GeriPal - Geriatrics and Palliative Care Blog

A Chance to Revise the POLST

2012-05-24T14:52:00.000-07:00

We have written a lot about POLST (Physician Orders for Life Sustaining Treatment) in previous GeriPal posts. Mostly, with great admiration for the entire program and for the amazing efforts of partnerships like the Coalition for Compassionate Care of California. But, just like every in life, even the best programs can always be made better. With that in mind, the Documentation Committee of the POLST Task Force is now considering suggestions and recommendations for changes to the form.

Submissions are due June 15th, 2012, and importantly, these submissions should provide significant or substantial improvement or clarification to the form. With that said, I'd first like to encourage all of you to submit recommendations if you have them. Secondly, I'd also like some feedback on two of the recommendations that we are considering submitting. Both come from previous posts (see here and here) and mainly revolve around avoiding value-laden phrases that we think add little to no value.

Recommendation #1: Change the title to POST (Physician Orders for Scope of Treatment)

Lets face it, for many of the interventions proposed on the POLST, it is a little bit of a stretch to say that they would actually sustain life in the population POLST targets. Take CPR in a frail patient with an advanced disease. Sustaining life is actually the much less common outcome of CPR than death. Furthermore, as Helen Kao wrote in a previous post:

making selections on a document labeled “Life-Sustaining Treatments” implies that you are making a choice between Life and the opposite of life — aka death — and that the Treatments listed must, of course, successfully sustain your life (or why would you label the document “Life-Sustaining Treatments”)?

What could be alternative titles? Well that is a question that I'd like to get some feedback from our audience before we submit our recommendations. My first thought was "Potentially Life-Sustaining Treatments" although something still feels a little lacking with this term. Dr. Kao recommended examples from other states including "Physician Orders for Scope of Treatment" or "Medical Orders for Scope of Treatment". The nice thing about scope of treatment is that it simply tells the "readers, caregivers, providers, what types and levels of care an individual wants" and removes the "implication that using a POLST form means choosing death over life."

Recommendation #2: Remove the words "Only" and “Full Treatment” from the Medical Interventions section

Comfort Measures Only versus Full Treatment? Really, is this a choice? This is akin to asking "do you want everything?" Of course I do, and that pretty damn well include expert symptom management hopefully from an interdisciplinary hospice or palliative care team. And why "only" before comfort measures? This is the type of wording that makes one feel that it is somehow a lesser alternative, further promoting the idea that when people choose not to die in the ICU on a ventilator they have in some ways "given up" their fight with their disease.

So what is the fix? Well, as mentioned previously, it would be helpful if we just stopped adding value laden terms to important end-of-life documents. Currently, the California POLST has this as one option:

[] Full Treatment: Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.

What if it just said:

[] Includes all care described above. In addition, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.

Which do you like better? Did the addition of the phrase “Full Treatment” add any more information that wasn't there in the revision? For me it's no, but I'm just one person. What do you think?

Final Note: How to Submit Your Own Recommendations

All suggestions may be submitted via e-mail to Erin Henke, ehenke@coalitionccc.org, by June 15, 2012. Submissions should comply with the following format:

Name of person/organization submitting suggestion
Section of the POLST Form affected (Section A, B, C, D, Introductory paragraph, Directions for Health Care Providers, etc.)
Specific revision being requested
Rationale for the change, or description of the issue the revision will address

Also, per the announcement, a guiding principle in the review process is that any change must provide significant or substantial improvement or clarification to the form. Two additional considerations are to (1) maintain the CA POLST form as a one-page, two-sided document, and (2) keep all the critical information on the front of the form for ease of reference.

by: Eric Widera (@ewidera)

Death of the Gerontological Nurse Practitioner: Part 1 of 2

2012-05-23T10:00:00.000-07:00

The Advanced Practice Registered Nurse Consensus Work Group and the National Council of State Boards of Nursing Advanced Practice Registered Nurses (APRN) Advisory Committee has decided to eliminate the Gerontological Nurse Practitioner track and its associated national certification exam by 2015.

At the University of California, San Francisco (UCSF), this means that the last class of Gerontological Nurse Practitioners (GNP) will graduate in 2013. Starting this fall, incoming UCSF Nurse Practitioner students who wish to focus on the care of older adults will be entering the Adult-Gerontology Primary Care Nurse Practitioner track. This new program will be preparing students to care for persons aged 15 to 105. Geriatric content will be merged into the current Adult Nurse Practitioner program. All graduate schools of nursing who once offered GNP programs are affected by this change.

I am struggling to make sense of this.

Most of us are aware that the population of adults 65 and over is anticipated to reach 70 million by the year 2030. Ten million Americans currently need long term care. This number is projected to rise to 15 million by 2020. Today, there is only one board certified geriatrician for every 2,620 Americans 75 and older. In 2030 there is expected to be only one for every 3,798. Additionally, there is a significant shortage of primary care providers in this country.

This serious gap in the provision of care for the elderly in America can be filled with well-trained nurse practitioners. The Institute of Medicine report on the Future of Nursing specifically speaks to the necessity of nurses to practice at the highest and full extent of their abilities. Gerontological NPs work in long term and transitional care facilities, acute care for the elderly (ACE) units in hospitals, clinics for older adults, home based primary care programs, inpatient and outpatient palliative care, with interdisciplinary teams and in primary practice. Gerontological Nurse Practitioners are in the perfect position to address the primary needs of the aging population.

I imagine that the intent of the new consensus model is to train generalists, generalists who can care for a wide variety of age groups. To that end, it makes sense to add geriatric content to all adult nurse practitioner programs.

However, I’m concerned that the depth and breadth of knowledge necessary to care for the unique needs of older adults cannot be adequately covered within already content packed adult NP programs. How can the new Adult-Gerontology NP track address all the competencies necessary for the care of the adolescent with primary reproductive health needs through the frail elderly with multiple complex chronic conditions and geriatric syndromes within the same time frame? Will Adult-Gerontology NPs be expected to keep up-to-date with all the changes for a population that spans 90 years? Even for the most ambitious, this would be a huge endeavor and no small task for those with only one population focus.

By 2030, one in every five Americans will be 65 or older. Will we all be losing out through the dilution of specialized training for this segment of the population? Are we best served by being generalists? Or is this another health care missed opportunity?

by Patrice Villars

Stay tuned for Part 2 of Death of the Gerontological Nurse Practitioner –perspectives from a graduating GNP student.

The longer you live, the longer it will take to die

2012-05-22T06:00:00.000-07:00

Age is one of the great modern adventures, a technological marvel—we’re given several more youthfulish decades if we take care of ourselves. Almost nobody, at least openly, sees this for its ultimate, dismaying, unintended consequence: By promoting longevity and technologically inhibiting death, we have created a new biological status held by an ever-growing part of the nation, a no-exit state that persists longer and longer, one that is nearly as remote from life as death, but which, unlike death, requires vast service, indentured servitude really, and resources...

Part of the advance in life expectancy is that we have technologically inhibited the ultimate event. We have fought natural causes to almost a draw. If you eliminate smokers, drinkers, other substance abusers, the obese, and the fatally ill, you are left with a rapidly growing demographic segment peculiarly resistant to death’s appointment—though far, far, far from healthy.

These are the words of Michael Wolff written in a cover story published in this week's New York Magazine. Even though there are some things I take issue with in this piece, the depth and honesty in his story moved me to want to write about it here.

Wolff's story revolves around his mothers diagnosis of Alzheimer's disease and the years of cognitive and functional decline caused by this slowly progressive neurodegenerative disorder. The course of her disease was marked by hospitalizations, major heart surgery for aortic stenosis, and what Wolff describes as a "series of stops, of way stations, of signposts" in which she goes from being at home, to needing assisted living, to needing nursing home care, to being at home with hospice.

What was most moving about this story was how he captures the heartache of a son seeing the slow destruction of the person he knew as his mother, and the frustrations of knowing that he is in part responsible for her current life:

And yet, I will tell you, what I feel most intensely when I sit by my mother’s bed is a crushing sense of guilt for keeping her alive. Who can accept such suffering—who can so conscientiously facilitate it?

The one aspect that I take some objection to is the one-sided and very negative view of disability in late life. He equates the "drawn-out, stoic, and heroic long good-bye" to "human carnage", and backs this up with studies showing that 70% of those older than 80 have a chronic disability with over half having at least one severe disability. However, at least one study by GeriPal's Alex Smith shows that it is possible to be significantly disabled and dependent on others for help with even basic activities of daily living, and yet also have a good self-rated quality of life.

