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In anticipation of the upcoming Annual Assembly for the AAHPM, we are going through some site re-design. We apologize for any glitches or inconvenience. Since the site has been up in the old form since its inauguration in June 2005, Drew and I have decided to move forward with some updating the look of Pallimed.

Some of the changes in the past month include (Drew has talked about some of these already but for sake of being complete):

1) New Domain Name - With a domain name comes some amount of legitimacy. The old address (pallimed.blogspot.com) will still work as Blogger is still our host. But with a domain name as simple as www.pallimed.org it will be very simple for our readers to remember our site and ease the informing of new readers about our great content.

2) Donation Button - We here at Pallimed create this content without remuneration. It is a labor of love and of knowledge. Although it sure does keep Drew and I up to date on the latest in our ever changing field. Some of the posts take quite a while to research and create so that you get quality content. And since some of our upgrades do come with bills, there is now a out-of-pocket expense (although minimal). So if you feel like donating that is wonderful and we thank you in advance, but if you just keep on reading, commenting and telling others about it that would be fine too. This site is not and will not be motivated by profit. (Thus no pesky Adsense!)

3) 3-Column Layout - The new version of Blogger has much more versatility built into it and we want to take advantage to bring you the information quickly. With 3-columns there is less scrolling down to get at the information you need.

4) New Color Scheme - We have tried to keep a color scheme of text and links that provides ease of reading. Please give us any comments on the new color scheme and if it works for you (or not).

5) New Logo - Trying to keep with a fresh new look, and better define our brand identity Pallimed is rolling out this new logo. Since we have been using the Pallimed name to bring great content since June 2005, we needed a logo that reflected our commitment. The logo is also clickable so if you get anywhere in the site and want to get back to the home page, just click the log at the top.

6) Welcome Button - Since Drew and I have a hunch that some Hospice & Palliative Medicine people are a bit technophobic (being such great people persons), we added the welcome button to give you an introduction on how to make the site work best for you. Click on it and see where it takes you.

7) Social Bookmarking - To take advantage of common tools in the blogosphere, we have included one-click buttons at the bottom of every post that allow you to save the post using social bookmarking services (Digg, del.icio.us, Google, My Yahoo!, Technorati, Spurl, Reddit)

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I have a rapidly escalating pile of articles to blog that it looks like I'm not going to be able to get into in depth. So, superficially speaking...

1)
A recent Archives of Internal Medicine had an article surveying informal caregivers of dying patients in the US. It gives a sense of the demographics of informal caregiving, what sort of services they used, how they felt about their role, etc. In short, most found the experience taxing, but also personally rewarding & meaningful.

2)
Cochrane recently published a metaanalysis of constipation treatments for palliative care patients. (Image is of cupping points for constipation [a therapy not mentioned in the metaanalysis]--click on the image for its website if you're interested.) I bet you can't guess their conclusions: only a few articles met Cochrane metaanalysis standards, overall scant evidence for anything, poor quality trials, etc. etc. Overall not much is added to the knowledge base other than another cry for quality symptom research.

3)
On the prognosis front Supportive Care in Cancer has a look at C-reactive protein (CRP) & prognosis in terminally ill cancer patients. This was a tiny (n=44) single-institution study. Median survival for those with CRP levels >2.2mg/dl was 9 days; under 2.2mg/dl was 30 days. This association withstood multivariate analysis for what that's worth. Interesting to be sure, but I'm not sure how this is really going to improve clinical management at this point.

