care as the Temel et al., article in the NEJM in July 2010. Pallimed contributors have posted more or less directly on the reverberations here, here, here, here, here, here and most recently here, where Lyle presaged this development. The background piece also highlights barriers to implementation including resource limitations such as the lack of clinic-based palliative care and community-based non-hospice palliative care, Stark law restrictions, reimbursement structures, more traditional oncology culture, and palliative care workforce limitations. The piece anticipates support and direction from payers as well as cultural changes among up-and-coming practitioners.
One unnerving thing that I noticed among the selected quotes in the background piece was an apparent, persistent confusion between palliative care and hospice, which I perceive as a barrier to effective integration. I face it fairly frequently in my polite chit chat with other residents, fellows and attendings about my training and career trajectory. This issue of confusion and naming has been remarked upon at Pallimed in the past, e.g., here, here and more humorously here.
Wednesday, February 8, 2012
Friday, February 3, 2012
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...
Friday, February 3, 2012
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