With that said, I still think this is truly a remarkable read. As one columnist said: "force yourself to get through "A Life Worth Ending"... not because it's a bad piece. It's beautifully written and evocative — it's just that it's almost too evocative for anyone who has ever watched a loved one die slowly from illness."

by: Eric Widera (@ewidera)

Coffee Is Bad For You. Coffee is Good For You. Why Am I So Confused?

2012-05-21T07:13:00.000-07:00

Coffee is one of the most widely consumed substances in the world. I suppose many drink coffee because they believe it tastes good. But for many, the appeal of coffee is for its medicinal properties-specifically the stimulant effects of caffeine.

The popularity of coffee and its dual use as a beverage and drug make its health effects an important public health issue. So, it is not surprising that a recent study in the New England Journal of Medicine received a lot of attention. The study had two important findings:

(1) People who drink coffee are more likely to die
(2) People who drink coffee are more likely to live

Huh?

Well, it is actually true. The study really did say both of these things. And in the end, the study does not really answer whether coffee is good or bad for you. But it is worth taking a few moments to try to understand these contradictions. Because if you do understand, you will be a better consumer of the research you read about in the medical literature and the popular press.

The study design is simple enough. The researchers administered a dietary questionaire to nearly 400,000 people between the age of 50 and 71 in 1995. They asked them if they drank coffee, and if so, how much. Then they determined who died by 2008. They compared death rates in those who did not drink coffee, light coffee drinkers, and heavy coffee drinkers.

And after 13 years, coffee drinkers did worse--actually a lot worse. In men, 13.1% of those who did not drink coffee died. 18.8% of those who drank 6 or more cups of coffee per day died. In women, 10.4% of those who did not drink coffee died. 15% of those who drank 6 or more cups of coffee per day died. This sure seems bad. No more Ventis for me. Oh Well. Perhaps I can put that $2.25 to better use.

But wait a second. Have you ever heard of the concept of confounding? In medical research studies, a confounder is something that is strongly associated with the risk factor (coffee drinker), that explains its association with the outcome (death). One way to think about this: Up to now, we were assuming that the higher rate of death in coffee drinkers was due to the coffee. But what if coffee drinkers are very different from non coffee drinkers? And what if those differences, rather than coffee consumption is what really explains the higher death rate in coffee drinkers.

Well, as it turns out, coffee drinkers are MUCH different from non coffee drinkers. They actually are a fairly unhealthy group. Most notably, coffee drinkers are much more likely to smoke. For example, in women, 8% of non coffee drinkers smoke, while 48% of those drinking more than 6 cups a day smoke. Coffee drinkers are also less physically active and have worse dietary habits. Could it be all this bad stuff (confounders), rather than the coffee that is leading to more deaths in coffee drinkers?

It turns out that if one can measure a confounder, it is pretty easy for the researchers to account for it. The researchers are able to use statistical tools to adjust for these confounders. This makes it possible to see what the difference in mortality would be if rates of smoking and other measured health markers were the same in coffee drinkers and nondrinkers. The point of these statistical procedures is to get closer to the truth by making apples to apples comparisons. For example, how would mortality rates compare in nonsmokers who don't drink coffee and nonsmokers who do drink coffee.

The result of this statistical adjustment is a rather stunning reversal of fortune for coffee drinkers. After accounting for all of the bad health habits of coffee drinkers, those who drink coffee actually have a lower risk of death than those who do not drink coffee. Men who drink 6 or more cups of coffee a day have a 10% lower risk of death than those who do not drink coffee. 6 or more cups in women is associated with a 15% lower risk of death. If you smoke and drink coffee, you live longer than if you smoke and don't drink coffee. If you don't smoke and drink coffee, you live longer than if you don't smoke and don't drink coffee.

So, coffee is good for you? Well not so fast. While it is true that researchers can statistically correct for confounders like smoking, they can only adjust for confounders that they actually measure. What if there are other unmeasured factors that make the coffee drinkers live longer? For example, what if wealthy people are more likely to drink coffee? What is people who have more medical problems drink less coffee? The study was able to do little to account for either of these highly plausible scenarios. It is quite possible the better outcomes of coffee drinkers have nothing to do with coffee.

So, the study first showed that coffee drinkers are more likely to die. When the researchers accounted for smoking, coffee drinkers were less likely to die. It is possible if they were able to account for additional differences between those who do and do not drink coffee, the results would swing back in the other direction.

So, in the end, we still do not know whether coffee is good or bad for you. (My best guess--it is probably neutral--drink coffee is you like coffee. If you don't like coffee, drink something else).

In the end, the most important lesson: Have some healthy skepticism when you read the latest news in your medical journals or newspaper about which foods are good or bad for you.

by: Ken Covinsky (@geri_doc)

Purity of Intention is A Shaky Foundation

2012-05-17T09:30:00.001-07:00

I wrote previously of the anti-choice attack on palliative care and the vulnerability of providers whose protection rests on proof of their “intent” when providing palliation. The powerful forces for which purity of intent is more important than relief of suffering are fixed on legislating their view of medicine’s proper role at life’s end. They are advancing their agenda with little opposition from practitioners.

At its own peril the medical lobby ignores bills that 1) raise the bar on what will pass for lawful practice and thought, 2) magnify penalties for those found guilty of forbidden thoughts and intentions and 3) encourage scrutiny and whistleblowing by onlookers and medical colleagues.

A recent Georgia bill illustrates the danger.

Georgia's Governor Nathan Deal

Georgia’s governor recently signed HB 1114, prohibiting assisted suicide. Shaped by Georgia Right to Life and the Georgia Catholic Conference (thanked from the floor of the Legislative Assembly) and with no visible objection from the physician community HB 1114 purports to outlaw suicide assistance. Here I would like to affirm my strong support for clear laws and harsh penalties for those who incite and abet suicide.

But a mere 19 of this bill’s 57 lines address actual criminal behavior. The bill’s drafters wasted few words on perpetrators of violence, guns, nooses and other atrocities by which online predators and other malicious enablers encourage self-destructive impulses of the mentally ill. The heinous crime of inciting a despondent or disturbed person to kill themselves seems almost an afterthought in this bill.

The bulk of the bill --- 37 lines --- frets over patient decision-making and medical treatment in minute detail. It focuses on doctors more than the voyeurs and predators that endanger society. The new law repeatedly specifies that any withholding, withdrawing, prescribing, administering or dispensing must be solely intended and calculated to relieve symptoms and never to cause death. Some tried to allow treatment that “eases the dying process,” but the lawmakers deemed that language too permissive and generous.

As readers of this blog well know, end-of-life medical practice is rarely as clear-cut as lawyers make it out to be. Opiates and sedatives upon ventilator removal, palliative sedation for symptoms requiring unconsciousness, increasing doses of opiates when patients suffer escalating pain or breathlessness in the throes of death, all constitute aggressive and legitimate treatment. The same medication, in the same dose, may both treat suffering and advance the time of death, depending on factors that include the patient’s weight, liver or kidney function, cardiac and respiratory reserve and the proximity of death. The two outcomes often lie beyond discernment. Some ambiguity is the norm. In this environment the Georgia felony depends on thoughts in the physician’s, pharmacist’s or nurse’s head as they deliver palliative care. Georgia law is unique in demanding not only evidence of pure intention, but also a “calculation” in support of that intention.

The standard for end-of-life treatment used to be that the correct medication dosage is that required to relieve suffering. Georgia lawmakers now insist the correct dose is a careful “calculation” of what may be expected to relieve the patient’s suffering but will not contribute to her death. It is understandable in such a climate if the calculation gets more attention than the suffering.

Georgia lawmakers not only pasted targets on healthcare professionals, they also armed those taking aim at forbidden intentions with the state’s RICO (Racketeer Influenced and Corrupt Organization) law. The heavy artillery of RICO magnifies the state’s policing authority, extends penalties, adds civil liability and enables prosecution of individuals only tangentially involved in the patient’s care.

Patients need more legislative vigilance on their behalf. Dying patients have no voice in our nation’s statehouses. Palliative care professionals should awaken to the traps set for them by political musclemen in state Catholic Conferences and Right-to-Life Committees. Without greater caution, creation of thought crimes, threats of exorbitant punishment and hyper-vigilant whistleblowers could define the future of palliative care.

This is an invited guest post by Barbara Coombs Lee, president of Compassion and Choices.