4)
The current Journal of Clinical Oncology has an Art of Oncology piece on "truth telling" (article here; supporting editorial here). It tells the story of a young man dying of leukemia and the silence surrounding the fact that he was dying. There's some very good writing here:

Though we may not know the truth of any patients' death, we are deeply woven into their journey. As oncologists, we provide the matrix against which decisions regarding life and death are made and through which communication travels. If we do not serve as open conduits, surely the perilous roller-coaster ride that bends and turns with mortality at every twist will be darker and more terrifying. If we do not speak freely of life and death, we shelter the truth that life and death complete each other's expression. Like light and darkness, they are a pair, as a foot before and a foot behind when walking. As physicians, if our own bodies house fear—fear of death, fear of the unknown—we will subversively transmit this to those for whom we care. By doing so, we hinder the very life we intend to care for, with our own stories. If honesty is a goal, then truth is the wave that carries us there. It is not an easy truth to face, and yet it is our work. We have each signed up to bear witness to the ultimate mystery, the transition from life to death. It falls to us to unravel the reins of paternalism and say what is so.

Thank you, is all I can say, to the author, for writing this.

5)
Lancet Oncology has an editorial asking whether palliative care should replace palliative treatment for cancer in poor countries (no abstract, link here). Despite its provocative theme, it's more or less a plea for increased palliative care training, resources, infrastructure, & know-how in the developing world, and less of an argument that palliative care should replace cancer treatment in resource-poor areas. The reality is, unfortunately, that frequently neither are available. Thanks to Christian "12 days of AAHPM SLC" Sinclair for alerting me to this.

6)
I am now the editor of Fast Facts. David Weissman (my boss, mentor, and all around palliative care go-to guy), who has edited Fast Facts pretty much since their beginning, deeply honored me by offering me their editorship. Fast Facts are a tremendous compendium of palliative care know-how and I look forward to continuing David's tradition and high standards. If any of you have ideas for Fast Facts, or are interested in writing one, please email me.

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(Late update: the full text of the article is available at BE's website here.)

Pallimed goes philosophical for a single post. Back to the literature next time.

The latest Harper's magazine has a provocative editorial by Barbara Ehrenreich about hope (This issue--as far as I can tell the essay is not available online...so 20th Century!) Specifically--against hope. Well, not hope itself but the culture (& industry) of hope-positive thinking in the US.

(First an aside which will take up most of the post...)
...Which is to highly recommend her essay from a few years ago "Welcome to Cancerland" which pillories Breast Cancer Inc. and its infantalizing pink ribbons and teddy bears, the cult of survivorship, makeovers for chemo patients, and the incessant positive narrative of hope&cure. These observations came out of her own diagnosis and treatment for breast cancer.

Some of her choicer quotes:

So pervasive is the perkiness of the breast-cancer world that unhappiness requires a kind of apology, as when "Lucy," whose "long term prognosis is not good," starts her personal narrative on breastcancertalk.org by telling us that her story "is not the usual one, frill of sweetness and hope, but true nevertheless."

For those who cease to be survivors and join the more than 40,000 American women who succumb to breast cancer each year-again, no noun applies. They are said to have "lost their battle" and may be memorialized by photographs carried at races for the cure-our lost, brave sisters, our fallen soldiers. But in the overwhelmingly Darwinian culture that has grown up around breast cancer, martyrs count for little; it is the "survivors" who merit constant honor and acclaim. They, after all, offer living proof that expensive and painful treatments may in some cases actually work.

[T]he mindless triumphalism of "survivorhood**" denigrates the dead and the dying. Did we who live "fight" harder than those who've died? Can we claim to be "braver," better, people than the dead? And why is there no room in this cult for some gracious acceptance of death, when the time comes, which it surely will, through cancer or some other misfortune?