A Thin Reed to Hang On

2012-05-16T09:18:00.000-07:00

It’s no news to most GeriPal readers that a cadre of anti-choice forces targets end-of-life care. In their sights are common end-of-life decisions and palliative support for those decisions. They are hostile to people who, at the end of a long decline or stuck in a prolonged dying process, intentionally advance the time of death and exercise their right to stop life-prolonging technology or treatment. The operative tactic is to tie the hands of doctors attending those patients, when palliative treatment might ease the patient’s chosen death.

As Dr. Timothy Quill recently pointed out in the Journal of Law, Medicine and Ethics, “Widespread agreement exists in the United States about a patient’s right to forego any life-sustaining therapy, even if his wish is to achieve an earlier death.” Treatments can be stopped, and should be stopped as humanely as possible, even if the patient expresses a wish to die in so doing.

Yet current understanding of the law and practice in most states relies heavily on the Roman Catholic Doctrine of double effect, in which physicians are not allowed to share or participate in a patient’s intention to cause death. Strict adherence to this doctrine stifles honest patient-physician communication, gagging patients who would express a wish to end their prolonged suffering by advancing death. If patients do speak of a wish to die, providers beat a hasty retreat from the bedside for fear of being labeled an accomplice.

Recently published research reveals that onlookers and watchful colleagues already threaten palliative care physicians with accusations of murder and euthanasia. Over half of palliative physicians report they have endured such accusations at least once, some as often as six times, over the past five years. No physician was found guilty of such charges. But the inquiries subjected them to worry, monetary loss, damage to reputation and career, medical license suspension and even dislocation.

Treatments most vulnerable to accusation were use of medication in the process of discontinuing mechanical ventilation and use of opiates for symptom management. When accusations led to serious investigations, the accusers were most likely members of the health care team.

The researchers did not ask the question that hangs heavy over their findings: “Has the palliative treatment you give patients changed since enduring an investigation?” It seems likely even a baseless investigation could increase the end-of-life suffering of an accused doctor’s patients for decades.

Empowering these watchdogs is an anti-choice tactic. Several years ago National Right to Life drafted a bill called, ‘Starvation and Dehydration of Persons with Disabilities Prevention Act” and introduced it in dozens of states. Building on the Terri Schiavo episode, the bills prohibited withdrawal of artificial food and hydration from those in permanent vegetative states unless the person had specified a wish to the contrary in writing.

Those bills encouraged whistleblowing by a host of onlookers, and gave them standing in court to challenge the health care decision. In addition to remote family members, the bills authorized any current or former health care provider (nurses, dentists, pharmacists, etc.) to initiate legal proceedings and get court-ordered tube feeding. It raised the specter of relative strangers posted as lookouts and running to court if a family tried to let their loved one die without a written advance directive. These bills mostly died in legislative committees across the nation, but language deputizing people remote from the primary family still appears in anti-choice bills.

Barbara Coombs Lee

The state of Georgia recently passed a bill that facilitates accusations of improper care by legislating a specific state of mind when providing end-of-life treatment. In a post to follow, I will discuss in detail how Georgia’s law endangers the best practice of palliative care.

To the degree that the palliative care community favors the physician’s beneficence over the patient’s autonomy in the framework for ethical practice and demands strict obedience to the rule of double effect, it facilitates the anti-choice agenda. Permissible “intention” is a thin reed on which to hang the distinction between felony and state-of-the-art palliative care. When the double effect doctrine becomes codified in statute, it subverts legitimate patient decision-making and leaves healthcare providers vulnerable to accusations of forbidden (i.e. criminal) intentions.

Billings and Churchill recently deplored exclusive reliance on the doctrine of double effect and argued for greater moral pluralism in approaching end-of-life decisions. I agree with their assessment that, “The dearth of attention to other ethical constructs represents a poverty in moral deliberation.” That state of poverty also puts palliative care practitioners at risk for accusation and prosecution.

It would be safer and more patient-centered to define legal medical practice by the patient’s clear and documented wishes and decisions, and best medical practices in support of them.

This is an invited guest post by Barbara Coombs Lee, president of Compassion and Choices.

Mostly Dead vs Completely Dead: A Distinction Best Left to Hollywood

2012-05-14T15:54:00.000-07:00

I was at a dinner a meeting of the Greenwall Faculty Scholars, a bioethics career development program for junior faculty, when an interesting issue came up. Several folks at our table argued that patients who donate organs after cardiac death are not "Dead" (capitol D) at the time the incision begins to harvest their organs. The question that arose was - should patients, families, and transplant doctors be informed that the patient is not completely "Dead" before organ procurement begins?

I am no transplant surgeon, but here is my basic understanding of the issue (with backup from these two articles in NEJM here and here). Patients who donate after cardiac (not brain) death are often kept alive using life-sustaining measures, such as mechanical ventilation supplied via a breathing tube, and medications that increase a persons blood pressure. In some situations, with the consent of the surrogate decision maker, the patient is taken to the operating room and IV catheters are inserted and heparin pumped into the organs to prevent blood clots from damaging them. Life-sustaining measures are stopped, the pulse stops (not electrical activity, the pulse), and the transplant surgeon waits two to five minutes after the pulse stops before making an incision to harvest organs. At this point, several folks at our dinner table stated that in many cases the patient could likely be revived using CPR and re-institution of life-sustaining measures. The brain could expect in many cases be expected to return at least some function after resuscitation.

Some at our table argued that patients, families, and physicians should be informed of this issue. The argument is based on the longstanding tradition that families be fully informed before they make a decision. The argument is that we owe it to patients and their families to be truthful about such momentous life and death decisions. If patients and families get wind that doctors are not being truthful, this could erode their sense of confidence in medicine in general, and the transplant enterprise in particular.

Several of us disagreed. We disagreed for two reasons. First, the distinction is meaningless to patients and families. Even a sensitive conversation is likely to be more confusing than it is helpful. For example, something like, "Your loved one has a condition that will result in a lack of blood flow without the use of machines. Most people would consider this condition to be death, although it is not strictly death from a medical standpoint. With your consent..." This sort of conversation is inevitably going to lead to a great deal of confusion at a very difficult time for families.

There is an infamous scene in the Princess Bride where where Miracle Max, played by Billy Crystal, explains the distinction between mostly dead and completely dead to Inigo, played by Mandy Patinkin.

                         INIGO
                  (stupefied)
             He's dead. He can't talk.

                         MIRACLE MAX
             Look who knows so much. Well, it
             just so happens that your friend
             here is only mostly dead. There's
             a big difference between mostly
             dead and all dead. Please open
             his mouth.

Inigo does. Max inserts the bellows in Westley's mouth and
starts to pump.

                         MIRACLE MAX
             Now, mostly dead is slightly
             alive. Now, all dead...well, with
             all dead, there's usually only
             one thing that you can do.

                         INIGO
             What's that?

He stops pumping.

                         MIRACLE MAX
             Go through his clothes and look
             for loose change.

Attempting to explain such distinctions in the real world will make families wonder if there is a possibility their loved one could live, just as they are coming to terms with their death. The farcical Princess Pride aside, semi-realistic Hollywood movies propagate this fantasy (think Flatliners). Such distinctions are best left to Hollywood.

The other reason for not disclosing the distinction has got me thinking the most. One of the people at the dinner table was friends with a transplant surgeon who refuses to make an incision unless the patient is declared "Dead." Even if this is a fiction, it may be important to maintain for reasons that are not completely rational.

It's clear that the surgeon will not be the cause of the patient's death - the disease that led to the cessation of effective circulation of blood flow is the cause - but it still may matter to the surgeon. And the reason it matters is not rational, or based on ethical principles, but rather irrational, based on emotion and a visceral reaction. There is something qualitatively different about cutting into a person who is dead and removing their organs than cutting into someone who might be alive. This is similar, for example, to how there may be no ethical distinction between withdrawing and not-starting life-sustaining treatment, but the reality is that they just feel different to patients, families, and clinicians.

A terrific recent New York Times article discussed just this question: how much weight we should give to irrational motivations? The article was hilariously titled The Amygdala Made Me Do It, and describes the invasion of "Can't Help Yourself Books" in the lay press, including "Thinking, Fast and Slow" by Nobel prize winner Daniel Kahneman. The article concludes:

Does this mean we have no “agency,” no capacity to act on our own? Or can autonomy thrive within the prison of self-ignorance? “We have to believe it does,” says Steven Lukes, a professor of sociology at New York University highly admired for his work in moral philosophy. “If we seriously thought that our intentions made no difference to how we behave, we couldn’t go on using the language of ethics. How would we go on living the lives we live?” Or doing what we think is right? “People have free will when they ‘feel’ they have free will,” says Professor Kahneman. “If we didn’t believe in it, we would have no responsibility.”

I think both are true. On the one hand, we must strive to understand the logical, rational, ethical reasons for our actions and strive to use normative reasoning to guide our actions. On the other hand, we must acknowledge that these irrational reasons carry some weight, like not wanting to cut into a person who might be slightly alive, even though such distinctions may be meaningless. And perhaps in some cases, such irrational reasoning will lead us to maintain what is technically a fiction: believing people are Dead when in fact they are only dead.

by: Alex Smith

The Fellowship Match: Geriatrics Is In, Palliative Care is Still Out

2012-05-02T15:34:00.003-07:00

The biggest announcement so far at the American Geriatrics Society Annual Meeting is that Geriatrics will be entering into the fellowship match for the 2014 academic year! This is huge news for geriatrics and should serve as a push for Hospice and Palliative Medicine to get out of the position of being the last fellowship program outside of the match.

Why is this important news? Both geriatrics and palliative care have been stuck with a dysfunctional matchless system. We have written on the chaos of not being in the match previously on GeriPal, heard what being 'matchless' means to applicants via a Pallimed post by Brian McMichael , and have had important foundations encourage us to join (see this Hartford Health AGEnda post).

With Geriatrics now agreeing to join the match, there is really one holdout among all other subspecialties that have agreed that residents deserve the opportunity to have more time to decide on a fellowship path (match lists are now due 5 months into the last year of residency), more opportunity to see other programs besides their home program, and more clarity on the timelines on when programs will take applications, interview, and make offers. The last remaining subspecialty is Hospice and Palliative Medicine.

If you are still on the fence, I again encourage you to read Brian McMichael’s post on what it is like to be an applicant in the current system:

“My [application] 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."

It is just sad that this is the first impression that we give to applicants coming into our field. We can and we must do better.

by: Eric Widera (@ewidera)

An Appeal to Bring Medical Eduction into Nursing Homes

2012-05-01T09:28:00.002-07:00

What happens when the head of one of the most prominent medical education journals publishes a call for every medical school and teaching hospital to develop educational experiences in nursing homes? Will a system that bows down at the alter of the hospital experience change to raise the importance of caring for the 1.4 million nursing home residents in the US, or will the status quo rule the day?

Steven Kanter, MD

Steven L. Kanter, MD, Editor-in-Chief of Academic Medicine, was the one to make the appeal in an editorial published this week (Acad Med. 2012 May;87(5):547-8). Dr. Kanter starts off his editorial posing the following question:

"Should nursing homes be part of mainstream medical education? In other words, in addition to being important sites to learn the basics of geriatrics and the principles of long-term care, should nursing homes be sites for residents and medical students to learn core clinical, communication, and team skills? Should nursing homes be among the standard sites used for education during residency rotations and medical student clerkships?"

Dr. Kanter then goes into describing several main reasons why we need to think of nursing homes differently in medical education. His reasons include that these sites of care can fill a need of medical schools and residents searching for training sites. With over 1.4 million nursing home residents in over 15,000 nursing homes, the capacity is definitely there to meet any educational demand. Dr. Kanter also describes how nursing homes can offer an opportunity to provide environments that offer interprofessional education where medical students and residents learn how to work with patients and families, as well as study patient safety, quality improvement, transitions in care, and public health issues.

In the end of his editorial, Dr. Kanter makes his appeal for change that should make any GeriPal reader giddy:

I call on every medical school and teaching hospital to develop collaborations with nursing homes, to study ways to make such collaborations effective and beneficial for all stakeholders, and to cultivate relationships that will improve clinical education, research, and, of course, the care of nursing home patients.

This editorial is very much a rallying cry for our GeriPal readers to start thinking about novel ways to bring learners into the nursing home environment and disseminating this on a national level. It also is an excellent resource when making a case to local deans and program directors on the importance of this clinical setting.

by: Eric Widera

Blogs to Boards: Question 11

2012-05-01T09:17:00.000-07:00

This is the eleventh 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).

Question 11

Mr. Z is a 87 year old with advanced dementia living in a nursing home. At baseline he cannot recognize family members, is dependent on all ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence. He speaks about 1-2 intelligible words per day and he has had progressive loss of ability to ambulate. He is now admitted to the hospital after sustaining a hip fracture from a fall.

When discussing treatment options for his hip fracture, his wife asks you how long he likely has to live.
Given his current state of health, what would be the most appropriate answer:

a) Given that he does not meet FAST 7C criteria his prognosis is likely greater than 6 months
b) He meets NHPCO Guidelines for hospice eligibility which means he likely has less than a 6 month prognosis
c) Given his advanced dementia and recent hip fracture, his 6 month mortality risk exceeds 50%
d) As with most individuals with advanced dementia, his life expectancy is likely weeks to months

Discussion:

Discussion: Correct answer is (c)

a) The FAST scale measures functional status in dementia and consists of 7 major stages split into 16 different sub-stages. Hospice eligibility criteria for dementia are based largely on whether a patient meets or exceeds Stage 7c on the FAST and whether they have at least one complication from their dementia. Unfortunately, these criteria do not accurately predict 6-month survival.

b) The current National Hospice and Palliative Care Organization (NHPCO) guidelines for hospice eligibility are of limited accuracy in predicting death within 6 months. In addition, NHPCO guidelines relies on the FAST staging, which fails to account for the observation that dementia often does not progress in a sequential pattern. The patient is dependent on ADLs (dressing, toileting, bathing) but does not have urinary or fecal incontinence (FAST Stage 6d and 6e). His speech has declined from less than 6 intelligible words per day (7a) to one or less (7b), and he has had progressive loss of ability to ambulate (7C), however since he does not have 6d and 6e, Mr. Z is not considered Fast Stage 7c, rather he is Fast 6C.

c) Is the correct answer: Individuals with advanced dementia that are either hospitalized for either pneumonia or for hip fracture have a very poor prognosis. In one study, six-month mortality for patients with end-stage dementia and hip fracture was 55% compared with 12% for cognitively intact patients.

d) Advanced dementia is a terminal condition; however estimating prognosis is difficult due to the prolonged period of severe functional and cognitive impairment that occurs prior to death. For those with advanced disease who reside in a nursing home, the 6-month mortality rate is 25% with a median survival in one study of only 478 days.

References:

http://www.geripal.org/2009/10/there-is-important-article-in-curr
Mitchell SL, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. Nov 3 2010;304(17):1929-1935.
Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. Jama. Jul 5 2000;284(1):47-52.
Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. Oct 15 2009;361(16):1529-1538.

(For email readers - click here for the answer and discussion)

Blogs to Boards: Question 9

2012-04-21T08:17:00.001-07:00

This is the ninth 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).

Question 9

BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer.

She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilaterally in her lower extremities both proximally and distally.

You obtain a stat MRI which shows a T12 vertebral metastasis and cord compression.

In addition to administering glucocorticoids, then next best step is to:

a) Arrange an urgent radiation oncology consultation for the next day
b) Admit her to the hospital, and arrange a stat radiation oncology consultation
c) Admit her to the hospital, and arrange a stat spine surgery consultation
d) Adjust her pain medications appropriately, and instruct her to contact you immediately if her pain or disability worsens

Discussion:

Gross National Happiness, Geriatrics, and Palliative Care

2012-04-18T17:35:00.001-07:00

I saw one of my favorite philosophers speak yesterday: Peter Singer. His book Animal Liberation is reason I became a vegetarian for 3 years...until I was an intern, post-call, hungry, and it was "rib day". It was either a baked potato or the ribs. The potato lost.

His current work focuses on a philosophical shift, from being a "preference utilitarian" to being a "hedonistic utilitarian." Loosely, his interpretation of hedonism in this context is "happiness." His talk ranged widely, from a discussion of strength of orgasm, to the movie "The Matrix," to Daniel Kahneman. I freely admit I understood less than 25%. But as near as I can tell, he was speaking about something that might relate in a profound way to geriatrics and palliative care.

What do we value as a society? In the US, we tend to value the accumulation of wealth, as in the Gross Domestic Product (GDP). Other societies have prioritized happiness. Singer gave the example of Bhutan, a country that has developed the idea of Gross National Happiness (GNH).