Note that BE is not arguing cancer is ok & we should just get used to it (she argues just the opposite). Instead, she's addressing the insistence (in popular culture in general, and in Breast Cancer Inc. specifically) on 'positivity,' cure, hopefulness, the-next-treatment, being-happy, "getting tested," "let's do something about this," etc. BE found cancer (& its treatment) to be a horrible, painful discontinuation in her life, and wishes, essentially, that the popular discussion of cancer could contain this reality, instead of (in the case of breast cancer literally) cosmetically painting a happy face on it all and insisting on "hope," "being positive," etc. I personally struggle with this too. I firmly believe death is natural (who doesn't I guess...), not in the sense of being happy/virtuous/good/healthy, but, in a very deep way a meaningful part of life for our species. Suffering then, along, with death, is also an absolute and inevitable, natural, part of life. "Meaningful," "natural," do not necessarily mean happy/fun/good--these concepts don't really enter into it. Why not, then, allow cultural space to address this straightforwardly, in a way that doesn't suggest that those who die of cancer are failures or who have been failed by medicine/The System, and that death, shudder, is OK. Not happy/fun/good OK, not let's stop working to forestall death via scientific/medical progress OK, but OK nonetheless. It's what happens to us mortals. If this doesn't make sense, well then rest assured I'll be back to blogging research ASAP.

...Anyway her latest editorial basically continues this point in her typical Ehrenreich cranky, idiosyncratic, and contrarian way. Worth the cover price of a Harper's. She ends the essay with:

The trick, as my teen hero Camus wrote, is to draw strength from the "refusal to hope, and the unyielding evidence of a life without consolation." To be hope-free is to acknowledge the lion in the tall grass, the tumor in the CAT scan, and to plan one's moves accordingly.

**I was just thumbing through the American Cancer Society's guidelines on nutrition and exercise for cancer patients--they explicitly define "cancer survivor" as anyone who has been diagnosed with cancer and is still alive. Technically true, but inclusive of those patients who are, like it or not, dying from cancer.

I guess you're either a survivor or nothing.

Other Pallimed articles with consonant themes here & here.

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This is the third post in a series previewing the sessions at the American Academy of Hospice & Palliative Medicine's Annual Assembly.

You can see all the posts in the series below:
2/14 - Pre-conferences
2/15 - AM Sessions

Click here for the AAHPM Annual Assembly Brochure 2007 (pdf)

Register soon if you have not already!

Thursday, February 15th - PM Sessions

2:15-3:15pm

Well, since I have only heard one of these talks before, I have to give a qualified word of support to Dr. Salacz talk on "Is 'Palliative' Chemotherapy Palliative?" during the first afternoon session. Mike is one of my colleagues here in Kansas City and he is a practicing oncologist trained under Weissman at MCW with a palliative care background as well. I would really like to see more of a knowledge base developed in Palliative Care regarding cancer treatments, because we have many misconceptions about oncology just as they may have misconceptions about hospice and palliative care. We have much to learn from one another.

There are a number of good topics during this session including the update on ALS, and management of dyspnea. I am not familiar with either of those speakers, but those are both good topics. Some hospices do a lot more ALS work than others. And as much of a 'classic' disease (in terms of trajectory, expectations, and palliative care benefits), I have not seen as many ALS patients in my care as much as I have read/learned about them. Similar (but for different reasons) to the HIV population in hospice. They seem to not be as prevalent as they are discussed or studied. That's my experience...what is yours?

And a quick shout out to Peggy Edwards from Hospice of Yuma who is talking on Palliative Care in Nursing Homes with ARNP's. Great topic and sorely needed in our field. Peggy is a great person who I met through the Harvard PCEP course, so I know she has great presentation skills since we learned 'how to teach' from Billings and Block. Anyone else who is a graduate of their excellent two-week course can attest to that.

3:30-4:30pm

One of my votes for best topic title goes to "Cachexia: Why Bother?" by Dr. del Fabbro. Classic for the concise and encompassing way it encompasses our knowledge and treatment of cachexia, while still instilling some hope that there is something that can be done about it. I just hope that the talk is not full of false hope as some of the recent studies Drew has pointed to have suggested. The two talks in this session lean towards communication issues, so it really is a take your pick. Although I am not a big policy-wonk, I am curious about the items to be covered in the Palliative Case Management in Medicaid talk. I wonder what angle they are going to approach this from.