What do we value in healthcare? One of the uniting features of geriatrics and palliative care is the focus on improving quality of life. One might quibble over the exact meaning of the terms, but promoting quality of life is generally accomplished by relieving suffering and promoting happiness, things that Singer has been concerned with throughout his career. Other fields of medicine value improving health. There is a subtle but important difference between these goals, just as there is a subtle but important difference between an ethical framework directed at maximizing preferences and another directed at maximizing happiness.

Can you imagine how different the US would be if we replaced the GDP with the GNH? Or if the goal of all medical specialties was maximizing happiness and the relief of suffering?

Sometimes culture changes starts with the philosophers (at least until rib day).

by: Alex Smith

The “Silver Tsunami” is coming. What am I doing to prepare?

2012-04-17T06:40:00.002-07:00

Everyone involved in geriatric care has heard the news: The “Silver Tsunami” is coming and the U.S. healthcare system is not prepared.

According to the Eldercare Workforce Alliance (EWA), the current health care system is already overwhelmed by demands for geriatric care and those specializing in the care of older adults cannot meet the current demand let alone the projected needs. EWA outlines the critical workforce shortage in detail. There are only 7,029 certified geriatricians practicing in the U.S., roughly half the number currently needed, and falling.

I remember first reading this and feeling somewhat saddened and overwhelmed. What could I do to address this shortage other than start taking an antidepressant and continue working with a population that I love? It occurred to me that I could make a difference by helping others prepare. My question changed from “how can I make a difference?” to “how can I help my non-geriatrics trained colleagues prepare to meet this need?”

Interestingly, my contribution to a possible small part of the solution began to unfold back in 2009, before I was even really aware of the workforce shortage problem at all. In 2009, I was a geriatric medicine fellow studying for my Boards exam by using the Geriatric Review Syllabus (GRS) and Geriatrics at Your Fingertips (GAYF) and making notes in an “H&P” format. I thought it might be helpful to share my notes with the residents on their geriatrics rotation. I contacted the American Geriatrics Society (AGS) to see if this would be possible and the response was incredibly positive and supportive. After a slew of emails, calls, meetings and drafts, the project morphed into a new AGS product series entitled Geriatric Evaluation and Management (GEM). An editorial subcommittee of the AGS Education Committee was formed last year so this would be a product of consensus. Eleven tools covering different topics were created over the past year using the “H&P” format and drawing from GRS and GAYF materials.

The GEM tools are clinical templates that follow an “H&P” format. They can be utilized as a quick consult for those with more experience in geriatric care, a reminder checklist for providers with less experience, and a teaching tool for medical students, residents, and fellows. Currently there are 11 tools with more in the works.

The GEM tools cover the following topics:

Appropriate Prescribing
Benign Prostatic Hyperplasia
Behavioral Problems in Dementia
Delirium · Depression
Dementia
Falls
Incontinence
Osteoporosis
Pressure Ulcers
Depression
Insomnia

The tools are available to download on the AGS website and currently require AGS membership to enter the site. I am working together with AGS to investigate wider access to the tools for non-AGS members and a possible smart-phone application. My hope is that my geriatric colleagues may find these tools useful as they also strive to educate their non-geriatrician colleagues in the care of older adults. http://www.americangeriatrics.org/membership/resources/gemtools

by: Shaida Talebreza Brandon

Eliminating Waste in US Health Care: Wise Words from Don Berwick

2012-04-14T17:16:00.006-07:00

The United States spends more on health care than any other country. By far. Yet life expectancy in the United States is about the lowest among Western industrialized countries. While I can't prove it, I am coming to believe these is at least a partial cause and effect relationship between these facts.

How can that be? How can spending so much on health care actually be bad for the health of our country? There are several possible links:

Many tests and procedures that are performed are unnecessary. Unnecessary tests and procedures cost a lot of money and harm patients.
The dysfunctional primary care system in the US leads to uncoordinated care, less opportunity for preventive care, and more care in expensive acute care settings instead of from primary providers. This leads to both higher costs and poor health outcomes.
The high cost of US health care makes both individuals and society poorer. Wealth is one of the strongest predictors of life expectancy--a fact that has been known for over 100 years. When an individual becomes poor because of their health costs, poverty may result in a decline in life expectancy. When health care increasingly robs the public purse, there is less available for other goods like education, which may have as much impact on life expectancy as health care.

In the most recent JAMA, there is a must read perspective from former (this word used with a mix of sadness and outrage) CMS head Don Berwick and Andrew Hackbarth that provides important insights into how we can reduce the cost of health care in the US.

Berwick suggests that is possible to markedly reduce the costs without depriving any patient of any needed service. No rationing needed at all. We just need to get serious about examining all the ways US health care spends money without benefiting patients.

Berkwick suggests we focus on 6 categories of waste that collectively cost hundreds of Billions of $$ a year:

Failures of Care Delivery: Much of this is the costs of medical error
Failures of Care Coordination: The costs when patients fall through the holes in our fragmented care system
Overtreatment: The costs when patients are subjected to "care" that can not possibly help them (and likely hurts them)
Administrative complexity: Costs from misguided policies and rules (such as complex billing procedures requiring doctors and hospitals to hire armies of coders)
Pricing failures: Costs resulting from the absence of transparency and complex markets (i.e., why is the cost of a MRI in the US cost several times the cost in other countries?)
Fraud and abuse: The costs of fake billing and health care scams

Berkwick estimates that getting serious about these 6 causes of waste at a minimum could save 21% of US health care costs (thats $558 billion dollars--$558,000,000,000). This is his conservative estimate. The actual savings are likely to be even greater.

The costs of the US healthcare system are unsustainable and if we don't do something they will bankrupt individuals, businesses, and our government. If we wait for bankruptcy, a slash and burn approach will probably result that will be bad for patients and providers. Berwick's wise counsel offers an approach that over the long term can cut costs and improve care. We should listen.

by: Ken Covinsky @geri_doc

Blogs to Boards: Question 7

2012-04-14T08:00:00.000-07:00

This is the seventh 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).

Question 7

JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam.

Prior to her hospitalization, she took oxycodone ER 30mg q12h. Currently she is on a hydromorphone IV PCA at 2mg/hour, with 2mg q30 minute boluses. She used 72mg of IV dilaudid in the last 24h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe for most of the day: 7-8/10, and ‘nearly intolerable’ during vest therapy

The best next step is to:

a) Increase her PCA basal and ‘bolus’ doses by 50% and monitor for 24 hours.
b) Add a 5% lidocaine patch to her chest wall over her rib fractures
c) Discontinue hydromorphone and switch the patient to another opioid
d) Advise the primary team to stop vest therapies

Discussion:

Blogs to Boards: Question 5

2012-04-07T08:00:00.000-07:00

This is the fifth 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).

Question 5

In hospice IDT, you discuss the case of a 68 year old female with ovarian cancer with abdominal pain and sudden onset nausea and vomiting. She has had no recent bowel movements and is on minimal opioids. You suggest a trial of octreotide for a likely malignant bowel obstruction and the nurses say “Doctor! You say we can use octreotide for everything! Is there anything octreotide can’t be used for in hospice?”

Which one of the following is not a potential scenario to use octreotide? Choose the best answer.

a) A 37 year old male with end stage alcoholic hepatitis who starts vomiting blood
b) A 90 year old with a severe diarrhea with a history of a rectal tumor and radiation burns to the perineal area
c) A 42 year old female with a tense distended abdomen leaking a small amount from a previous paracentesis site.
d) A 27 year old male with a malignant wound with copious drainage
e) A 31 year old female with abdominal pain from opioid-induced constipation

Discussion:

The correct answer is (e)

a) Octreotide is the Swiss Army Knife of palliative medications. It is a synthetic analog of somatostatin and has many mechanisms of action: in general, it has a global effect to decrease secretions primarily in the GI tract It can be costly as a medication alone but it could reduce the system cost by avoiding hospitalizations. You should talk with your local pharmacist to see about availability and cost in your local programs. It is typically administered via intermittent subcutaneous dosing. Study published in 2000 compared octreotide infusion with sclerotherapy and found that octreotide to be as effective as sclerotherapy regarding hemostasis at 48 hours and on day 7 after the index bleeding episode. So for the patient looking to avoid hospitalization with acute variceal bleed this may be a helpful (but expensive) medication.

b) While it does not work as a prophylactic treatment to prevent chemo and radiation induced diarrhea a few studies have shown that it can treat existing diarrhea related to these two common cancer treatments.

c) Rapidly accumulating ascites or situations where repeat paracentesis or drain may not be readily available have been shown to be responsive to octreotide. It also has been reported for use in pleural effusions related to cirrhosis.

d) Tumor related secretions have been show to respond to octreotide

e) Indications for octreotide include (via palliativedrugs.com) : symptoms associated with unresectable hormone-secreting tumors, e.g. carcinoid, VIPomas, glucagonomas and acromegaly; prevention of complications after elective pancreatic surgery; †bleeding esophageal varices; †salivary, pancreatic and enterocutaneous fistulas; †intractable diarrhea related to high output ileostomies, AIDS, radiotherapy, chemotherapy or bone marrow transplant;†inoperable bowel obstruction in patients with cancer; †hypertrophic pulmonary osteo-arthopathy;†ascites in cirrhosis and cancer; †buccal fistula; †death rattle (noisy respiratory secretions); †bronchorrhea;†reduction of tumor-related secretions.