4:30-6:30pm

Poster Session and Job Fair

It is always fun to go to the poster section and see all of the pilot projects that are out there. A lot of seeds are started here and it is always nice to get around and talk to the folks who put these projects together. I just wish that the posters were not so darn expensive and that the deadline for the poster and paper sessions was later in the year so fellows could submit. It is also very interesting that they are having a job fair. I will be interested to see how that goes. I hope it is successful in matching people up as this is still a small community and our communication (despite our focus on communication with patients) about jobs and prospects is still woefully inadequate.

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(Image of Salt lake City courtesy of Flickr user - oroooo)
This is the second post in a series previewing the sessions at the American Academy of Hospice & Palliative Medicine's Annual Assembly.

You can see all the posts in the series below:
2/14 - Pre-conferences

Click here for the AAHPM Annual Assembly Brochure 2007 (pdf)

Register soon if you have not already!

Thursday, February 15th - AM Sessions

8-9:45am Plenary Session
Dying with Dignity: A Contemporary Challenge in Palliative Care (101)
Harvey Chochinov, MD PhD FRCPC, University of Manitoba

Dr. Chochinov has written some really wonderful articles that we have blogged about here. He has a very sharp mind when it comes to defining such a nebulous concept as dignity. I have not heard him speak before but am looking forward to his talk, although I can hope to say that it not just a recap of some of his major articles.

10-11am Concurrent Sessions

There are a lot of big names during this time slot (Lyckholm, Von Gunten, Casarett, Weissman, Coyne, Ritchie, Bailey, Teno), but the one that first caught my eye was Heaven and Hell: Understanding Your Patient’s View of the Afterlife by James Scott Boal, MD, Angela Hospice. I have not heard him speak before, but I am curious how he will tie this to patient care. Curiously there was just an article in the Kansas City Star Faith section on denominational differences in the perception of hell.

I am glad to see a session on preparing manuscripts by Von Gunten, Casarett, and Weissman as that may push our field into a more rigorous scientific direction to answer some of these questions that have only had anecdotal questions for so long in our field.

The other talk that I think will have some strong attendance is the one on organ donation by the folks from VCU. There are a lot of interesting ethical issues as well as communication dynamics when organ donation and palliative care come together. I am planning on going to this one to see what processes they propose/use at VCU. One last word to support my peer Laura Morrison (one of the founding PIT-SIG members) who is also speaking at this time. Her talk is about the PACE program for Assisted Living Facilities, but I am more excited about her next talk.

(Note, I will post on the paper sessions later, just the big talks for now)

11:30am-12:30pm Concurrent Sessions

Laura will be talking with Rodney Tucker on Devices at the EOL in Heart Failure in one of the late morning sessions. Laura and I have collaborated on a few works in this area. Unfortunately some have not always taken flight, but I am glad to see her push forward in this field. Obviously as our medical world becomes more technologically advanced, we will always have work to do since the conversations will eventually turn to when is the right time to turn these devices off and how do we do that safely, and with comfort. I just wish that conversation happened when these devices are invented as well. LVAD anyone?

The other talk that looks pretty interesting to me is the one on Pain Research, although I hope it does not get to bogged down in discussions on opioid receptor subtypes in mice, because that will likely lose me pretty quick. Although I am very interested in advancement of pain research, my tolerance for discussing lab results without focus on the clinical picture left me some time in organic chemistry lab in 1994.

The talks on ICU & Palliative Care, and Mental Illness are probably good core talks, likely to be helpful to many, but the talks on Large National Datasets and Federal Regulations leave me guessing how they can fill up so much time. And these two talks probably appeal to the same group of people, so it is too bad they are at the same time. If anyone who reads Pallimed is talking in one of those or is really interested in those talks I would love to hear your opinion.