References:

http://cases.pallimed.org/2008/06/am-i-really-going-to-have-to-live-like.html
http://www.pallimed.org/2008/11/octreotide-for-radiation-induced.html
Freitas DS, Sofia C, Pontes JM, Gregório C, Cabral JP, Andrade P, Rosa A, Camacho E, Ferreira M, Portela F.... (2000) Octreotide in acute bleeding esophageal varices: a prospective randomized study. Hepato-gastroenterology, 47(35), 1310-4. PMID: 11100339
Kalambokis, G. (2006-01) Octreotide in the treatment of refractory ascites of cirrhosis. Scandinavian Journal of Gastroenterology, 14(1), 199-121. DOI: 10.1080/00365520510024043
Martenson et al. The efficacy of octreotide in the therapy of acute radiation-induced diarrhea: a randomized controlled study. International Journal of Radiation OncologyBiologyPhysics, 54(1), 195-202. DOI: 10.1016/S0360-3016(02)02870-5

(For email readers - click here for the answer and discussion)

Many Disabled Seniors Have a Good Quality of LIfe

2012-04-06T08:08:00.000-07:00

A dominant focus of research in Geriatric Medicine has been on the prevention of the types of disability that are common in older persons. This research is important, because if it is successful it will lead to more years of independent living in which seniors do not need the help of caregivers or care in nursing homes.

But in our zeal to prevent disability in older persons, we sometimes paint an overly bleak picture of disability. Preventing and delaying disability is a very good thing. But there are no interventions or lifestyle changes that fully prevent late life disability. Rather, effective interventions slow down the process. The vast majority of persons who live to old age will experience a period of disability, and this period will often be prolonged. Our research on prevention of disability needs to complemented by studies that teach us how to help frail and disabled elders have an excellent quality of life.

Is it really possible for a senior to be significantly disabled, dependent on others for help with basic activities of daily living, yet consider their quality of life good? A recent study in the Journal of the American Geriatrics Society suggests that the answer is an emphatic YES.

This fascinating study interviewed 62 elderly persons who were cared for by On Lok, a San Francisco based program that cares for disabled older persons who are eligible for nursing home care, but wish to continue living in the community. In extended interviews, the seniors were asked about positive and negative aspects of their life.

The article title, "Quality of Life in Late-Life Disability: I don't feel bitter because I am in a wheelchair," nicely sums up the major themes. Despite severe disability (most needed help with multiple ADL), 78% of the seniors rated their quality of life as good or better.

The two central factors that were most important to maintaining quality of life were maintaining control over their daily lives and preservation of dignity. Maintaining a sense of control was often fostered by continuing activities that were important to each individual. Sometimes this meant being allowed to take risks. For example, some seniors felt providers and families too often tried to restrict their activities out of a fear they would fall.

Dignity meant being respected and valued as an individual. One participant noted how societal attitudes can be more harmful to seniors than activity limitations: "It is unfortunate that a lot of family or other people feel that once you're old, you don't know anything anymore, or you are just kind of in the way."

The article also provides a wealth of insights into other factors that impact quality of life in disabled elders. A few examples:

Adaptation: The ability to overcome physical limitations through assistive devices or behavioral modifications
Social well being: Positive relationships with family and friends, not feeling like you are a burden, and avoiding interpersonal conflicts
Psychological well being: Maintaining a positive attitude and the absence of depression or anxiety
Spiritual and religious well being: Faith in God, a sense of inner peace, and finding meaning in your daily activities

The study, which nicely bridges the disciplines of Geriatrics and Palliative Medicine (GeriPal research) was led be Dr. Jennifer King, now a family medicine resident at the Santa Rosa Family Medicine Residency, who completed the study while a medical student at UCSF. The senior author was Alexander Smith of the UCSF Division of Geriatrics.

One important lesson for clinicians and researchers is that most of the factors identified as important to these seniors are not included in any of our measurement or assessment tools. It will be hard to learn how to improve care for disabled seniors if we don't bother to measure the outcomes that matter the most to them. If we want to learn how to care for seniors with disability, we need to start by talking to them and learning from them.

by: Ken Covinsky (@geri_doc)

Name 5 Tests or Treatments We Overuse in Geriatrics or Palliative Care

2012-04-04T13:11:00.000-07:00

For the most part in geriatrics and palliative care we like to point the finger at other medical providers and say, "STOP." Stop giving so much chemotherapy. Stop giving so many medications. Stop scanning.

But now it's time to take a long hard look in the mirror.

Medical specialty organizations are being asked to come up with a list of 5 tests or treatments that are over-utilized or may actually be harmful. This effort, called the Choosing Wisely Initiative, is being spearheaded by the American Board of Internal Medicine (ABIM) Foundation. ABIM President and renowned geriatrician Christine Cassel was quoted in today's New York Times saying:

“In fact, rationing is not necessary if you just don’t do the things that don’t help.”

This same article notes that as much as 1/3 of health care costs are wasted on unnecessary hospitalizations, tests, and treatments.

So far 9 specialty boards have come up with their lists - the boards and there list are here - but Geriatrics and Palliative Medicine are not one of the 9. Are we really "holier than thou?" I don't think so.

I suspect we can come up with 5 tests or treatments for each specialty. It might be more fun to come up with lists for the cardiologists, oncologists, or surgeons, but that's not the point. Ask not what another specialty should not be doing, but what you can do less of yourself.

It's easier to come up with ideas if you don't think of them as a hard and fast rules (never do x), but as a list of things doctors and patients should question routinely doing in geriatrics or palliative care.

So to jump start things, here are two from each field:

Geriatrics
1. Screening for cancer in patients who are unlikely to benefit.
2. Insulin sliding scales

Palliative Care
1. Using more expensive analgesics without evidence of superiority to less expensive alternatives
2. Using oxygen instead of forced air

Let's figure this out together. Or someone from another specialty may come up with our list for us!

by: Alex Smith

Honoring Wishes: A Story by Nancy Lundebjerg

2012-04-03T09:35:00.000-07:00

Have you ever read something that made you very sad? I did at the end of last week. It was an earlier post on this blog – Being Accused of Murder – that Dan Matlock had written. It’s frustrating, as I know all too well, this system of ours when it comes to letting – or not letting -- someone die.

The story below is the tale of a death when there isn’t a champion like Dan who is inside an institution and who stands up to speak for a patient. It’s the tail end of a story that began when a family caregiver was rescued from an endless round of diagnostic appointments by a geriatrician who said “here’s what we’re going to do” and laid out a practical course of action that covered the medical and social needs of the patient in question. It’s a tale of a death in a nursing home where hospice beds were very new and the culture change had been slow to follow. It’s been over a decade now and the story still makes me mad. It’s the story of my aunt, the story of how she died.

I wanted to share this story from my personal blog because I don’t want clinicians to ever despair at being that clinician who stands up for his or her patient at the end of life. Honoring someone’s wishes about how they want to die is the most important thing we can do for each other. I know, I’ve been there. I’m the family caregiver in this story.

So, thank you Dan for honoring your patient's wishes. I hope someone does that for me when it’s my turn to go.

I well remember those last days of my aunt's life. Her court appointed guardian, armed with all the health care proxies and orders that I needed, it was still a struggle to let her go. Sheila wasn't going out with her boots on -- no sirree, she was in the last throes of a full-blown dementia that had started out with self-reports of little people living in her ceiling. A warrior woman in a man's world -- her life is a story for another day.

When I tell about how she died, I will often say that I fought on multiple fronts so that we could let her go. It was the ending battle of a war that began when I first started to pay her bills. Sitting in her apartment, sorting paper, and gamely trying to carry on a normal conversation about those little people living in the ceiling.