And again, the above previews express my basic opinion. By no means do I mean to offend anyone if your talk is not mentioned or even slighted. If you feel that I have misrepresented someone or their talk, then please correct me, because the whole point of me writing this is because I enjoy talking with other people at the conference what they are interested in. It is somewhat naive but still amazing to me that there are so many people is this (growing) niche of a field that we could have such a diverse range of topics. So tell me what you like out of this group!

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Well if you are not regularly reading this blog (you should be if you are in hospice or palliative medicine...), I figure I can at least get your attention if I put 'sex' in the title of the post.

The Oxford Mail (UK) reports on a recent complicated case at the Douglas House, the world's first hospice designed specifically for young adults. A 22 year old resident suffering from Duchenne's Muscular Dystrophy wanted to have sex before he died. His solution was to find a prostitute since his prospects at developing a loving relationship in such a short amount of time to have a meaningful sexual encounter was unlikely given his condition. He brought his request to the staff and they debated in their ethics committee whether or not they should honor his request. The debate centered on providing for the patients safety and helping fulfill his wishes. They had concluded that he would have to use his own money, it could not be in the hospice house, and that they would have someone present in his home (in a separate room) in case he needed assistance. Sister Frances Dominica made a lot of great comments about the debate on the Douglas House website. Apparently this conundrum is also featured on the BBC2 in a series about the Helen (children) and Douglas (young adult) House. Nick Willis, the patient in discussion even wrote a very mature and important column in the Guardian. He states very wisely here:

Strangely, talking to people - especially parents and carers - about death and dying may be easier than talking to them about sex.

It is a very fascinating read regardless of what you may think about his actions. I must say that this situation has never come up in my career in hospice thus far, but at least now thanks to Pallimed I have at least one case study to refer back to. A final quote from his column:

My experience taught me a lot and gave me a sense of normality to a degree. It also helped me to realise that I could make things happen if I really wanted them enough. But it did not give me what I most want. I continue to hope that I may be able to establish a relationship with the right person. The same as any other "dude", as my older brother Tom would say, I want to be able to hold hands with someone, to love and be loved.

2) A new blog to interest those in the nursing home and hospice world is: Hospice and Nursing Homes. The first two posts look promising. We'll keep an eye on it and post it on the links on the right if the quality continues.

3)I enjoy reading first person accounts of hospice experiences. I like to think it may be a family member of someone under my care and I am getting a glimpse into how they are thinking/feeling. A blogger 'named' Solitary posted a well-written account of her Grandfather's death. I will occasionally post one of these every few weeks if there is something outstanding about the story or writing.

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From the latest Journal of the American Geriatrics Society...

1)
Megace makes you fat and weak. Which is a crude, sensationalistic way of saying that in a small randomized trial looking at muscle strength and function those taking megestrol acetate (MA) had worse outcomes than those taking placebo. The findings come from a study looking at progressive resistance muscle strength training (PRMST) and MA in elderly people with an acute functional decline after an illness--to see if these promoted speedier/better recovery. This was a small study involving 29 people who were followed for 12 weeks; they were randomized independently to 800mg MA daily or placebo and PRMST or some sort of low-resistance muscle exercise regimen. Most of the outcomes were non-clinical (standardized muscle strength/performance characteristics, etc.). The findings were:

a) Patients performing PRMST improved substantially more than the patients doing the other exercises. (Details on what PRMST entails are in the article).

b) Patients receiving MA all around did worse: it attenuated or nullified improvements from PRMST, muscle strength went down or didn't improve, and aggregate physical functioning scores worsened in patients receiving MA. Weight-wise, the findings were consistent with what is known about MA: weight went up a little--all fat--& muscle mass didn't change at all.

Despite the small numbers, most of the damning findings for MA achieved statistical significance (highlighting just how profoundly poorer the MA subjects did). That said, it's tough to get super-excited about such a small study, unless you're a MA skeptic looking for another reason not to use this drug (ahem). It should also be noted that this is a substantially different look at MA than how it's been evaluated in advanced cancer patients, for which there is indeed evidence it increases appetite and leads to a small amount of weight (fat, not muscle) gain--and equivocal evidence it improves quality of life (a few patients, certainly, seem to love it). This study, however, raises the spectre that MA may actually be doing harm in frail, elderly patients.