It was my friend Lisa (a young internist/psychiatrist on the cusp of completing her fellowship) who made the last argument that freed her -- who took up my fight, my burden, and bore it for me on those last few steps. I had arrived on her doorstep -- armed with all our favorite edible goodies and a story to tell. A story of a visit to a nursing home, an IV fluid having been started by the doctor on call, and a nurse that was crying about her baby. Her baby -- my aunt -- a woman who would have likely chosen to die much earlier in this journey if it had been left to her. The crying nurse who only meant the best. Who had called the doctor on call to ask that IV hydration be ordered. Made the call despite a clear notation on the chart -- no artificial nutrition or hydration. None. Nothing. Nada.

Yet, there was that IV, there was that crying nurse, and there was I -- unable to cause pain to someone in so much distress, with no strength to pull the plug -- for what seemed like the umpteenth time in a battle that had gone on far too long. Drained and spent by the last few weeks -- weeks of parsing out a palliative surgery (the surgeon’s and my preference) rather than a restorative surgery with a doctor who wanted to then go on to restorative surgery (her attending physician). Weeks that included learning that the nursing home DNR would not cover the ambulance or the hospital -- one needed one executed for each setting of care. That's three doctors' signatures, three times of saying, these are her wishes, she would want to die. Weeks that included a family meeting around the meaning of artificial nutrition -- how would my Aunt define it and what would she want? A family meeting where for the first time ever in all the years that my aunt resided there -- they wheeled her in to attend it. To preside in her diminished state over my decision on her behalf. A silent witness to my voicing that enough was enough.

"I just couldn't," I said that night after I told my sad tale of woe about the feelings of a nurse as they intersected with what I knew to be right. Feelings that so overpowered me with the rawness of the emotion that I couldn't pull that plug yet again. Looking back, I am in awe at the love that nurse had for her baby, my aunt. At the time, I dismissed it but it was true -- that was her baby and I was taking her away. Forever.

"You have to," Lisa said -- "if that IV runs all night, she could live another week." How stark, how cold those words must sound but they brought me comfort because I knew that -- even without the favorite foods - the next words out of her mouth would be: "I will call and take care of this." And, she did.

She called, she got the doctor on call and the IV was removed. Just like that. And, a couple of days later, my aunt exited this world. It was fitting that she would exit on a Shrove Tuesday -- this gregarious woman who built a share house on Fire Island and filled it with laughter and good times. As I remarked to my Mom -- she left at the height of the party before the penance of lent and that is how she would have wanted it.

by: Nancy Lundebjerg

Interview with Geriatrician, Eden Alternative Founder, and Author Bill Thomas

2012-04-02T11:51:00.000-07:00

Bill Thomas is a very busy man. He is the founder of the Eden Alternative that has been on the forefront of transforming nursing homes into elder-centered communities. He developed the Green House Project, which focuses on replacing institutional nursing homes with smaller, 10-12 person homes. He has given talks on the need to change the culture of aging (see the TEDx video below). And now, he has released his latest book, the Tribes of Eden, a novel inspired by his "life’s work as a self-proclaimed nursing home abolitionist seeking to change the way society views aging."

I was given the opportunity to interview Bill Thomas about the experience of being a writer and how the Tribes of Eden book can impact the way we care for our aging population. Here is the transcript:

Widera: So what is the connection between the Eden alternative and your new book Tribes of Eden?

Thomas: For the past twenty years the Eden Alternative has been working to make long-term care environments into better places to live and work. About eight years ago I began to see elements of "nursing home life" creeping into society as a whole. I started to wonder about a future where the "tribes of eden" might extend beyond remaking long-term care and begin to challenge the structure of a dystopian society. This book is an exploration of how that might play out-- in the very near future.

Widera: Why do you think it is important to use storytelling as a tool to change the culture of aging? Have you found it to be effective?

Thomas: Storytelling is the only thing that has the power to change the world we live in. It is through stories that we make sense of our lives and the changes that are happening around us. Some people have asked me-- "why did you spend all this time on a novel?" My answer is always, "I am a storyteller, I needed to tell this story."

Widera: If storytelling is important, why science fiction and not non-fiction?

Thomas: I guess "Tribes of Eden" might qualify as science fiction because it is set in the near future but technology plays a very limited role in the story. What it really offers is an examination of trust and the role trust plays in holding society together. I am working on a new non-fiction book right now and I am excited about it but "Tribes of Eden" offers something that readers can only find in novels. It creates a world that readers can become part of it paints a picture of the world as it might be.

Widera: We recently had a discussion on GeriPal on the terminology on aging, and in particular, should we use older adults, seniors, or elders? Some of our readers thought that the term elder might perpetuate aging stereotypes. However, in this book and in your work, you use the term elder and elderhood. Is this something we should all consider doing?

Thomas: First off, I think people have a right to choose what kinds of terms are used to refer to them. Having that privilege is essential to even a basic level of human dignity. Second, our language has a limited and quite dismissive aging-related vocabulary. That said, I use the term "elder" for one simple reason. I believe that there is life beyond adulthood. I believe that it is manifested in a developmental stage called "elderhood." From there it is a short leap to recognizing that a child is a person living in childhood and an adult is a person living in adulthood. Not surprisingly, I see an elder as a person living in elderhood.

In Tribes of Eden it is an alliance between the young and the old that rises up to change the world. That, not surprisingly, it is my hope that elders might have a similar impact in the real world.

Widera: Is there anything else that you think is important for the GeriPal audience to know about your book?

Thomas: Yes, readers, writers and stories are entering into a new relationship. It used to be that panels of experts would judge the worth and value of a book and publishing houses would grant or deny access to an audience. Now, the readers are a big part of the life of a book. Readers determine whether a book rises or falls. We are running a "Join the Ride" campaign over at www.edenunderground.com because we recognize that we are in this with the reader. I like that feeling, it is direct it is authentic and I have found over the years that my readers are passionate people who love to talk about life and what they are learning. I think Tribes of Eden will appeal to them and they will make it a success.

Thanks to Bill Thomas for the interview. To learn more about the book check out the ChangingAging website.

by: Eric Widera

Blogs to Boards: Question 3

2012-03-30T08:00:00.000-07:00

This is the third 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).

Question 3

During a hospice interdisciplinary team meeting, you hear about a 53 year old resident of the local nursing home. He has ALS with bulbar attributes, and is starting to have difficulty swallowing and speaking. He is bedbound most of the day. He has had two episodes of aspiration pneumonia in the last month.

His nurse describes the scene with the patient’s wife, Sally, at his side, squeezing his hand with one hand and her rosary with the other.

He explained to the nurse, “I told Sally that I don’t want a feeding tube. I’ve had a good life and have few regrets. I saw my father-in-law die on a feeding tube and I would not want to go through that, or put my wife through that. But I am Catholic. Our friend at the parish said that I have to ‘do everything’ to prolong my life – especially when it comes to nutrition - or I will go hell. I don’t want to go to hell.” His wife nods emphatically.

During the interdisciplinary care meeting, the chaplain (in his role as teacher) asks you to explain to the team what your understanding of the Catholic doctrine is as pertaining to this patient.

What do you say?

a) My understanding is that medically assisted nutrition is obligatory for patients who are unable to take food by mouth.
b) My understanding is that medically assisted nutrition is morally optional for most patients at the end of life.

Discussion:

Aricept 23 - Another Victory for Marketing Over Patients

2012-03-22T21:02:00.004-07:00

"What is the difference between 20 and 23? If you said three, you are off by millions—of dollars in sales, that is—at least from the perspective of Eisai, the manufacturer of donepezil (marketed as Aricept by Pfizer)."

Lisa Schwartz and Steven Woloshin, BMJ 2012

An article in today's New York Times online covers a superb piece in BMJ describing the saga of Aricept 23 - a new low in the triumph of marketing over science and patient well-being. Drug manufacturers, when faced with loss of patent protection and exclusivity for their drugs, have relied on a package of tricks to maintain a healthy revenue stream. Some have rolled out slightly modified versions (e.g., omeprazole to esomeprazole, albuterol to levalbuterol). Some have rebranded their product for special and sometimes dubious indications (e.g., rebranding fluoxetine as Sarafem). Some have delayed entry of generic competitors onto the market through dubious litigation and "pay-to-delay" arrangements.