2)
Confirmatory evidence that poor motor function is associated with worse prognosis in the elderly. I'm not going to comment on this much but it might be of interest to those of you who track these things.

3)
And a footnote to Christian's recent post on Art Buchwald's death: a nice, pro-hospice article from the NY Times by Jane Brody (who frequently writes about end of life issues, usually pretty reasonably). Thanks to Tom Quinn for alerting me to this.

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1)
JAMA has another Perspectives on Care at the Close of Life piece about fatigue in the dying.  It's a nice review; comprehensive, accurate, based in a nice case, etc.  I sort of had this weird feeling while reading it though like I was missing something, or that its structure was disjointed--something was wrong.  That's when I realized the article kept on veering its discussion from fatigue to depression to pain to weight loss back to fatigue, etc.  I then realized that the article, itself, embodied the slug-like epistemological goo surrounding fatigue in the dying/the advanced cancer patient.  Is it a discreet disease (or syndrome) with risk factors, treatments, etc.?  Or is it just a symptom of other diseases/syndromes (cancer, depression, COPD, etc.) whose treatment is the same as the underlying condition's?  Or is it an inevitable, normal part of the human condition, as one's body begins the cascade of dysfunctions which will lead to death--a normal, expected part of dying?  The article sort of acknowledges this, but then just jumps around from one version of fatigue to another without warning and it makes for some off-kilter reading. 

There is a very welcome section at the end about 'managing expectations' about fatigue which has this quote from the doctor interviewed in the piece:

"I have a number of patients who suffer from fatigue who I think mostly just want...someone to listen to them tell them their story." 

This is absolutely the most important sentence in this article.  Insofar as our treatments for this thing called fatigue generally suck, and insofar as it is often a inexorable part of the transformation of a patient's life from healthy to sick to dying to dead (and is therefore unfixable), fatigue is frequently not something to be diagnosed and fixed.  Instead it is an aspect of suffering, a stigmata of that transformation, and our (clinicians') role is to...well...everyone has their own words they like to use here and I always struggle with the right ones...bear witness to it, offer a presence, listen, and acknowlege the mystery and pain of dying.

2)
There's also a coda for the recent Perspectives on palliative care for homeless patients.  The patient is still alive, still homeless/transient, and still receiving palliative care.

3)
And super-briefly--Archives of Internal Medicine has a prospective cohort study further validating the association with SSRI use and osteoporotic fractures in the elderly.  Although the study wasn't really designed to look at this fully, the authors postulate that the mechanism of this is not necessarily increased falls (as with tricyclic antidepressants) but via bone density & health.  The same issue has an article linking psychologic factors with cardiovascular disease:  apparently " cynical distrust" will raise your levels of inflammatory markers.  Does this mean all bloggers are destined to die young? 

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Some more quick stuff on Art Buchwald's death this week. The New York Times has a new video feature on its website called 'The Last Word.' Art Buchwald is apparently the first guest to be interviewed about their life and death before they died (obviously). For big fans of Art, view all 4 short videos (about 3 mins. each) . For those just interested in hospice and palliative care, view Video 1 and 4.

The best and most classic moment (which I will do no justice here by typing...you just gotta see it) is when Art says..."Hi. I'm Art Buchwald and I just died." I totally laughed out loud. I have watched it a couple of times because he is a pretty funny guy in person not just on paper. (about 30 seconds into video 1)

The second best moment is his newly coined phrase "A celebrity for death" in video 4.

It would be nice to see some of these things for all people not just celebrities. I know people typically make photo collage videos, but it is nice to have some insight into who the person is, if they have been able to face their own mortality.