In the case of Aricept (donepezil), the manufacturer tried a different tack - getting FDA approval for a new dose of the drug (23 mg), which they alone would be able to market even as generic manufacturers could compete on the traditional 5 and 10 mg doses. Why 23 mg? Presumably this dose was chosen because it would be difficult to replicate by combining standard-dose pills available through generic competitors.

If the 23 mg dose provided a clear therapeutic benefit, that would be one thing. However, as Schwartz and Woloshin explain, the single trial that compared the standard and new doses failed to demonstrate any benefit in daily functioning yet found a substantially greater risk of harms from the higher dose including nausea and vomiting, diarrhea, and anorexia. As a result, FDA reviewers recommended against approving the new dose. However, they were overruled by senior officials. To add insult to injury, lack of FDA oversight led to an erroneous statement on the product label that the higher dose improved overall functioning...and because of this, the company was legally allowed to perpetuate this falsehood in their advertisements.

Beware drug companies bearing prime numbers!

by: Mike Steinman

Being Accused of Murder

2012-03-21T22:05:00.003-07:00

“You would have been hung in World War II for doing what you are doing now,” I was told by a prominent member of a surgical service at my hospital when I suggested we stop the intravenous hydration.

The patient had suffered a devastating stroke. Her advance directive (notarized no less) stated that she did not want any artificial means of life support specifically mentioning artificial nutrition or hydration. Further, she also clearly stated that she would never want to be in a nursing home. The palliative care service on which I was attending was consulted to assist in removing the ventilator. We did. The next day, she was breathing on her own, showing no signs of decline, and even opening her eyes so the prominent doctor on this surgical service started intravenous hydration. I was immediately uncomfortable with this value discordant move so I called her sister who was listed as the medical power of attorney to clarify what the patient meant in her advance directive (because apparently it wasn’t clear enough for the primary team). She told me a story about her sister hunting deer outside her house and dragging them down the mountain all by herself at the age of 70. She used this story to explain how her sister would never want to be in a nursing home and if the best that she could hope for after this stroke, then she would definitely rather be dead. She agreed that we should stop the hydration. There was no ambiguity here.

I called this prominent member of this surgical service and explained what the MDPOA had told me about stopping the hydration. That’s when he said, “You would have been hung in World War II for doing what you are doing now.” It is a good thing that we were on the phone because this was one of the few times in my life where I remember having that rageful sensation of my blood “boiling” – I could feel my face turn red. I remember making some comment about “modern ethical theory evolving from the time of WWII” and hung up the phone before I got into any trouble.

This is actually one of the most disturbing interactions I have ever had in the hospital. I’ve asked several of my mentors what I could have done differently and I get the feedback that perhaps I could have explored his perspective (typical palliative care response!). I honestly don’t think I was capable. Sometimes it is frankly unfair that we in palliative care always have to be the bigger people educating these dinosaurs about modern ethics. Frankly, I wanted to just drop the gloves and go at it with fists. I still do…I’m not over it. When I see this doctor on the elevator, I cannot even look at him.

I found some comfort today though! A beautiful and important survey by Goldstein et al. showed that a large percentage of clinicians who care for dying patients have been accused of murder. The authors argue that “further efforts are needed to explain to the health care community and the public that treatments often used to relieve patient suffering at the end of life are ethical and legal.” This is indeed one implication of this study but the other important implication is that people like me who are victims of this kind of verbal onslaught have clear evidence that they are not alone.

by: Dan Maltock, MD, MPH

“Elders?” “Older Adults?” “Seniors?” Language Matters

2012-03-21T12:00:00.000-07:00

In a recent paper, some colleagues and I held the position that clinicians should routinely offer to discuss prognosis with very elderly patients.

I was later interviewed about this paper by a reporter who revealed that she is in her 70’s. She asked, “what does ‘elderly’ mean? When does a person become ‘elderly’?” I bravely (read ‘foolishly’) replied, “We use the word elder as a term of respect for the older adult patients we care for. In the paper we refer to individuals over the age of 85 as the ‘very elderly.’ This is an accepted term in the geriatrics literature.”

“When does someone become an ‘older adult’?” she responded.

I finally sensed danger. Using my palliative care communication skills, I quickly flipped the question. “You write about issues for older adults and have been for some time. What term do you use?”

“I never use term ‘elderly,’” she responded. “My readers don’t respond to ‘older adult’ either. They don’t want to be ‘older.’ We prefer the term ‘senior.’ That’s the phrase I use in all my writing.”

Pick up any general medicine or geriatrics journal, and you’ll see the words “older adult” and “elderly” all over the place. People in my division are conflicted about the best of these terms to use. Some argue that “elder” is more respectful, others that “older adult” makes them less “other.”

But these are not the preferred terms in the lay press. They generally use the word “senior.” I can’t recall a journal article that used the term “senior.”

So what’s it going to be? What term should we use in academia? When we’re communication with the public about our work? If we drop the terms “elderly” and “older adult,” are we capitulating to a culture that denies the realities of aging?

Here is my thinking, at an admittedly early and basic stage in thinking about this issue: as a general rule, we should use the term that people use to describe themselves.

For example, in academic journals, we should stop calling Latinos “Hispanics.” Hispanic is a term made up by the government; Latino is the term that persons of Latin-American ethnicity prefer to call themselves. Similarly, Americans of African ancestry should be called “African Americans” not “blacks.”

And, perhaps, in academics, persons in the second half of life should be called “seniors,” as they are in the lay press, not “elders” or “older adults.” It’s the term they prefer.

by: Alex Smith @alexsmithmd

Rights and Dignity of Seniors in Assisted Living: A Victory

2012-03-19T09:00:00.002-07:00

An unfortunate practice has been tolerated for too long at some continuing care retirement communities (CCRs). CCRs provide housing and services for seniors, often with a wide range of needs. Residents who are fully independent may be in one part of the CCR, while residents who are disabled and need assistance may live in the assisted living wing. Often over time, a resident will transfer from the independent to the assisted living wing.

But many CCRs needlessly go way beyond separating the housing units for independent and disabled seniors. They completely separate independent seniors from those who need assistance, sometimes actively preventing contact between these groups. In these facilities, the independent and assisted living seniors eat in different facilities and participate in completely different social activities. They may never see each other.

Many of the facilities claim that health needs dictate this segregation. But the need for this level of segregation is seldom justified on health or clinical grounds. Some have alleged that one reason for this segregation is marketing. The housing communities want to portray the seniors in their independent living facility as active and vigorous. And seeing disabled elders in the dining room may force the non disabled to confront their fear of aging and disability.

It is bad enough that many facilities minimize interaction and socialization between independent and assisted living seniors. But particularly egregious is what happens to seniors who start on the independent side of the community, but then become frailer and move to the assisted living side. They are no longer permitted to dine in the "independent living" dining room and they are no longer permitted to participate in the independent living social activities. I have heard of situations in which the grounds of the independent living wing are practically off limits to those in the assisted living wing.

So at the same time an older person is trying to cope and adapt to new needs for assistance, they are ripped away from their social networks and friends--and sometimes even their spouses.

In the community my Grandmother lived during the last 5 years of her life, the independent residents would talk about neighbors who had gone over to the "other side". I was always really proud that my Grandmother visited her friends on the assisted living side. She even organized a weekly bridge game in the assisted living wing. Her loyalty to her friends was one of many things that made her special.

But it should have been much easier. There should have never been an "other side." There was no medical reason why the move to assisted living should necessitate this degree of social separation. Her friends should have still had a seat at their old dining table and at their favorite bridge game.

But recently, some courageous seniors have begun to fight back. As reported by Paula Span in a series of posts on the New York Times New Old Age Blog (here and here) an upscale retirement community told residents in the assisted living wing that they no longer had a seat at the table in the independent living dining room. Many had eaten in this dining room for years. But the facility then banned assisted living residents from the independent living dining room. In some cases, assisted living residents could no longer share dinner with their independent living spouses. Assisted living residents were also banned from social activities in the independent living facility.

But these seniors reminded us that just because you need some help does not mean you are a pushover. They and their families fought back. They protested to board members and hired an elder care attorney. And by calling Paula Span, they shined a national spotlight on their plight. In the end, the retirement community did the right thing. Residents can once again eat in any dining room. 86 year old Dorothy Evans summed it up best: "Don't mess with us." Bravo!

So we should all give a big thank you to these seniors who have won an important victory for the rights of persons in assisted living. And thanks to Paula Span for telling this story.

For now, this is just a local victory, but it will hopefully spur a national movement.

by: Ken Covinsky (@geri_doc)