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Since the AAHPM's Annual Assembly is coming up, I would like to go through the schedule with you day-by-day and highlight which talks or presenters might be particularly good or interesting. I look forward to getting the brochure for the first time ans seeing all the different people speaking and what topics are 'hot' or 'not this year. This is not a ringing endorsement or a session to tell you which talks you should or should not go to. If I don't mention anything about a session, it is way more likely I do not have a strong enough opinion to waste your time reading a weak preview. If you have any comments on any of the presenters or talks please feel free to add.

Click here for the AAHPM Annual Assembly Brochure 2007 (pdf)

Register soon if you have not already!

Wed, Feb 14th - Preconference Workshops
All Day

Hospice Medical Director Course - Module A - Clinical Skills
I enjoyed the Module (B) I went to a few years ago, and thought it was really well put together. Since I did fellowhsip this session probably would not add too much for me, but is likely a great overview for those just starting in the field. I wonder what will happen to these sessions after fellowship becomes mandatory?

Career Development Bootcamp (Casarett and the Palliative Care Rock Stars)
I went to this session two years ago (or a previous incarnation of it). I found it quite helpful and met some good contacts during the session who were in similar boats to mine. i think the difficulty with sessions like this is that depending on your clinical location and organizations ability to respond some of the issues here may be beyond reach for some. I think the cast they have for this is outstanding as you can tell by my fawning over the crew they have selected for this session. It just reads like a list of the last journal of JPM.

8a-Noon
Opioids in Pain Management (Mellar Davis and Susan LeGrand, among others)
Probably a good choice if the Module seems a bit too simple. Have not heard these two talk before but I know they know what they are talking about.

Billing for Hospice Services (Chamberlain)
Great choice if your clinical skills are honed but you just can't seem to keep your physician billing to the level that you might expect with a specialty practice that has no procedures. There are some pretty confusing things in understanding and optimizing billing so if you have not been to a billing talk before this is probably the Daddy of them all.

Home Visits (Woods, Farmer, others)
I don't know Woods, but I do know Chad Farmer as he was one of the original founders of the Fellow's email list that eventually became the Professionals in Training Special Interest Group. Never heard him talk, but he is a pretty good guy. And since this group is all from LifePath, I am sure they know how to make your home visit program more worthwhile.

1p-5p

Evidence-Based Formulation of Prognosis (Sinclair, Salacz, Affield)
(Shameless plug) I submitted this talk because prognostication is one of my favorite topics in palliative medicine. It combines the mystery of the unknown with science and exploration. Prognostication is always asked of us as professionals, but we frequently are working from gut rather than data. Since I was never taught how to prognosticate, and only been to a single hour lecture (by Christakis), I have really jumped into this subject whole-heartedly. We are planning a very interactive and informative 4 hours, so I would probably call this the pick of the day. :-)

Implementing a Nursing Home Palliative Care Program (Levy)
I don't know the speaker, and the topic probably deserves a 4 hour time slot. There are a lot of pearls to be gained from those that have managed to work well with the nursing home population. It looks like it goes beyond how to market to them (more pens!) and actually how to work together clinically which should be the goal.

Competency-Based Assessment for Fellowship Faculty (Billings/Block)
It is too bad I am talking during this time, because anytime you get a chance to see Billings and Block present you should try and make it if the topic interests you at all. I was honored to be a part of their Harvard PCEP program (you should do it too!) and get to know both of them. I learned how to teach others from them. They are great teachers. This should be a good session but may end up being a small group workshop based on the small audience it is geared towards which works in its favor.

No comments on the HPNA sessions because I am not familiar with any of the speakers. I have heard good things about the BOATING one-act play about goals of care which is in the afternoon session. And APN billing is probably a big issue for those of us working with APN's. I work with a very good APN at KC Hospice and given all the confusing state regulations for this new discipline, anything to help work through the red tape is welcome.

Again, leave your comments especially if you want to advocate for your talk!